Graham H. Creasey

International standards for neurological and functional classification of spinal cord injury

International Standards for Neurological and Functional Classification of Spinal Cord Injury

The International Standards Booklet for Neurological and Functional Classification of Spinal Cord Injury

The International Standards Booklet for Neurological and Functional Classification of Spinal Cord Injury

International standards to document remaining autonomic function after spinal cord injury.

Study design:Experts opinions consensus.Objective:To develop a common strategy to document remaining autonomic neurologic function following spinal cord injury (SCI).Background and Rationale:The impact of a specific SCI on a persons neurologic function is generally described through use of the International Standards for the Neurological Classification of SCI. These standards document the remaining motor and sensory function that a person may have; however, they do not provide information about the status of a persons autonomic function.Methods:Based on this deficiency, the American Spinal Injury Association (ASIA) and the International Spinal Cord Society (ISCoS) commissioned a group of international experts to develop a common strategy to document the remaining autonomic neurologic function.Results:Four subgroups were commissioned: bladder, bowel, sexual function and general autonomic function. On-line communication was followed by numerous face to face meetings. The information was then presented in a summary format at a course on Measurement in Spinal Cord Injury, held on June 24, 2006. Subsequent to this it was revised online by the committee members, posted on the websites of both ASIA and ISCoS for comment and re-revised through webcasts. Topics include an overview of autonomic anatomy, classification of cardiovascular, respiratory, sudomotor and thermoregulatory function, bladder, bowel and sexual function.Conclusion:This document describes a new system to document the impact of SCI on autonomic function. Based upon current knowledge of the neuroanatomy of autonomic function this paper provides a framework with which to communicate the effects of specific spinal cord injuries on cardiovascular, broncho-pulmonary, sudomotor, bladder, bowel and sexual function.

Outcome measures in spinal cord injury: Recent assessments and recommendations for future directions

Study design:Review by the spinal cord outcomes partnership endeavor (SCOPE), which is a broad-based international consortium of scientists and clinical researchers representing academic institutions, industry, government agencies, not-for-profit organizations and foundations.Objectives:Assessment of current and evolving tools for evaluating human spinal cord injury (SCI) outcomes for both clinical diagnosis and clinical research studies.Methods:a framework for the appraisal of evidence of metric properties was used to examine outcome tools or tests for accuracy, sensitivity, reliability and validity for human SCI.Results:Imaging, neurological, functional, autonomic, sexual health, bladder/bowel, pain and psychosocial tools were evaluated. Several specific tools for human SCI studies have or are being developed to allow the more accurate determination for a clinically meaningful benefit (improvement in functional outcome or quality of life) being achieved as a result of a therapeutic intervention.Conclusion:Significant progress has been made, but further validation studies are required to identify the most appropriate tools for specific targets in a human SCI study or clinical trial.

Electrical stimulation for the treatment of bladder dysfunction: current status and future possibilities

Abstract Electrical stimulation of peripheral nerves can be used to cause muscle contraction, to activate reflexes, and to modulate some functions of the central nervous system (neuromodulation). If applied to the spinal cord or nerves controlling the lower urinary tract, electrical stimulation can produce bladder or sphincter contraction, produce micturition, and can be applied as a medical treatment in cases of incontinence and urinary retention. This article first reviews the history of electrical stimulation applied for treatment of bladder dysfunction and then focuses on the implantable Finetech-Brindley stimulator to produce bladder emptying, and on external and implantable neuromodulation systems for treatment of incontinence. We conclude by summarizing some recent research efforts including: (a) combined sacral posterior and anterior sacral root stimulator implant (SPARSI), (b) selective stimulation of nerve fibers for selective detrusor activation by sacral ventral root stimulation, (c) microstimulation of the spinal cord, and (d) a newly proposed closed-loop bladder neuroprosthesis to treat incontinence caused by bladder overactivity. [Neurol Res 2002; 24: 413-430]

Tendon transfers and functional electrical stimulation for restoration of hand function in spinal cord injury

Spinal cord injury at the C5 and C6 level results in loss of hand function. Electrical stimulation of paralyzed muscles is one approach that has demonstrated significant capacity for restoring grasp and release function. One potential limitation of this approach is that key muscles for stimulation may have lower motor neuron damage, rendering the muscles unexcitable. We have used surgical modification of the biomechanics of the hand to overcome this limitation. Tendon transfer of paralyzed but lower motor neuron intact muscles can compensate for potential function lost owing to muscles with lower motor neuron damage. Such procedures have been performed to provide finger extension, thumb extension, finger flexion, and wrist extension. Additional surgical procedures have been performed to enhance the function provided with electrical stimulation. These are side-to-side synchronization of the finger flexor and extensor tendons, the flexor digitorium superficialis Zancolli-lasso procedure, and thumb interphalangeal joint arthrodesis. These procedures have been performed in 11 patients with C5 and C6 level spinal injuries and functional electrical stimulation neuroprostheses. In these patients, 41 different functional electrical stimulation-related procedures were performed and 38 gave the desired result after surgery. One procedure resulted in no increase or decrease in function or muscle output, and two procedures resulted in a decrease in muscle force or joint range of motion. The issues that must be considered in performing functional electrical stimulation-related tendon transfers are discussed.

Clinical Applications of Electrical Stimulation After Spinal Cord Injury

Abstract Summary: During the last one-half century, electrical stimulation has become dinically significant for improving health and restoring useful function afterspinal cord injury. Short-term stimulation can be provided by electrodes on the skin or percutaneous fine wires, but implanted systems are preferable for long-term use. Electrical stimulation of intact lower motor neurons can exercise paralyzed musdes and reverse wasting; improve strength, endurance, and cardiovascular fitness; and may reduce the progression of osteoporosis. Other potential therapeutic uses being investigated indude reduction of spasticity, prevention of deep vein thrombosis, and improvement of tissue health. Pacing of intact phrenic nerves in high tetraplegia can produce effective respiration without mechanical ventilation, allowing improved speech, increased mobility, and increased sense of well-being. lmprovement of cough has also been demonstrated. Stimulation of intact sacral ne.rves can produce effective micturition and reduce urinary tract infection; it can also improve bowel function and erection. lt is usually combined with posterior sacral rhizotomy to improve continence and bladder capacity, and the combination has been shown to reduce costs of care. Electroejaculation can now produce semen in most men with spinal cord injury. Significant achievements have also been made in restoring limb function . Useful hand grasp can be provided in CS and C6 tetraplegia, reducing dependence on adapted equipment and assistants. Standing, assistance with transfers, and walking for short distances can be provided to selected persons with paraplegia, improving their access to objects, places, and opportunities that are inaccessible from a wheelchair. This review summarizes the current state of therapeutic and neuroprosthetic applications of electrical stimulation afterspinal cord injury and identifies some future directions of research and dinical and commercial development.

A urethral afferent mediated excitatory bladder reflex exists in humans.

An excitatory reflex between urethral flow receptors and the bladder has been established in animals, but attempts to demonstrate this reflex in humans using urethral fluid flow have been inconclusive. Intraurethral electrical stimulation has recently been shown to generate bladder contractions in animals and was applied to study the presence of an excitatory urethra to bladder reflex in humans. The prostatic urethra was stimulated electrically via a catheter-based electrode in five men with complete spinal cord injury. Bladder contractions were generated in four of five individuals, however, only when the bladder volume was sufficiently large. These results demonstrate the presence of a volume dependent excitatory bladder reflex mediated by urethral afferent nerve fibers and the lumbosacral spinal cord.

Constipation associated with chronic spinal cord injury: the effect of pelvic parasympathetic stimulation by the Brindley stimulator

Ten subjects with severe constipation due to complete spinal cord injury (SCI) had prolonged oro-anal transit time (p<0.01), diminished faecal water content (p<0.05) and a reduced frequency of defaecation (p<0.01) compared to 10 non-SCI subjects. Paraplegics with an implanted Brindley S234 anterior sacral nerve root stimulator had a significant increase in frequency of defaecation (p<0.01), compared to the SCI group while the faecal water content was less although not significantly so. The Brindley stimulator group also showed a more rapid colonic transit than the SCI group but this did not reach statistical significance. SCI is associated with constipation which therefore appears to be favourably influenced by the Brindley S234 anterior nerve root stimulator. The effects produced are compatible with stimulation of left colonic motility, which facilitates the emptying of the distal colon, but also suggest that part of the response restricts transit in some areas of the colon or rectum. Since the motility changes induced by the Brindley stimulator do not affect the right colon a relatively greater residence time of the faecal bolus in this part of the large bowel would enhance water absorption.

Decreased Colonic Motility in Persons With Chronic Spinal Cord Injury

OBJECTIVES:In persons with spinal cord injury (SCI), several studies have shown that large bowel transit is decreased at the level of the left colon and rectum, and that postprandial colonic response to food is absent. To define these parameters further, the effects of food on colonic motility in persons with SCI were studied and compared to those of spinally intact (SI) individuals.METHODS:The study was conducted in eight subjects with SCI (four paraplegic and four quadriplegic) and six age-matched SI subjects. After routine bowel preparation, colonoscopy was performed with the proximal end of a solid state pressure transducer catheter (four sensors each separated by 10 cm) tethered to the splenic flexure using endoclips (Olympus). The subjects were then allowed to carry out their usual daily activities. Two phases were compared: 1 h before breakfast, designated as the “resting phase,” and 1 h during breakfast, designated as the “food-ingestion phase.”RESULTS:Baseline colonic activity of the SCI group was significantly less than in SI subjects. During meals, the motility index, mean amplitude of the waves, percent activity, and number of waves was significantly less in the SCI group. In both the SI and SCI groups, a postprandial colonic response was observed. However, in the SCI group, the response was seen only in the descending colon and not in the rectosigmoid region.CONCLUSIONS:SCI decreases colonic motility, and this alteration may relate to difficulty with evacuation. The postprandial colonic response in SCI is present but is suboptimal and confined to the descending colon.