Upper-limb exercise in tetraplegia using functional electrical stimulation

Cervical spinal cord injury can result in dysfunction in both the lower and upper limbs (tetraplegia), andmay be accompanied by a range of secondary complications. The degree of upper-limb dysfunctiondepends upon the level and completeness of the lesion; in this paper we consider tetraplegics with a neurological level in the range C4-C6. A person with a C5- or C6-level injury will generally retain control of the shoulder and elbow flexor muscles biceps), but will have no control of the hand, wrist or elbow extensors (triceps).With a complete C4 injury voluntary control of the entire arm is lost. Thus, we propose that functional electrical stimulation (FES) of the biceps and triceps muscles may enhance the efficacy of cyclical upper-limb exercise. Alternatives for partial restoration of function include tendon transfer surgery or mechanical orthoses1. Previous FES research for C4-C6 tetraplegics has focused on systems for hand function2,3 and improved working area (i.e. overhead reach)4,5,6,7, but the provision of upper-limb exercise modalities using FES assistance has been neglected. This is important because the lack of effective exercise can lead rapidly to severe cardiopulmonary deconditioning in this population

Effect of detraining on bone and muscle tissue in subjects with chronic spinal cord injury after a period of electrically-stimulated cycling: a small cohort study

Objective: To investigate adaptive changes in bone and muscle parameters in the paralysed limbs after de-training or reduced functional electrical stimulation (FES) induced cycling following high-volume FES-cycling in chronic spinal cord injury (SCI). Subjects: Five subjects with motor-sensory complete SCI (age 38.6 years, lesion duration 11.4 years) were included. Four subjects stopped FES-cycling completely after the training phase whereas one continued reduced FES-cycling (2-3 times/week, for 30min). Methods: Bone and muscle parameters were assessed in the legs using peripheral quantitative computed tomography at six and twelve months after cessation of high-volume FES-cycling. Results: Gains achieved in the distal femur by high-volume FES-cycling were partly maintained at one year of detraining: 73.0% in trabecular bone mineral density (BMD), 63.8% in total BMD, 59.4% in bone mineral content and 22.1% in muscle cross-sectional area (CSAmuscle) in the thigh. The subject who continued reduced FES-cycling maintained 96.2% and 95.0% of the previous gain in total and trabecu-lar BMD, and 98.5% in CSAmuscle. Conclusion: Bone and muscle benefits achieved by one year of high-volume FES-cycling are partly preserved after 12 months of detraining whereas reduced cycling maintains bone and muscle mass gained. This suggests that high-volume FES-cycling has clinical relevance for at least 1y after detraining

Arm-cranking exercise assisted by Functional Electrical Stimulation in C6 tetraplegia: a pilot study

Tetraplegic volunteers undertook progressive exercise training, using novel systems for arm-cranking exercise assisted by Functional Electrical Stimulation (FES). The main aim was to determine potential training effects of FES-assisted arm-crank ergometry (FES-ACE) on upper limb strength and cardiopulmonary {fitness} in tetraplegia. Surface FES was applied to the biceps and triceps during exercise on an instrumented ergometer. Two tetraplegic volunteers with C6 Spinal Cord Injury (SCI) went through muscle strengthening, baseline exercise testing and three months of progressive FES-ACE training. Repeat exercise tests were carried out every four weeks during training, and post-training, to monitor upper-limb strength and cardiopulmonary fitness. At each test point, an incremental test was carried out to determine peak work rate, peak oxygen uptake, gas exchange threshold and oxygen uptake-work rate relationship during FES-ACE. Peak oxygen uptake for Subject A increased from 0.7 l/min to 1.1 l/min, and peak power output increased from 7 W to 38 W after FES-ACE training. For Subject B, peak oxygen uptake was unchanged, but peak power output increased from 3 W to 8 W. These case studies illustrate potential benefits of FES-ACE in tetraplegia, but also the differences in exercise responses between individuals. Keywords: electrical stimulation; spinal cord injury; cardiopulmonary fitness; rehabilitation; tetraplegi

Predicting patient-specific rates of bone loss at fracture-prone sites after spinal cord injury

People with spinal cord injury (SCI) experience bone loss and have an elevated rate of fracture in the paralysed limbs. The literature suggests an exponential time course of bone loss after SCI, but true rates may vary between patients. We propose systematic evaluation of bone status in the early stages of SCI to identify fast bone losers. A case series of six patients with complete SCI were scanned using peripheral quantitative computed tomography within 5 weeks and at 4, 8 and 12 months post-injury. Bone mineral density (BMD) and bone mineral content (BMC) were measured at fracture-prone sites in the tibia and femur. Patient-specific-predictions (PSP) of expected rates of bone loss were produced by individualising published model equations according to each patient’s measured values at baseline. Wilcoxon Signed-Rank tests were used to identify changes between time-points; chi-squared tests for differences between measured and PSP values. In the lower limbs, mean values decreased significantly between baseline and 8 months post-injury, by 19–31% for trabecular BMD, 21–32% for total BMD, and 9–29% for BMC. Most subjects showed no significant differences between PSP and measured values, but individuals with significantly faster rates of bone loss than predicted should be investigated further. There was considerable intersubject variability in rates of bone loss after SCI. Patients showing the fastest bone loss could benefit from continued follow-up and possibly treatment

Methods and protocols for incremental exercise testing in tetraplegia, using arm-crank ergometry assisted by Functional Electrical Stimulation

Cervical spinal cord injury (SCI) leads to tetraplegia, with paralysis and loss of sensation in the upper and lower limbs. The associated sedentary lifestyle results in an increased risk of cardiovascular disease. To address this, we require the design of exercise modalities aimed specifically at tetraplegia and methods to assess their efficacy. This paper describes methods for arm-crank ergometry (ACE) assisted by Functional Electrical Stimulation (FES) applied to the biceps and triceps. The instrumented ergometer enables work-rate control during exercise, implemented here for incremental exercise testing during FES-ACE. Detailed protocols for the tests are given. Experimental data collected during exercise tests with tetraplegic volunteers are provided to illustrate the feasibility of the proposed approach to testing and data analysis. Incremental tests enabled calculation of peak power output and peak oxygen uptake. We propose that the high-precision exercise testing protocols described here are appropriate to assess the efficacy of the novel exercise modality, FES-ACE, in tetraplegia

Role of peripheral quantitative computed tomography in identifying disuse osteoporosis in paraplegia

Objective: Disuse osteoporosis is a major long-term health consequence of spinal cord injury (SCI) that still needs to be addressed. Its management in SCI should begin with accurate diagnosis, followed by targeted treatments in the most vulnerable subgroups. We present data quantifying disuse osteoporosis in a cross-section of the Scottish paraplegic population to identify subgroups with lowest bone mineral density (BMD). Materials and Methods: Forty-seven people with chronic SCI at levels T2-L2 were scanned using peripheral Quantitative Computed Tomography (pQCT) at four tibial sites and two femoral sites, at the Queen Elizabeth National Spinal Injuries Unit, Glasgow (U.K.). At the distal epiphyses, trabecular BMD (BMDtrab), total BMD, total bone cross-sectional area (CSA), and bone mineral content (BMC) were determined. In the diaphyses, cortical BMD, total bone CSA, cortical CSA, and BMC were calculated. Bone, muscle and fat CSAs were estimated in the lower leg and thigh. Results: BMDtrab decreased exponentially with time since injury, at different rates in the tibia and femur. At most sites, female paraplegics had significantly lower BMC, total bone CSA and muscle CSA than male paraplegics. Subjects with lumbar SCI tended to have lower bone values and smaller muscle CSAs than in thoracic SCI. Conclusion: At the distal epiphyses of the tibia and femur, there is generally a rapid and extensive reduction in BMDtrab after SCI. Female subjects, and those with lumbar SCI, tend to have lower bone values than males or those with thoracic SCI, respectively. Keywords: Bone loss, osteoporosis, paraplegia, peripheral Quantitative Computed Tomography, spinal cord injur

Spatiotemporal responses of trabecular and cortical bone to complete spinal cord injury in skeletally mature rats

Objective: Characterise the spatiotemporal responses of trabecular and cortical bone to complete spinal cord injury (SCI) in the skeletally mature rat in the acute (4-week) period following injury. Methods: The spinal cord of 5-month old male rats was transected at the T9 level. Outcome measures were assessed using micro-computed tomography, three-point bending and serum markers at 1-, 2-, and 4-weeks post-transection. Comparison was made with time-0 and sham animals. Results: Lower levels of circulating serum bone formation markers and higher bone resorption markers suggested uncoupled bone turnover as early at 1-week post-transection. Micro-computed tomography showed metaphyseal and epiphyseal trabecular bone loss was observed only at 4-weeks post-transection. The bone loss was site-specific with a more severe reduction in trabecular BV/TV observed in the metaphyseal (50%) relative to epiphyseal (19%) region. Metaphyseal trabecular bone exhibited a 110% reduction in connectivity density while the epiphyseal trabecular bone was unaffected. Cortical bone deficits were not seen over the time periods examined. Conclusions: The study demonstrates that the skeletally mature spinal cord transected rat model replicates the biphasic pattern of osteoporotic changes observed in the human SCI population, providing a relevant model for testing the efficacy of interventions against SCI-induced osteoporosis

Is rapid bone loss captured by bone shape in spinal cord injury patients?

Introduction: Spinal Cord Injury (SCI) can trigger bone loss below the level of injury. Bone loss and fractures most commonly occur at the distal femur and proximal tibia and are associated with significantly increased morbidity. Bone loss following SCI has been shown to vary between 0 and 40% in the first year, with no current biomarkers to predict who will suffer severe bone loss. Standard osteoporosis treatments are risky for SCI patients and most effective in the early stages, therefore early identification of those at greatest risk is desirable. Active Shape Modelling (ASM) is a statistical technique for modelling bone morphology that predicts postmenopausal hip fractures. SCI can be considered an accelerated model of osteoporosis progression, and biomarkers for bone loss in SCI may be applicable to those at high risk of developing osteoporosis in the general population. This study investigated whether ASM predicts SCI-associated bone loss.Material and Methods: 25 patients with motor complete SCI (aged 16-76 years, 21 male and 4 female, 10 paraplegic and 15 tetraplegic) were scanned at the distal femur and proximal tibia using peripheral quantitative CT (Stratec Medizintechnik GmbH) at <5weeks, 4, 8 and 12 months post-injury. An ASM was made for each site. Links between 7 shape-modes (defined as standard deviations from the mean shape) and 12 month BMD loss were analysed using multiple linear regression (SPSS V21).Discussion: One mode from each ASM significantly predicted bone loss after adjustment for age (P < 0.05). High mode 4 femur scores showed a taller and narrower intercondylar notch. A +1 score was associated with an additional 6% BMD loss at 12 months. High tibia mode 1 scores represented a flatter tibial tuberosity. A +1score at baseline was associated with an additional 7% loss of BMD at 12 months. Conclusion: This is the first study to use ASM to predict bone loss. Baseline bone shape predicts 12-month bone loss in SCI patients. This imaging biomarker may help in early identification, treatment and prevention of SCI osteoporosis, with wider implications for postmenopausal osteoporosis