Brain-machine interfaces (BMIs) provide a new assistive strategy aimed at restoring mobility in severely paralyzed patients. Yet, no study in animals or in human subjects has indicated that long-term BMI training could induce any type of clinical recovery. Eight chronic (3-13 years) spinal cord injury (SCI) paraplegics were subjected to long-term training (12 months) with a multi-stage BMI-based gait neurorehabilitation paradigm aimed at restoring locomotion. This paradigm combined intense immersive virtual reality training, enriched visual-tactile feedback, and walking with two EEG-controlled robotic actuators, including a custom-designed lower limb exoskeleton capable of delivering tactile feedback to subjects. Following 12 months of training with this paradigm, all eight patients experienced neurological improvements in somatic sensation (pain localization, fine/crude touch, and proprioceptive sensing) in multiple dermatomes. Patients also regained voluntary motor control in key muscles below the SCI level, as measured by EMGs, resulting in marked improvement in their walking index. As a result, 50% of these patients were upgraded to an incomplete paraplegia classification. Neurological recovery was paralleled by the reemergence of lower limb motor imagery at cortical level. We hypothesize that this unprecedented neurological recovery results from both cortical and spinal cord plasticity triggered by long-term BMI usage.
Spinal cord injuries disrupt bidirectional communication between the patient’s brain and body. Here, we demonstrate a new approach for reproducing lower limb somatosensory feedback in paraplegics by remapping missing leg/foot tactile sensations onto the skin of patients' forearms. A portable haptic display was tested in eight patients in a setup where the lower limbs were simulated using immersive virtual reality (VR). For six out of eight patients, the haptic display induced the realistic illusion of walking on three different types of floor surfaces: beach sand, a paved street or grass. Additionally, patients experienced the movements of the virtual legs during the swing phase or the sensation of the foot rolling on the floor while walking. Relying solely on this tactile feedback, patients reported the position of the avatar leg during virtual walking. Crossmodal interference between vision of the virtual legs and tactile feedback revealed that patients assimilated the virtual lower limbs as if they were their own legs. We propose that the addition of tactile feedback to neuroprosthetic devices is essential to restore a full lower limb perceptual experience in spinal cord injury (SCI) patients, and will ultimately, lead to a higher rate of prosthetic acceptance/use and a better level of motor proficiency.
Cell transplantation in patients suffering spinal cord injury (SCI) is in its initial stages, but currently there is confusion about the results because of the disparity in the techniques used, the route of administration, and the criteria for selecting patients.
Excessive reliance on wheelchairs in individuals with tetraplegia or paraplegia due to spinal cord injury (SCI) leads to many medical co-morbidities, such as cardiovascular disease, metabolic derangements, osteoporosis, and pressure ulcers. Treatment of these conditions contributes to the majority of SCI health care costs. Restoring able-body-like ambulation in this patient population can potentially reduce the incidence of these medical co-morbidities, in addition to increasing independence and quality of life. However, no biomedical solution exists that can reverse this loss of neurological function, and hence novel methods are needed. Brain-computer interface (BCI) controlled lower extremity prostheses may constitute one such novel approach.
Interruption of spinal cord (SC) continuity leads to functional loss below the lesion level. The purpose of this study was to evaluate the safety and efficacy of bone marrow nucleated cells (BMNCs) and multiple mesenchymal stem cells (MSCs) transplantations in spinal cord injury (SCI). A patient with total SC interruption at the Th2-3 level underwent experimental therapy with BMNCs and MSCs transplantations followed with intensive neurorehabilitation treatment. At admission, 6 hours after SCI, the patient was scored ASIA A, had a Th1 sensation level, paraplegia with sphincter palsy and was without the ability to control trunk movement. Neurophysiology examination showed bilateral axonal damage to the motor and sensory neural fibers with no motor unit potentials or peripheral motor nerve conduction in the lower extremities. The standard therapy had been applied and had not produce any positive results. The patient was treated with autologous BMNCs injected intravenously (3.2x10(9)) and intrathecally (0.5x10(9)) 10 weeks after the SCI and with five rounds of MSCs every 3-4 months (1.3-3.65x10(7)) administered via lumbar puncture. Total number of transplanted MSC cells during the course of treatment was 1.54x10(8). There were no complications related to transplantations, and no side effects related to the therapy during 2 years treatment. The ASIA score improved from A to C/D (from 112 to 231 points). The sensation level expanded from Th1 to L3-4, and the patients' ability to control the body trunk was fully restored. Bladder filling sensation, bladder control and anal sensation were also restored. Muscle strength in the left lower extremities improved from plegia to deep paresis (1 on the Lovett scale). The patient’s ability to move lower extremities against gravity supported by the movements in quadriceps was restored. The patient gained the ability to stand in a standing frame and was able to walk with the support of hip and knee ortheses. Magnetic resonance imaging (MRI) revealed that at the Th2/Th3 level, where the hemorrhagic necrosis was initially observed, small tissue structures appeared. Our results suggest that repeated intrathecal infusions of mesechymal stem cells might have the potential to produce clinically meaningful improvements for SCI patients.
Assistive and rehabilitative powered exoskeletons for spinal cord injury (SCI) and stroke subjects have recently reached the clinic. Proper tension and joint alignment are critical to ensuring safety. Challenges still exist in adjustment and fitting, with most current systems depending on personnel experience for appropriate individual fastening. Paraplegia and tetraplegia patients using these devices have impaired sensation and cannot signal if straps are uncomfortable or painful. Excessive pressure and blood-flow restriction can lead to skin ulcers, necrotic tissue and infections. Tension must be just enough to prevent slipping and maintain posture. Research in pressure dynamics is extensive for wheelchairs and mattresses, but little research has been done on exoskeleton straps. We present a system to monitor pressure exerted by physical human-machine interfaces and provide data about levels of skin/body pressure in fastening straps. The system consists of sensing arrays, signal processing hardware with wireless transmission, and an interactive GUI. For validation, a lower-body powered exoskeleton carrying the full weight of users was used. Experimental trials were conducted with one SCI and one able-bodied subject. The system can help prevent skin injuries related to excessive pressure in mobility-impaired patients using powered exoskeletons, supporting functionality, independence and better overall quality of life.
Background/Aims: To describe the epidemiology of spinal cord injury (SCI) in the developing world. Methods: Developing countries were selected based on the definition proposed by the International Monetary Fund. A literature search was performed in July 2012 in Medline and Embase. Further article procurement was obtained via the reference lists of the identified articles, websites, and direct contact with the authors of the identified studies. We designed search strategies using the key words: SCI, epidemiology, incidence, and prevalence. According to the inclusion criteria, 64 studies from 28 countries were included. Results: The incidence of SCI in developing countries is 25.5/million/year (95% CI: 21.7-29.4/million/year) and ranges from 2.1 to 130.7/million/year. Males comprised 82.8% (95% CI: 80.3-85.2) of all SCIs with a mean age of 32.4 years (95% CI: 29.7-35.2). The two leading causes of SCI were found to be motor vehicle crashes (41.4%; 95% CI: 35.4-47.4) and falls (34.9%; 95% CI: 26.7-43.1). Complete SCIs were found to be more common than incomplete injuries (complete SCI: 56.5%; 95% CI: 47.6-65.3; incomplete SCI: 43.0%; 95% CI: 34.1-52.0). Similarly, paraplegia was found to be more common than tetraplegia (paraplegia: 58.7%; 95% CI: 51.5-66.0; tetraplegia: 40.6%; 95% CI: 33.3-48.0). Conclusion: Through an understanding of the epidemiology of SCI in developing countries, appropriate preventative strategies and resource allocation may decrease the incidence and improve the care of these injuries.
OBJECTIVE:Numerous studies in animals have shown the unique property of olfactory ensheathing cells tostimulate regeneration of lesioned axons in the spinal cord. In a Phase I clinical trial, weassessed the safety and feasibility of transplantation of autologous mucosal olfactoryensheathing cells and olfactory nerve fibroblasts in patients with complete spinal cord injury.METHODS:Six patients with chronic thoracic paraplegia (American Spinal Injury Association class AASIA A) were enrolled for the study. Three patients were operated and three served as acontrol group. The trial protocol consisted of pre- and postoperative neuro-rehabilitation,olfactory mucosal biopsy, culture of olfactory ensheathing cells, and intraspinal cell grafting.Patient’s clinical state was evaluated by clinical, neurophysiological and radiological tests.RESULTS:There were no adverse findings related to olfactory mucosa biopsy or transplantation of olfactory ensheathing cells at one year after surgery. There was no evidence of neurologicaldeterioration, neuropathic pain, neuroinfection or tumorigenesis. In one cell-grafted patient an asymptomatic syringomyelia was observed. Neurological improvement was observed only intransplant recipients. The first 2 operated patients improved from ASIA A to ASIA C andASIA B. Diffusion tensor imaging showed restitution of continuity of some white mattertracts throughout the focus of spinal cord injury in these patients. The third operated patientalthough remained ASIA A, showed improved motor and sensory function of the first spinalcords segments below the level of injury. Neurophysiological examinations showedimprovement in spinal cord transmission and activity of lower extremity muscles in surgicallytreated patients but not in patients receiving only neuro-rehabilitation.CONCLUSIONS:Observations at 1 year indicate that the obtaining, culture and intraspinal transplantation ofautologous olfactory ensheathing cells was safe and feasible. The significance of theneurological improvement in the transplant recipients and the extent to which the celltransplants contributed to it will require larger numbers of patients.
Objectives:The study was conducted with the aim of assessing the effects of paraplegia caused by spinal cord injuries on the quality of life of patients and their family economy.Study design:A descriptive cross-sectional study.Setting:The study was carried out in Accident Service, Orthopedic and Neurosurgery Units of the National Hospital of Sri Lanka and the Spinal Injury Unit of Rehabilitation Hospital Ragama.Methods:One hundred traumatic paraplegic patients were included as the study sample. Modified Ferrans and Powers quality of life index: spinal cord injury version was used to measure the quality of life. Pre- and post-family economic data were collected using an interviewer-administered questionnaire.Results:Quality of Life was calculated under four major components. Paraplegics' family component (mean=3.50) and social, economic aspects (mean=3.24) are considerably good when compared with health and functioning (mean=2.83) and psychological (mean=2.78) components. Also the study revealed that expenditures are significantly high (P=0.001) and income is significantly less (P=0.001) after injury than before.Conclusion:Quality of life is relatively good on family and social aspects, whereas the physical and psychological aspects are somewhat poor. Regarding family economy, expenses are significantly high and earnings are significantly less after the injury. Contribution to the income from self-employment shows the most significant decline. Findings suggest that the family economy of such patients should be supported.Spinal Cord advance online publication, 4 November 2014; doi:10.1038/sc.2014.183.
Cooling strategies that help prevent a reduction in exercise capacity whilst exercising in the heat have received considerable research interest over the past 3 decades, especially in the lead up to a relatively hot Olympic and Paralympic Games. Progressing into the next Olympic/Paralympic cycle, the host, Rio de Janeiro, could again present an environmental challenge for competing athletes. Despite the interest and vast array of research into cooling strategies for the able-bodied athlete, less is known regarding the application of these cooling strategies in the thermoregulatory impaired spinal cord injured (SCI) athletic population. Individuals with a spinal cord injury (SCI) have a reduced afferent input to the thermoregulatory centre and a loss of both sweating capacity and vasomotor control below the level of the spinal cord lesion. The magnitude of this thermoregulatory impairment is proportional to the level of the lesion. For instance, individuals with high-level lesions (tetraplegia) are at a greater risk of heat illness than individuals with lower-level lesions (paraplegia) at a given exercise intensity. Therefore, cooling strategies may be highly beneficial in this population group, even in moderate ambient conditions (~21 °C). This review was undertaken to examine the scientific literature that addresses the application of cooling strategies in individuals with an SCI. Each method is discussed in regards to the practical issues associated with the method and the potential underlying mechanism. For instance, site-specific cooling would be more suitable for an athlete with an SCI than whole body water immersion, due to the practical difficulties of administering this method in this population group. From the studies reviewed, wearing an ice vest during intermittent sprint exercise has been shown to decrease thermal strain and improve performance. These garments have also been shown to be effective during exercise in the able-bodied. Drawing on additional findings from the able-bodied literature, the combination of methods used prior to and during exercise and/or during rest periods/half-time may increase the effectiveness of a strategy. However, due to the paucity of research involving athletes with an SCI, it is difficult to establish an optimal cooling strategy. Future studies are needed to ensure that research outcomes can be translated into meaningful performance enhancements by investigating cooling strategies under the constraints of actual competition. Cooling strategies that meet the demands of intermittent wheelchair sports need to be identified, with particular attention to the logistics of the sport.