Jesus Benito

Cerebral hemorrhage due to autonomic dysreflexia in a spinal cord injury patient

Study design:Case report.Objective:To report an uncommon case of cerebral hemorrhage due to autonomic dysreflexia (AD) in a spinal cord injury (SCI) patient.Setting:Institut Guttmann, Neurorehabilitation Hospital in Barcelona, Spain.Case report:An SCI patient developed AD due to urinary tract infection after surgery for a pressure sore. The hypertension was difficult to control and the case progressed to hypertensive encephalopathy. MRI of the brain was performed showing a hemorrhagic lesion on the left occipital area. The hypertension was finally controlled and the neurological status improved although with some cognitive deficits.Conclusion:This is an uncommon case of cerebral hemorrhage due to AD, showing the importance of an adequate diagnosis and treatment of AD to avoid this life-threatening complication.

Motor and gait improvement in patients with incomplete spinal cord injury induced by high-frequency repetitive transcranial magnetic stimulation.

OBJECTIVE To assess the effect of high-frequency repetitive transcranial magnetic stimulation (rTMS) on lower extremities motor score (LEMS) and gait in patients with motor incomplete spinal cord injury (SCI). METHOD The prospective longitudinal randomized, double-blind study assessed 17 SCI patients ASIA D. We assessed LEMS, modified Ashworth Scale (MAS), 10-m walking test (10MWT), Walking Index for SCI (WISCI II) scale, step length, cadence, and Timed Up and Go (TUG) test at baseline, after the last of 15 daily sessions of rTMS and 2 weeks later. Patients were randomized to active rTMS or sham stimulation. Three patients from the initial group of 10 randomized to sham stimulation entered the active rTMS group after a 3-week washout period. Therefore a total of 10 patients completed each study condition. Both groups were homogeneous for age, gender, time since injury, etiology, and ASIA scale. Active rTMS consisted of 15 days of daily sessions of 20 trains of 40 pulses at 20 Hz and an intensity of 90% of resting motor threshold. rTMS was applied with a double cone coil to the leg motor area. RESULTS There was a significant improvement in LEMS in the active group (28.4 at baseline and 33.2 after stimulation; P = .004) but not in the sham group (29.6 at baseline, and 30.9 after stimulation; P = .6). The active group also showed significant improvements in the MAS, 10MWT, cadence, step length, and TUG, and these improvements were maintained 2 weeks later. Following sham stimulation, significant improvement was found only for step length and TUG. No significant changes were observed in the WISCI II scale in either group. CONCLUSION High-frequency rTMS over the leg motor area can improve LEMS, spasticity, and gait in patients with motor incomplete SCI.

Decrease of spasticity with muscle vibration in patients with spinal cord injury

OBJECTIVE Spasticity is common after spinal cord injury (SCI). Exaggerated tendon jerks, clonus, and spasms are key features of spasticity that result from hyperexcitability of the stretch reflex circuit. Here we studied the effects of vibration on the rectus femoris muscle (RF) on clinical and electrophysiological measures of spasticity in the leg. METHODS Nineteen SCI patients with spasticity and nine healthy subjects were studied at baseline and under stimulation (vibration at 50 Hz during 10 min on the thigh). Neurophysiological studies included evaluation of the soleus T wave and Hmax/Mmax ratio. Clinical measurements of spasticity were the score in the Modified Ashworth Scale (MAS), range of motion (ROM), and duration and frequency of clonus. RESULTS Patients with incomplete SCI (iSCI) presented higher number of cycles and longer duration of clonus than patients with complete SCI (cSCI). The Hmax/Mmax ratio and T wave amplitude at baseline were significantly larger in iSCI patients than in cSCI or healthy subjects. During vibration, we found a significant reduction of MAS and duration of clonus, and an increase in ROM, in all patients as a group. The Hmax/Mmax ratio and the T wave amplitude decreased significantly in both, patients and controls. CONCLUSIONS Prolonged vibration on proximal lower extremity muscles decreased limb spasticity in patients with spinal cord injury, regardless of whether the lesion is complete or incomplete. SIGNIFICANCE Muscle vibration may be useful for physical therapy, by facilitating passive and active movements of the extremities in spastic SCI patients.

RETRACTED: Effects of High-Frequency Repetitive Transcranial Magnetic Stimulation on Motor and Gait Improvement in Incomplete Spinal Cord Injury Patients:

Kumru H, Benito J, Murillo N, et al. Effects of high-frequency repetitive transcranial magnetic stimulation on motor and gait improvement in incomplete spinal cord injury patients. Neurorehabil & Neural Repair. 2013;27:421-429. Original DOI: 10.1177/1545968312471901. The above article has been retracted because of substantial overlap with a previously published article in another journal.

Exaggerated auditory startle responses in patients with spinal cord injury

ObjectiveCentral nervous system reorganization following spinal cord injury (SCI) may cause functional changes in the motor tracts in patients in whom increased auditory startle responses (ASRs) have been previously reported. We hypothesized that if increased ASRs in patients with incomplete SCI were due to compensatory mechanisms, these changes would be related to severity and/or localization of the lesion.MethodsWe examined ASR characteristics in 29 SCI patients and 14 age-matched healthy volunteers. Fourteen patients had incomplete and 15 complete SCI; 10 patients had cervical and 19 thoracolumbar SCI. Five auditory stimuli were applied binaurally to subjects in a sitting position, with a 5-min interstimulus interval. Surface electromyographic recordings were obtained from orbicularis oculi (OOc), sternocleidomastoid (SCM), biceps brachii (BB), and tibialis anterior (TA) muscles.ResultsASR probability was significantly higher and area-under-the-curve was significantly larger in SCM and BB in patients than in controls. ASR latency was significantly shorter in SCM and BB in patients with cervical than in those with thoracolumbar SCI (p < 0.02), but there were no statistically significant differences between complete and incomplete SCI (p > 0.1). Time span since onset correlated significantly with ASR area in OOc, SCM and BB (p < 0.05).ConclusionThe capability of the adult central nervous system to reorganize its circuits over time for improved functionality following injury is probably the key to understanding the increased ASRs in patients with SCI. The exaggeration of the startle reflex is potentially important since it may be useful for augmenting voluntary movement in the clinical rehabilitation of patients with SCI.

Gait training after spinal cord injury: safety, feasibility and gait function following 8 weeks of training with the exoskeletons from Ekso Bionics

Study designProspective quasi-experimental study, pre- and post-design.ObjectivesAssess safety, feasibility, training characteristics and changes in gait function for persons with spinal cord injury (SCI) using the robotic exoskeletons from Ekso Bionics.SettingNine European rehabilitation centres.MethodsRobotic exoskeleton gait training, three times weekly over 8 weeks. Time upright, time walking and steps in the device (training characteristics) were recorded longitudinally. Gait and neurological function were measured by 10 Metre Walk Test (10 MWT), Timed Up and Go (TUG), Berg Balance Scale (BBS), Walking Index for Spinal Cord Injury (WISCI) II and Lower Extremity Motor Score (LEMS).ResultsFifty-two participants completed the training protocol. Median age: 35.8 years (IQR 27.5–52.5), men/women: N = 36/16, neurological level of injury: C1-L2 and severity: AIS A–D (American Spinal Injury Association Impairment Scale). Time since injury (TSI) < 1 year, N = 25; > 1 year, N = 27.No serious adverse events occurred. Three participants dropped out following ankle swelling (overuse injury). Four participants sustained a Category II pressure ulcer at contact points with the device but completed the study and skin normalized. Training characteristics increased significantly for all subgroups. The number of participants with TSI < 1 year and gait function increased from 20 to 56% (P = 0.004) and 10MWT, TUG, BBS and LEMS results improved (P < 0.05). The number of participants with TSI > 1 year and gait function, increased from 41 to 44% and TUG and BBS results improved (P < 0.05).ConclusionsExoskeleton training was generally safe and feasible in a heterogeneous sample of persons with SCI. Results indicate potential benefits on gait function and balance.

Restless leg syndrome in patients with spinal cord injury

BACKGROUND The presence of restless leg syndrome (RLS) in patients with spinal cord injury (SCI) is not well established. We studied the frequency and severity of RLS in a population of patients with SCI and the effect of treatment with dopaminergic drugs when clinically indicated. METHODS Consecutive patients with SCI admitted to an out-patient clinic of a neurorehabilitation hospital (n:195) were evaluated for the presence of RLS between February 2013 and May 2014. A diagnosis of RLS was made according to the criteria of the International RLS Study Group, and severity was assessed by the RLS rating scale. Information on gender, age, time since SCI, level and severity of SCI, was obtained. RESULT The mean age was 54.7 ± 15.6 years (range: 22-81 year); with time since SCI: 16.9 ± 11.4 years (range: 1-50 years). Thirty-five of 195 patients (17.9%) presented RLS. Twenty-two out of 154 (14.3%) patients with cervicothoracic SCI and 13 out of 41 (31.7%) patients with lumbosacral SCI presented RLS. Restless leg symptoms were mild in 2 patients, moderate in 10 patients, severe in 12 patients and very severe in 11. Ten patients received dopaminergic agonist treatment with a significant reduction in RLS severity scale from 29.1 ± 5.9 to 10.2 ± 7.9. DISCUSSION RLS occurs frequently in SCI patients and responds to dopaminergic treatment. Physicians have to be aware of this diagnosis to avoid unnecessary suffering in this patient population.

Pronóstico de la polineuropatía secundaria a porfiria aguda intermitente

La porfiria aguda intermitente (PAI) es una enfermedad hereditaria autosómica dominante causada por el defecto primario de la enzima porfobilinógeno desaminasa, implicada en la sı́ntesis del hem. Sus manifestaciones clı́nicas incluyen dolor abdominal, sı́ntomas autonómicos (taquicardia, hipertensión arterial, estreñimiento, vómitos, arritmia cardiaca), sı́ntomas de afectación del sistema nervioso central (insomnio, ansiedad, depresión, alucinaciones, convulsiones), cambios metabólicos (hiponatremia) y polineuropatı́a rápidamente progresiva, que puede evolucionar a insuficiencia respiratoria y parálisis bulbar. Debido a que es poco frecuente y con sı́ntomas poco especı́ficos, el diagnóstico suele ser tardı́o, lo que puede conllevar la presencia de polineuropatı́as muy graves. El pronóstico de estas polineuropatı́as no ha sido bien documentado y conocerlo tiene una importante implicación en el manejo de estos pacientes. Presentamos tres pacientes afectados de polineuropatı́a axonal motora por PAI, atendidos en nuestro centro para recibir tratamiento rehabilitador. Todos ellos, al ingreso, presentaban una grave tetraparesia con dependencia total y sin capacidad de marcha ni de autopropulsar una silla de ruedas. Caso n.8 1: Varón de 46 años, con antecedente de sı́ndrome de Guillain-Barré variante AMSAN tres años antes, del que se recuperó con secuelas (debilidad distal de las extremidades inferiores e insuficiencia respiratoria). A raı́z del tratamiento quirúrgico de una fractura de Colles, presentó cuadro de infección respiratoria y tetraparesia progresiva con hiponatremia, precisando ingreso en unidad de cuidados intensivos (UCI) y conexión a ventilación mecánica. Se diagnosticó PAI, iniciándose tratamiento con hemina. Durante la estancia en UCI presentó múltiples y graves complicaciones (infecciosas, hemorragia digestiva alta, alteraciones electrolı́ticas). A los 7 meses ingresó en nuestro centro. A pesar del tratamiento con hemina, los sı́ntomas de porfiria se agravaron requiriendo reingreso en la UCI por anemia y alteraciones electrolı́ticas graves, ası́ como hemorragia pulmonar. Posteriormente siguió controles en consultas externas y a los 14 meses del ingreso presentaba un balance muscular y nivel funcional similares a su estado inicial. Caso n.8 2: Mujer de 28 años con historia de episodios de dolor abdominal de dos años de evolución, que ingresó en ginecologı́a por sospecha de enfermedad inflamatoria pélvica. Durante el

Reappearance of sympathetic skin response below a thoracic level-9 complete spinal cord injury

Reappearance of sympathetic skin response (SSR) below lesion is reported in a patient with a complete thoracic-9 spinal cord injury 6 months following injury. SSR was elicited by electrical stimulation of supraorbital nerve (SON) and pudendal nerve (PN). SON stimulation induced SSRs only in the hand. SSRs were initially absent below the level of SCI but reappeared only with PN stimulation. This case suggests that 6 months following a complete lesion, the isolated spinal cord can generate a SSR. Possible underlying mechanisms and implications for autonomic plasticity below spinal lesion are discussed in view of the literature.