Argyrios Stampas

Intensity Dependent Effects of Transcranial Direct Current Stimulation on Corticospinal Excitability in Chronic Spinal Cord Injury

OBJECTIVE To investigate the effects of anodal transcranial direct current stimulation (a-tDCS) intensity on corticospinal excitability and affected muscle activation in individuals with chronic spinal cord injury (SCI). DESIGN Single-blind, randomized, sham-controlled, crossover study. SETTING Medical research institute and rehabilitation hospital. PARTICIPANTS Volunteers (N = 9) with chronic SCI and motor dysfunction in wrist extensor muscles. INTERVENTIONS Three single session exposures to 20 minutes of a-tDCS (anode over the extensor carpi radialis [ECR] muscle representation on the left primary motor cortex, cathode over the right supraorbital area) using 1 mA, 2 mA, or sham stimulation, delivered at rest, with at least 1 week between sessions. MAIN OUTCOME MEASURES Corticospinal excitability was assessed with motor-evoked potentials (MEPs) from the ECR muscle using surface electromyography after transcranial magnetic stimulation. Changes in spinal excitability, sensory threshold, and muscle strength were also investigated. RESULTS Mean MEP amplitude significantly increased by approximately 40% immediately after 2mA a-tDCS (pre: 0.36 ± 0.1 mV; post: 0.47 ± 0.11 mV; P = .001), but not with 1 mA or sham. Maximal voluntary contraction measures remained unaltered across all conditions. Sensory threshold significantly decreased over time after 1mA (P = .002) and 2mA (P = .039) a-tDCS and did not change with sham. F-wave persistence showed a nonsignificant trend for increase (pre: 32% ± 12%; post: 41% ± 10%; follow-up: 46% ± 12%) after 2 mA stimulation. No adverse effects were reported with any of the experimental conditions. CONCLUSIONS The a-tDCS can transiently raise corticospinal excitability to affected muscles in patients with chronic SCI after 2 mA stimulation. Sensory perception can improve with both 1 and 2 mA stimulation. This study gives support to the safe and effective use of a-tDCS using small electrodes in patients with SCI and highlights the importance of stimulation intensity.

Improved motor performance in chronic spinal cord injury following upper-limb robotic training

BACKGROUND Recovering upper-limb motor function has important implications for improving independence of patients with tetraplegia after traumatic spinal cord injury (SCI). OBJECTIVE To evaluate the feasibility, safety and effectiveness of robotic-assisted training of upper limb in a chronic SCI population. METHODS A total of 10 chronic tetraplegic SCI patients (C4 to C6 level of injury, American Spinal Injury Association Impairment Scale, A to D) participated in a 6-week wrist-robot training protocol (1 hour/day 3 times/week). The following outcome measures were recorded at baseline and after the robotic training: a) motor performance, assessed by robot-measured kinematics, b) corticospinal excitability measured by transcranial magnetic stimulation (TMS), and c) changes in clinical scales: motor strength (Upper extremity motor score), pain level (Visual Analog Scale) and spasticity (Modified Ashworth scale). RESULTS No adverse effects were observed during or after the robotic training. Statistically significant improvements were found in motor performance kinematics: aim (pre 1.17 ± 0.11 raduans, post 1.03 ± 0.08 raduans, p = 0.03) and smoothness of movement (pre 0.26 ± 0.03, post 0.31 ± 0.02, p = 0.03). These changes were not accompanied by changes in upper-extremity muscle strength or corticospinal excitability. No changes in pain or spasticity were found. CONCLUSIONS Robotic-assisted training of the upper limb over six weeks is a feasible and safe intervention that can enhance movement kinematics without negatively affecting pain or spasticity in chronic SCI. In addition, robot-assisted devices are an excellent tool to quantify motor performance (kinematics) and can be used to sensitively measure changes after a given rehabilitative intervention.

Transcranial direct current stimulation (tDCS) of the primary motor cortex and robot-assisted arm training in chronic incomplete cervical spinal cord injury: A proof of concept sham-randomized clinical study

BACKGROUND After cervical spinal cord injury, current options for treatment of upper extremity motor functions have been limited to traditional approaches. However, there is a substantial need to explore more rigorous alternative treatments to facilitate motor recovery. OBJECTIVE To demonstrate whether anodal-primary motor cortex (M1) excitability enhancement (with cathodal-supra orbital area) (atDCS) combined with robot-assisted arm training (R-AAT) will provide greater improvement in contralateral arm and hand motor functions compared to sham stimulation (stDCS) and R-AAT in patients with chronic, incomplete cervical spinal cord injury (iCSCI). METHODS In this parallel-group, double-blinded, randomized and sham-controlled trial, nine participants with chronic iCSCI (AIS C and D level) were randomized to receive 10 sessions of atDCS or stDSC combined with R-AAT. Feasibility and tolerability was assessed with attrition rate and occurrence of adverse events, Changes in arm and hand function were assessed with Jebson Taylor Hand Function Test (JTHFT). Amount of Use Scale of Motor Activity Log (AOU-MAL), American Spinal Injury Association Upper Extremity Motor Score and Modified Ashworth Scale (MAS) at baseline, after treatment, and at two-month follow-up. RESULTS None of the participants missed a treatment session or dropped-out due to adverse events related to the treatment protocol. Participants tended to perform better in JTHFT and AOU-MAL after treatment. Active group at post-treatment and two-month follow-up demonstrated better arm and hand performance compared to sham group. CONCLUSION These preliminary findings support that modulating excitatory input of the corticospinal tracts on spinal circuits may be a promising strategy in improving arm and hand functions in persons with incomplete tetraplegia. Further study is needed to explore the underlying mechanisms of recovery.

Communicating Hydrocephalus due to Traumatic Lumbar Spine Injury: Case Report and Literature Review

Hydrocephalus is a rare complication of traumatic spine injury. A literature review of hydrocephalus in traumatic spine injury reflects the rare occurrence with cervical spine injury. In the spinal cord tumor literature, distal thoracolumbar tumors are known to cause hydrocephalus. In our literature review, there have been no published cases or reviews of a traumatic injury distal to the cervical spine causing hydrocephalus. We present a case of traumatic injury to the lumbar spine from a gunshot wound which caused communicating hydrocephalus. The patient sustained a gunshot wound to the lumbar spine and had an L4-5 laminectomy with exploration and removal of foreign bodies. At the time of surgery, the patient was found to have dense subarachnoid hemorrhage in the spinal column. He subsequently had intermittent headaches and altered mental status that resolved without intervention. Workup of the headaches for infection including lumbar tap was performed which revealed no growth. The patient was discharged to an acute rehabilitation facility and had followup 20 days later. Follow up CT of the lumbar spine was significant for interim development of a traumatic lumbar pseudomeningocele. The intermittent headaches had been worsening while in rehabilitation so a CT Brain was performed which revealed hydrocephalus and the patient was emergently transferred to the neurosurgery service. IR-guided cervical spinal tap was performed that again did not demonstrate meningitis. A ventricle peritoneal shunt was placed and repeat CT Brain showed reduced ventricle size. The patient returned to rehabilitation with complete resolution of hydrocephalus symptoms. Conclusion: Remote subarachnoid hemorrhage with subsequent arachnoiditis causing obstruction at the level of the arachnoid granulations was thought to lead to communicating hydrocephalus in this case of lumbar spine penetrating trauma. Hydrocephalus should be on the headache and/or altered mental status differential in a bloody, traumatic spinal injury.

Spinal cord injury medicine and rehabilitation.

The rehabilitation of spinal cord injury (SCI) is a complicated process, but one in which new research is developing novel and increasingly promising methods of restorative neurology. Spinal cord injury medicine addresses not only the neurologic injury, but all the secondary complications in other organ systems whose regulation is disrupted after SCI. To some degree, the rehabilitation of SCI is focused on return to the community and functional goals are paramount, regardless of whether they can be achieved through some mechanism of compensation or due to a growing effort at engendering neurologic plasticity and recovery. The authors present a typical case of cervical incomplete SCI and discuss the medical complications and considerations for care during acute rehabilitation. They also review current methods of planning and executing rehabilitation, along with emerging methods that are leading to, in varying degrees, greater neurologic recovery. Finally, new approaches in SCI rehabilitation, namely neuromodulation, are discussed as efforts are made to further augment neural plasticity and recovery in SCI.

Is the Routine Use of a Functional Electrical Stimulation Cycle for Lower Limb Movement Standard of Care for Acute Spinal Cord Injury Rehabilitation

You lead the rehabilitation team at a large, rural freestanding rehabilitation hospital with a small but growing and respected spinal cord injury (SCI) rehabilitation programdinpatient and outpatient. You are caring for a 25-year-old man, 3 weeks after a T10 American Spinal Injury Association Impairment Scale (AIS) B injury due to a motor vehicle accident. He is medically stable and participating well in his program. The man’s parents happen to have substantial resources. After doing research online, they approach you concerning the absence of a functional electrical stimulation (FES) cycle treatment for their son. They express their shock at this oversight as “everybody is convinced this technology is considered standard of care” for acute SCI and promise to take this up with the CEO of the rehabilitation hospital. After being told that the hospital’s budget will not support purchase of the device, the parents offer to buy one “if you feel that having one will benefit my son.” Would you accept the kind offer of this couple, taking the position that the FES is an essential component of care in acute SCI, or would you attempt to dissuade the couple from spending a great deal of their own money for an unnecessary treatment? Arguing in favor of accepting the gift and implementing FES is Argyrios Stampas, MD, and arguing against is Henry York, MD.

Robotic Hand–Assisted Training for Spinal Cord Injury Driven by Myoelectric Pattern Recognition: A Case Report

Abstract A 51-year-old man with an incomplete C6 spinal cord injury sustained 26 yrs ago attended twenty 2-hr visits over 10 wks for robot-assisted hand training driven by myoelectric pattern recognition. In each visit, his right hand was assisted to perform motions by an exoskeleton robot, while the robot was triggered by his own motion intentions. The hand robot was designed for this study, which can perform six kinds of motions, including hand closing/opening; thumb, index finger, and middle finger closing/opening; and middle, ring, and little fingers closing/opening. After the training, his grip force increased from 13.5 to 19.6 kg, his pinch force remained the same (5.0 kg), his score of Box and Block test increased from 32 to 39, and his score from the Graded Redefined Assessment of Strength, Sensibility, and Prehension test Part 4.B increased from 22 to 24. He accomplished the tasks in the Graded Redefined Assessment of Strength, Sensibility, and Prehension test Part 4.B 28.8% faster on average. The results demonstrate the feasibility and effectiveness of robot-assisted training driven by myoelectric pattern recognition after spinal cord injury.

Communicating Hydrocephalus Due to Traumatic Lumbar Spine Injury: Case Report and Literature Review.

: Hydrocephalus is a rare complication of traumatic spine injury. A literature review reflects the rare occurrence with cervical spine injury. We present a case of traumatic injury to the lumbar spine from a gunshot wound, which caused communicating hydrocephalus. The patient sustained a gunshot wound to the lumbar spine and had an L4-5 laminectomy with exploration and removal of foreign bodies. At the time of surgery, the patient was found to have dense subarachnoid hemorrhage in the spinal column. He subsequently had intermittent headaches and altered mental status that resolved without intervention. The headaches worsened, so a computed tomography scan of the brain was obtained, which revealed hydrocephalus. A ventriculoperitoneal shunt was placed, and subsequent computed tomography scan of the brain showed reduced ventricle size. The patient returned to rehabilitation with complete resolution of hydrocephalus symptoms. Intrathecal hemorrhage with subsequent obstruction or decreased absorption of cerebrospinal fluid at the distal spinal cord was thought to lead to communicating hydrocephalus in this case of lumbar penetrating trauma. In patients with a history of hemorrhagic, traumatic spinal injury who subsequently experience headaches or altered mental status, hydrocephalus should be included in the differential diagnosis and adequately investigated.

Poster 70: Neuromodulation of the Bladder in Acute Traumatic SCI with Transcutaneous Tibial Nerve Stimulation

Participants: Adults with chronic, troublesome sialorrhea due to Parkinson’s disease, stroke, and other etiologies. Interventions: Subjects received placebo, 75U or 100U incobotulinumtoxinA in the first treatment cycle (MP) and either 75U or 100U incobotulinumtoxinA in each of 3 further treatment cycles in the EP. Main Outcome Measures: Unstimulated Salivary Flow Rate (uSFR); Global Impression of Change Scale (GICS), Drooling Severity and Frequency Scale (DSFS); modified Radboud Oral Motor Inventory in Parkinson’s Disease (mROMP) drooling. Adverse events were monitored throughout. Results: Subjects who received incobotulinumtoxinA throughout the MP and EP demonstrated sustained improvements in uSFR across treatment cycles. In the 75U group, mean uSFR (g/min) was 0.42 at study baseline (n1⁄474) and 0.36 (n1⁄468), 0.28, 0.23, and 0.23 at respective week 4 follow-ups after injections 1 to 4. Response was numerically greater in the 100U group (n1⁄474): 0.40 at study baseline and 0.27 (n1⁄472), 0.22, 0.21, and 0.17 at week 4 follow-ups after consecutive injections. Mean subject GICS scores indicated sustained improvement in both treatment groups. Similar trends of improvement were also observed for the DSFS and mROMP analyses. In the small group of subjects (n1⁄432), who switched from placebo in the MP to incobotulinumtoxinA in the EP, treatment benefit was also shown. Consistent with the MP, safety and tolerability were favorable in the EP, with no new/unexpected findings. Conclusions: Repeated treatment with incobotulinumtoxinA is safe and effective for sustained improvement in sialorrhea. Level of Evidence: Level I

Poster 97: The First 24 Hours: The Impact of Opioids on Spinal Cord Injury Recovery

Disclosures: Jennifer Bush: Research Grants Mission Connect grant Objective: To identify correlates of acute opioid use after human traumatic spinal cord injury (SCI) with quality of life outcomes at 1 year. Design: Retrospective chart review. T-tests and Rank-Sum test were used to detect differences between those that responded to the 1year survey (R) and non-responders (NR). Spearman correlation was performed on all variables in the R group. Significant correlates were used in the linear regression models. Setting: Level I trauma center and rehabilitation hospital. Participants: 180 consecutive admissions to the SCI Model Systems (SCIMS) database from 2008-2011. 90 had complete initial medication records, of which 51 answered the subjective pain question on the SCIMS 1 year post-injury survey. Interventions: Not applicable. Main Outcome Measures: Correlates to opioids administered within 4, 12, 24 hours, to 7 days post-injury, and correlates to pain scores at 1 year. Results: The R group (n1⁄451) was administered greater amounts of opioids from24hours to 1week (P<.05) compared toNR (n1⁄439). Therewere 8 variables correlated to opioid subtotals, of which the 24 hour subtotal was most frequently correlated. There were six correlates to pain at 1 year, of which four were opioid subtotals, the earliest being 24 hours (rs 1⁄40.409, P 1⁄4 .005). Linear regression was significant for increases in pain score by 0.007 (P 1⁄4 .01) and mobility score decreases by 0.04 (P 1⁄4 .043) for every 1 mg of morphine equivalents (ME) within 24 hours. For example, a decrease of 143 mgME in 24 hours could result in a decreased pain scoreby 1 point and increasedmobility score by5.72 points at 1 year. Conclusions: There is a positive correlation between acute SCI opioid dosage and chronic pain, and an inverse relationship with mobility at 1 year, supporting the animal evidence of Hook et al. Future prospective studies should be performed to examine the relationship of acute pain medications and long-term outcomes. Level of Evidence: Level IV