Alison Lichy

Automating activity-based interventions: The role of robotics

We have seen a continued growth of robotic devices being tested in neurorehabilitation settings over the last decade, with the primary goal to improve upper- and lower-motor function in individuals following stroke, spinal cord injury, and other neurological conditions. Interestingly, few studies have investigated the use of these devices in improving the overall health and well-being of these individuals despite the capability of robotic devices to deliver intensive time-unlimited therapy. In this article, we discuss the use of robotic devices in delivering intense, activity-based therapies that may have significant exercise benefits. We also present preliminary data from studies that investigated the metabolic and cardiac responses during and after 6 months of lower-limb robotic training. Finally, we speculate on the future of robotics and how these devices will affect rehabilitation interventions.

Intensive electrical stimulation attenuates femoral bone loss in acute spinal cord injury.

To determine whether intensive electrical stimulation (ES) can reduce femoral bone mineral density (BMD) loss in acute spinal cord injury (SCI).

The Association of Race, Cultural Factors, and Health-Related Quality of Life in Persons With Spinal Cord Injury

OBJECTIVE To examine the association of race and cultural factors with quality-of-life factors (participation, life satisfaction, perceived health status) in people with spinal cord injury (SCI). DESIGN Cross-sectional multisite study using structured questionnaires. SETTING Six National SCI Model Systems centers. PARTICIPANTS People with SCI (N=275; age ≥16y; SCI with discernable neurologic impairments; used power or manual wheelchair for >1y as primary means of mobility; nonambulatory except for exercise purposes). INTERVENTIONS None. MAIN OUTCOME MEASURES Participation (Craig Handicap Assessment and Reporting Technique Short Form); satisfaction (Satisfaction With Life Scale); and perceived health status (2 items from 36-Item Short Form Health Survey). RESULTS African American (n=96) with SCI reported more experiences of discrimination in health care, greater perceived racism, more health care system distrust, and lower health literacy than whites (n=156; P range, <.001-<.05). Participants who reported experiencing more discrimination in health care reported better occupational functioning (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.07-2.09; P<.05). Those who perceived more racism in health care settings reported better occupational functioning (OR, 1.65; 95% CI, 1.12-2.43; P<.05) and greater perceived health (β=.36; 95% CI, .05-.68; P<.05). Those who reported more distrust in the health care system reported better current health compared with 1 year ago (β=.38; 95% CI, .06-.69; P<.05). Those who reported better communication with their health care provider reported higher levels of mobility (OR, 1.5; 95% CI, 1.05-2.13; P<.05) and better general health (β=.27; 95% CI, .01-.53; P<.05). CONCLUSIONS In this cross-sectional study of people with SCI, higher levels of perceived discrimination and racism and better communication with health care providers were associated with an increase in participation and functioning and improvements in perceptions of well-being. These associations are different from those reported in other study populations and warrant confirmation in future prospective studies.

Asymmetric Lower-Limb Bone Loss after Spinal Cord Injury: Case Report

Osteoporosis is a significant secondary condition that occurs acutely after spinal cord injury (SCI). This article reports on a patient with motor incomplete SCI and asymmetric lower-limb bone loss as it correlates with lower-limb motor function and gait characteristics. A 32-year-old Caucasian male completed a comprehensive inpatient rehabilitation program, including 3 months of robotic body-weight-supported treadmill training three times a week. Bone mineral density (BMD) was monitored up to 1.5 years post-SCI by dual-energy X-ray absorptiometry. Ground reaction forces were measured through an instrumented treadmill for bilateral weight-bearing comparison. At 1.5 years postinjury, neurological examination revealed thoracic 4 American Spinal Injury Association Impairment Scale D SCI with less strength, reduced weight bearing, and lower BMD in the more neurologically impaired leg. These results suggest that osteoporosis may vary according to severity of impairment within individuals and that monitoring lower-limb BMD is especially important for patients who ambulate.

Disparities in Wheelchair Procurement by Payer Among People With Spinal Cord Injury

To identify insurance provider‐related disparities in the receipt of lightweight, customizable manual wheelchairs or power wheelchairs with programmable controls among community‐dwelling people with spinal cord injury (SCI).

Monitoring the impact of pressure on the assessment of skin perfusion and oxygenation using a novel pressure device

Skin perfusion and oxygenation is easily disrupted by imposed pressure. Fiber optics probes, particularly those spectroscopy or Doppler based, may relay misleading information about tissue microcirculation dynamics depending on external forces on the sensor. Such forces could be caused by something as simple as tape used to secure the fiber probe to the test subject, or as in our studies by the full weight of a patient with spinal cord injury (SCI) sitting on the probe. We are conducting a study on patients with SCI conducting pressure relief maneuvers in their wheelchairs. This study aims to provide experimental evidence of the optimal timing between pressure relief maneuvers. We have devised a wireless pressure-controlling device; a pressure sensor positioned on a compression aluminum plate reads the imposed pressure in real time and sends the information to a feedback system controlling two position actuators. The actuators move accordingly to maintain a preset value of pressure onto the sample. This apparatus was used to monitor the effect of increasing values of pressure on spectroscopic fiber probes built to monitor tissue oxygenation and Doppler probes used to assess tissue perfusion.

Skin microvascular and metabolic response to pressure relief maneuvers in people with spinal cord injury

Clinician’s recommendations on wheelchair pressure reliefs in the context of the high prevalence of pressure ulcers that occur in people with spinal cord injury is not supported by strong experimental evidence. Some data indicates that altered tissue perfusion and oxygenation occurring under pressure loads, such as during sitting, induce various pathophysiologic changes that may lead to pressure ulcers. Pressure causes a cascade of responses, including initial tissue hypoxia, which leads to ischemia, vascular leakage, tissue acidification, compensatory angiogenesis, thrombosis, and hyperemia, all of which may lead to tissue damage. We have developed an advanced skin sensor that allows measurement of oxygenation in addition to perfusion, and can be safely used during sitting. The sensor consists of a set of fiber optics probes, spectroscopic and Laser Doppler techniques that are used to obtain parameters of interest. The overriding goal of this project is to develop the evidence base for clinical recommendations on pressure reliefs. In this paper we will illustrate the experimental apparatus as well as some preliminary results of a small clinical trial conducted at the National Rehabilitation Hospital.

The efficacy of pressure relief maneuvers in spinal cord injury patients, a clinical study

Pressure reliefs are recommended to wheelchair bound individuals to control and minimize skin damage. To this date recommendation on duration and intervals between pressure reliefs is not clear. Recent studies have shown a relationship between reduction in tissue perfusion and oxygenation due to pressure and skin pathophysiologic changes. We have developed a fiber-optics probe that allows measurement of oxygenation in addition to perfusion in real time; this low profile probe can be utilized while sitting and during pressure reliefs. We have conducted a clinical trial at the National Rehabilitation Hospital on individual with spinal cord injury. The overriding goal of this project was to develop the evidence base for clinical recommendations on pressure reliefs. Results of the study will be presented.

Poster 405: Differential and Asymmetric Bone Mineral Density Loss in an Ambulatory Individual With Spinal Cord Injury: A Case Report

Disclosures: K. A. Velez, None. Patients or Programs: A 51-year-old man with traumatic central cord syndrome (TCCS). Program Description: After a head-on motor vehicle collision with a concrete barrier at 40 mph, our patient experienced weakness in all extremities, along with severe neck pain radiating into his shoulders and pain in the right C6 distribution. Spine imaging showed an acute C4-5 spinal cord contusion with a 2-mm C4-5 anterolisthesis, right C5 facet, and transverse process fracture, and C7 burst fracture. Results of a physical examination revealed weakness below the C4 level with leg sparing and hyperreflexia in all extremities. He was started on antiplatelet therapy and was placed in a hard collar with plans for future elective spinal stabilization. Setting: Inpatient spinal cord injury (SCI) unit. Results: Upon transfer to our inpatient SCI unit, the patient was having difficulties participating in therapy because of ongoing neck, shoulder, and arm pain refractory to nonopiate and opiate medications. He was dependent with all ADLs, mobility, and transfers. Given functional decline and severe pain, neurosurgical intervention was expedited, and he underwent a C4-5 anterior cervical diskectomy. Two days after the procedure, patient reported decreased pain and was able to perform all ADLs, mobility, and transfers with minimal assistance. Discussion: Surgical spine intervention (SSI) after TCCS is controversial. Those in favor state that patients who are mobilized earlier experience less medical complications and shorter hospital length of stay. Others believe that SSI carries multiple risks and do not improve neurofunctional outcomes when compared with conservative management. Furthermore, optimal timing of SSI in individuals with TCCS remains unclear. Despite the ongoing controversy, early SSI was beneficial in our patient because of its dramatic effect on pain and function. Conclusions: Early SSI should be considered in patients with TCCS who are not able to fully participate in rehabilitation so to prevent medical comorbidities, improve functional outcomes, and promote early community reintegration. Poster 405 Differential and Asymmetric Bone Mineral Density Loss in an Ambulatory Individual With Spinal Cord Injury: A Case Report. Hasan Badday, MD (National Rehabilitation Hospital, Washington, DC); Suzanne L. Groah, MD; Alison Lichy, DPT; Cynthia G. Pineda, MD.