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Objectives: To determine whether spinal cord injury (SCI) is associated with adverse changes in coagulation and fibrinolytic factors that underlie thrombogenesis and contribute to atherothrombotic events such as myocardial infarctions (MIs) and strokes., Design: Cross-sectional study., Setting: Neurorehabilitation hospital and general community., Participants: Thirty young and middle-aged (20-58 years) adults (N=30) were studied: 14 non-injured community dwelling adults. (11M/4F) and 16 with subacute tetraplegic motor complete SCI during initial inpatient rehabilitation (13M/3F; time since injury: 11.8±5.3 wk)., Interventions: Not applicable., Main Outcome Measures: Circulating markers of coagulation [von Willebrand factor (vWf) and factors VII, VIII, and X], the fibrinolytic system [tissue-type plasminogen activator (t-PA), and plasminogen activator inhibitor-1 (PAI-1) antigen and activity], and fibrin formation (D-dimer) were determined by enzyme immunoassay., Results: Thirty young and middle-aged (20-58 years) adults were studied: 14 non-injured (11M/4F) and 16 with subacute tetraplegic motor complete SCI (13M/3F; time since injury: range 4-25 wk). Circulating levels of coagulation factors VII, VIII, and X were significantly higher (∼20%-45%; P<.05) in the adults with SCI than non-injured adults, whereas vWf was similar between groups. Fibrinolytic markers were adversely disrupted with SCI with t-PA antigen, PAI-1 antigen and PAI-1 activity were markedly higher (∼50%-800%; P<.05) in adults with SCI compared with non-injured adults. The molar concentration ratio of active t-PA to PAI-1 was significantly higher (∼350%) in adults with SCI. Concordant with coagulation cascade activation and fibrinolytic system inhibition, D-dimer concentrations were markedly ∼70% higher (P<.05) in adults with SCI compared with non-injured adults., Conclusions: Subacute tetraplegic motor complete SCI is associated with a prothrombotic hemostatic profile. Adverse changes in the coagulation cascade and fibrinolytic system appear to occur early after injury and may contribute to the increased atherothrombotic risk in adults living with SCI., (Copyright © 2023 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate changes in duration of physical activity (PA) and sedentary behavior (SB) from discharge to 1 year after inpatient rehabilitation in ambulatory people with spinal cord injury (SCI)., Design: Longitudinal cohort study with objective measurements of physical behavior at discharge and at 6 and 12 months post discharge., Setting: Three rehabilitation centers and the participant's home environment., Participants: Participants (N=47) with ambulatory function were consecutively recruited from the self-management and self-efficacy in patients with SCI cohort (age 18 years or older, recent SCI, expected inpatient stay ≥4wk). Mean age was 54.5±12.9 years, all had incomplete lesions, 53% were men, 49% had tetraplegia, and 51% were community ambulators at discharge., Interventions: Not applicable., Main Outcome Measures: Duration (min) of PA (summed duration of walking, cycling, running, and wheeling) and SB (sitting/lying)., Results: Mean duration of PA increased by 21 min/d (95% confidence interval, 7-35) and SB decreased by 64 min/d (95% confidence interval, -94 to -35) from discharge to 6 months after inpatient rehabilitation. No changes were found in the second half-year. One year after discharge mean PA was 116±59 min/d and mean SB was 665±121 min/d. The increase in PA was the result of an almost doubling of time spent walking. Variability in physical behavior and its change was large. Older age and lower ambulation level were associated with lower PA, lower ambulation level with higher SB, and tetraplegia was associated with a reduced increase in PA., Conclusions: At group level, duration of PA and SB improved following inpatient rehabilitation in ambulatory people with SCI. However, there were large differences between individuals. Levels 1 year after discharge were still unfavorable, particularly regarding SB., (Copyright © 2020 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To explore the potential effects of incorporating exoskeletal-assisted walking (EAW) into spinal cord injury (SCI) acute inpatient rehabilitation (AIR) on facilitating functional and motor recovery when compared with standard of care AIR., Design: A quasi-experimental design with a prospective intervention group (AIR with EAW) and a retrospective control group (AIR only)., Setting: SCI AIR facility., Participants: Ten acute inpatient participants with SCI who were eligible for locomotor training were recruited in the intervention group. Twenty inpatients with SCI were identified as matched controls by reviewing an AIR database, Uniform Data System for Medical Rehabilitation, by an individual blinded to the study. Both groups (N=30) were matched based on etiology, paraplegia/tetraplegia, completeness of injury, age, and sex., Intervention: EAW incorporated into SCI AIR., Main Outcome Measures: FIM score, International Standards for Neurological Classification of Spinal Cord Injury Upper Extremity Motor Score and Lower Extremity Motor Scores (LEMS), and EAW session results, including adverse events, walking time, and steps., Results: Changes from admission to discharge LEMS and FIM scores were significantly greater in the intervention group (LEMS change: 14.3±10.1; FIM change: 37.8±10.8) compared with the control group (LEMS change: 4.6±6.1; FIM change: 26.5±14.3; Mann-Whitney U tests: LEMS, P<.01 and FIM, P<.05). One adverse event (minor skin abrasion) occurred during 42 walking sessions. Participants on average achieved 31.5 minutes of up time and 18.2 minutes of walk time with 456 steps in one EAW session., Conclusions: Incorporation of EAW into standard of care AIR is possible. AIR with incorporated EAW has the potential to facilitate functional and motor recovery compared with AIR without EAW., (Copyright © 2019 American Congress of Rehabilitation Medicine. All rights reserved.)

Objective: To demonstrate naturalistic motor control speed, coordinated grasp, and carryover from trained to novel objects by an individual with tetraplegia using a brain-computer interface (BCI)-controlled neuroprosthetic., Design: Phase I trial for an intracortical BCI integrated with forearm functional electrical stimulation (FES). Data reported span postimplant days 137 to 1478., Setting: Tertiary care outpatient rehabilitation center., Participant: A 27-year-old man with C5 class A (on the American Spinal Injury Association Impairment Scale) traumatic spinal cord injury INTERVENTIONS: After array implantation in his left (dominant) motor cortex, the participant trained with BCI-FES to control dynamic, coordinated forearm, wrist, and hand movements., Main Outcome Measures: Performance on standardized tests of arm motor ability (Graded Redefined Assessment of Strength, Sensibility, and Prehension [GRASSP], Action Research Arm Test [ARAT], Grasp and Release Test [GRT], Box and Block Test), grip myometry, and functional activity measures (Capabilities of Upper Extremity Test [CUE-T], Quadriplegia Index of Function-Short Form [QIF-SF], Spinal Cord Independence Measure-Self-Report [SCIM-SR]) with and without the BCI-FES., Results: With BCI-FES, scores improved from baseline on the following: Grip force (2.9 kg); ARAT cup, cylinders, ball, bar, and blocks; GRT can, fork, peg, weight, and tape; GRASSP strength and prehension (unscrewing lids, pouring from a bottle, transferring pegs); and CUE-T wrist and hand skills. QIF-SF and SCIM-SR eating, grooming, and toileting activities were expected to improve with home use of BCI-FES. Pincer grips and mobility were unaffected. BCI-FES grip skills enabled the participant to play an adapted "Battleship" game and manipulate household objects., Conclusions: Using BCI-FES, the participant performed skillful and coordinated grasps and made clinically significant gains in tests of upper limb function. Practice generalized from training objects to household items and leisure activities. Motor ability improved for palmar, lateral, and tip-to-tip grips. The expects eventual home use to confer greater independence for activities of daily living, consistent with observed neurologic level gains from C5-6 to C7-T1. This marks a critical translational step toward clinical viability for BCI neuroprosthetics., (Copyright © 2019 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Brain-computer interfaces (BCI) are implantable devices that interface directly with the nervous system. BCI for quadriplegic patients restore function by reading motor intent from the brain and use the signal to control physical, virtual, and native prosthetic effectors. Future closed-loop motor BCI will incorporate sensory feedback to provide patients with an effective and intuitive experience. Development of widely available BCI for patients with neurologic injury will depend on the successes of today's clinical BCI. BCI are an exciting next step in the frontier of neuromodulation., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: To assess the feasibility of measuring ventilatory threshold (VT) in higher-level motor-complete spinal cord injury (SCI) using 4 different analysis methods based on noninvasive gas exchange., Design: Observational., Setting: Laboratory testing., Participants: Individuals with C4-T6 motor-complete SCI (16 paraplegia, 22 tetraplegia; American Spinal Injury Association Impairment Scale A/B; 42±10 years old)., Interventions: Not applicable., Main Outcome: VT from a graded arm cycling test to volitional exhaustion using 4 methods: ventilatory equivalents, excess CO 2 , V-slope, and combined method., Results: VT could be identified in all individuals with paraplegia, but in only 68% of individuals with tetraplegia. Individuals without observable VT completed the graded exercise test with lower ventilatory rate, peak power output, and peak oxygen consumption (Vo 2 peak) (all P<.05), compared to those with a detectable VT. Bland-Altman plots indicate minimal bias between methods (range: 0.01-0.03 L/min), with 95% limits of agreement of the difference within 0.25 L/min. Absolute V.o 2 at VT with individual methods were all correlated to peak power output (r>0.74; P<.01) and Vo 2 peak (r>0.91; P<.01), with negligible differences between methods., Conclusions: The assessment of VT is a feasible alternative to peak exercise testing for aerobic fitness in individuals with higher-level, motor-complete SCI, although care should be taken when interpreting VT in individuals with tetraplegia who have lower cardiorespiratory fitness and lower peak power outputs., (Copyright © 2018 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: (1) To measure the amount of cardiovascular stress, self-reported physical activity, and accelerometry-measured physical activity by individuals with spinal cord injury (SCI) during physical therapy (PT) and occupational therapy (OT); and (2) to investigate the relations between these measures., Design: Observational study., Setting: Two inpatient SCI rehabilitation centers., Participants: Patients with SCI (N=87) were recruited from consecutive admissions to rehabilitation., Interventions: Not applicable., Main Outcome Measures: Heart rate was recorded by a Holter monitor, whereas physical activity was captured by self-report (Physical Activity Recall Assessment for People with SCI questionnaire) and real-time wrist accelerometry during a total of 334 PT and OT inpatient sessions. Differences between individuals with paraplegia and tetraplegia were assessed via Mann-Whitney U tests. Spearman correlations were used to explore the relation between measurements of physical activity and heart rate., Results: Time spent at a heart rate within a cardiovascular training zone (≥40% heart rate reserve) was low and did not exceed a median of 5 minutes. In contrast, individuals reported at least 60 minutes of higher-intensity time during therapy. There was a low but statistically significant correlation between all measures., Conclusions: The cardiovascular stress incurred by individuals with SCI during inpatient PT and OT sessions is low and not sufficient to obtain a cardiovascular training effect to optimize their neurologic, cardiovascular, or musculoskeletal health; this represents a lost opportunity to maximize rehabilitation. Self-reported minutes of higher-intensity physical activity do not reflect actual time spent at a higher intensity measured objectively via a heart rate monitor., (Copyright © 2017 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To identify the long-term clinical, individual, and social risk factors for the development of pressure ulcers (PUs) in traumatic spinal cord-injured persons with tetraplegia (TSCIt)., Design: Cohort survey with self-applied questionnaires in 1995 and 2006., Setting: Thirty-five French-speaking European physical medicine and rehabilitation centers participating in the Tetrafigap surveys., Participants: Tetraplegic adults (N=1641) were surveyed after an initial posttraumatic period of at least 2 years. Eleven years later, a follow-up was done for 1327 TSCIt, among whom 221 had died and 547 could be surveyed again., Interventions: Not applicable., Main Outcome Measures: The proportion of PUs documented at the various defined time points, relative to the medical and social situations of the TSCIt, by using univariate analyses followed by logistic regression., Results: Of the participants, 73.4% presented with a PU during at least 1 period after their injury. Four factors had an effect on the occurrence of PUs in the long-term. Protective features for this population were incomplete motor impairment (odds ratio, 0.5) and the ability to walk (odds ratio, 0.2), whereas a strong predictive factor was the development of a PU during the initial posttrauma phase (odds ratio, 2.7). Finally, a significant situational factor was the lack of a social network (odds ratio, 3.1)., Conclusions: We believe that the highlighting of a motor incomplete feature of SCI (protective against the development of a PU) and of a medical risk factor, an early PU (which served as a definitive marker of the trajectory of TSCIt), together with a social situational factor, indicates the crucial role of initial management and long-term follow-up., (Copyright © 2017 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Scientific advances are increasing the options for improved upper limb function in people with cervical level spinal cord injury (SCI). Some of these interventions rely on identifying an aspect of paralysis that is not uniformly assessed in SCI: the integrity of the lower motor neuron (LMN). SCI can damage both the upper motor neuron and LMN causing muscle paralysis. Differentiation between these causes of paralysis is not typically believed to be important during SCI rehabilitation because, regardless of the cause, the muscles are no longer under voluntary control by the patient. Emerging treatments designed to restore upper extremity function (eg, rescue microsurgical nerve transfers, motor learning-based interventions, functional electrical stimulation) all require knowledge of LMN status. The LMN is easily evaluated using surface electrical stimulation and does not add significant time to the standard clinical assessment of SCI. This noninvasive evaluation yields information that contributes to the development of a lifetime upper extremity care plan for maximizing function and quality of life. Given the relative simplicity of this assessment and the far-reaching implications for treatment and function, we propose that this assessment should be adopted as standard practice for acute cervical SCI., (Copyright © 2016 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate the longitudinal effects of wheelchair rugby (WR) training on body composition of subjects with tetraplegia., Design: Subjects were evaluated at baseline and after WR training., Setting: Faculty of physical education settings., Participants: Individuals with tetraplegia (N=13; age, 26.6±6.0y)., Interventions: Four sessions per week of WR training composed by aerobic and anaerobic activities and technical and tactical aspects of WR. The average time of intervention was 8.1±2.5 months., Main Outcome Measures: Body composition assessed by dual-energy x-ray absorptiometry., Results: After training, fat mass was significantly reduced in the whole body (15,191±4603 vs 13,212±3318 g, P=.016), trunk (7058±2639 vs 5693±1498 g, P=.012), and legs (2847±817 vs 2534±742 g, P=.003). Conversely, increased bone mineral content (183±35 vs 195±32 g, P=.01) and fat-free mass (2991±549 vs 3332±602 g, P=.016) in the arms and reduced bone mineral content in the trunk (553±82 vs 521±86 g, P=.034) were observed after training. Furthermore, no significant correlation between the duration of training and changes in body composition was detected., Conclusions: Regular WR training increased lean mass and bone mineral content in the arms and decreased total body fat mass. Conversely, WR training was associated with decreased bone mineral content in the trunk. These results suggest that regular WR training improves body composition in subjects with tetraplegia., (Copyright © 2016 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To examine postural constraints in children with moderate-to-severe cerebral palsy (CP) using a segmental approach., Design: Quasi-experimental repeated-measures study; case series., Setting: Motor control research laboratory., Participants: Children (N=15; age range, 4-16y) with moderate (Gross Motor Function Classification System [GMFCS] IV; n=8; 4 boys) or severe (GMFCS V) (n=7; 4 boys) CP., Interventions: Each child participated in 3 data collection sessions. During each session, we evaluated postural control for sitting using kinematics and clinical assessments., Main Outcome Measures: Kinematic data were used to document head alignment and stabilization with external support at 4 levels (axillae, midrib, waist, hip). Two clinical assessments, the Segmental Assessment of Trunk Control and behavioral assessment for stage of trunk control, were also used to compare results for children with CP to previous longitudinal data from typically developing (TD) infants (3-9mo of age)., Results: Children with GMFCS V had difficulty aligning and stabilizing their head along the medial-lateral and anterior-posterior axes. External support improved postural control for children with GMFCS V but not for those classified as GMFCS IV, who had opposite responses to support compared with TD infants., Conclusions: Children with GMFCS V have limited trunk control but respond to support similarly to young TD infants, suggesting delayed postural control. Response to external support for children with GMFCS IV suggests a unique strategy for trunk control not observed in typical infants. Overall a segmental approach offers new insights into development of trunk control in children with moderate-to-severe CP., (Copyright © 2015 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: Increased prevalence of heart rate and blood pressure abnormalities are evident in persons with spinal cord injury (SCI), but age, comorbid medical conditions, and prescription medication use may contribute. To determine differences in the prevalence of cardiac acceleration (heart rate ≥80 beats per minute), hypotension (blood pressure ≤110/70mmHg), orthostatic hypotension (OH) (-20/-10mmHg with upright positioning), and hypertension (HTN) (blood pressure ≥140/90mmHg) in veterans with and without SCI., Design: Observational trial., Setting: Medical center., Participants: Subjects included veterans with SCI (n=62; cervical: tetraplegia, C3-8; high thoracic, T1-5; low thoracic, T7-L2) and veterans without SCI (n=160)., Interventions: None., Main Outcome Measures: We assessed medical history, prescription medication use, and heart rate and blood pressure during a routine clinical visit. Prevalence rates of cardiac acceleration, hypotension, OH, and HTN were calculated using binary logistic regression analysis with 95% confidence intervals. The influence of SCI status, age, smoking status, cardiovascular diagnoses, and use of prescribed antihypertensive medications on the prevalence of abnormal heart rate and blood pressure recordings was determined., Results: The diagnosis of HTN was reduced in the high thoracic and tetraplegia groups compared with the non-SCI and low thoracic groups. Use of antihypertensive medications was increased in the low thoracic group compared with the other 3 groups and was increased in the non-SCI group compared with the tetraplegia group. The prevalence of cardiac acceleration was reduced, and the prevalence of systolic hypotension was increased in the tetraplegia group. The prevalence of diastolic hypotension was increased in all SCI groups compared with the non-SCI group. For all analyses, increased prevalence of abnormal heart rate and blood pressure recordings was not further explained by the covariates, with the exception of age, cardiovascular diagnoses, and antihypertensive medications in the cardiac acceleration model; however, SCI status remained significant and was the dominant predictor variable., Conclusions: Our data suggest that SCI status contributes to the prevalence of cardiac acceleration and systolic and diastolic hypotension regardless of cardiovascular medical conditions or prescription antihypertensive medication use., (Copyright © 2015 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: Establish reference values of cardiorespiratory fitness applicable to the general, untrained spinal cord injury (SCI) population., Design: Data were retroactively obtained from 12 studies (May 2004 to May 2012)., Setting: An institution-affiliated applied physiology research laboratory., Participants: A total of 153 men and 26 women (age, 18-55y) with chronic SCI (N=179) were included. Participants were not involved in training activities for 1 or more months before testing and were able to complete a progressive resistance exercise test to determine peak oxygen consumption (Vo2peak)., Interventions: Not applicable., Main Outcome Measure: Percentile ranking (poor<20%; fair; 20%-40%; average, 40%-60%; good, 60%-80%; excellent, 80%-100%) used to establish reference values., Results: Reference cardiorespiratory fitness values based on functional classification as paraplegic or tetraplegic were established (paraplegic: median, 16.0mL·kg(-1)·min(-1); range, 1.4-35.2mL·kg(-1)·min(-1); tetraplegic: median, 8.8mL·kg(-1)·min(-1); range, 1.5-21.5mL·kg(-1)·min(-1)) for untrained men and women. For the primary outcome measure (Vo2peak), persons with paraplegia had significantly higher values than did persons with tetraplegia (P<.001). Although men had higher values than did women, these differences did not reach significance (P=.256). Regression analysis revealed that motor level of injury was associated with 22.3% of the variability in Vo2peak (P<.001), and an additional 8.7% was associated with body mass index (P<.001). No other measure accounted for additional significant variability., Conclusions: Established reference fitness values will allow investigators/clinicians to stratify the relative fitness of subjects/patients from the general SCI population. Key determinants are motor level of injury and body habitus, yet most variability in aerobic capacity is not associated with standard measures of SCI status or demographic characteristics., (Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To examine racial and ethnic differences in self-care and mobility outcomes for persons with a motor complete, traumatic spinal cord injury (SCI) at discharge and 1-year follow-up., Design: Retrospective cohort study., Setting: Sixteen rehabilitation centers contributing to the Spinal Cord Injury Model Systems (SCIMS) database., Participants: Adults with traumatic, motor complete SCI (N=1766; American Spinal Injury Association Impairment Scale grade A or B) enrolled in the SCIMS between 2000 and 2011. Selected cases had complete self-reported data on race and ethnicity (non-Hispanic white, non-Hispanic black, or Hispanic) and motor FIM scores assessed at inpatient rehabilitation admission, discharge, and 1-year follow-up., Interventions: Not applicable., Main Outcome Measures: Functional outcomes were measured by FIM self-care and mobility scores on a 1 to 7 FIM scale, at discharge and 1-year follow-up., Results: Multiple regression models stratified by neurologic category and adjusted for sociodemographic and injury characteristics assessed racial and ethnic group differences in FIM self-care and mobility change scores at discharge and 1-year follow-up. At discharge, non-Hispanic black participants with tetraplegia and paraplegia had significantly poorer gains in FIM self-care and mobility scores relative to non-Hispanic white and Hispanic participants. At 1-year follow-up, similar FIM self-care and mobility change scores were found across racial and ethnic groups within each neurologic category., Conclusions: Non-Hispanic white and Hispanic participants had comparatively more improvement in self-care and mobility during inpatient rehabilitation compared with non-Hispanic black participants. At 1-year follow-up, no differences in self-care and mobility outcomes were observed across racial and ethnic groups. Additional research is needed to identify potential modifiable factors that may contribute to racially and ethnically different patterns of functional outcomes observed during inpatient rehabilitation., (Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To test whether treatment with assisted movement with enhanced sensation (AMES) using vibration to the antagonist muscle would reduce impairments and restore upper limb function in people with incomplete tetraplegia., Design: Prospective, pre-post study., Setting: Laboratory and rehabilitation hospital., Participants: We recruited 15 arms from 10 individuals (8 men; mean age, 40.5 y; mean years postspinal cord injury [SCI], 3) with chronic, incomplete tetraplegia., Intervention: Two or three 20-minute sessions per week over 9 to 13 weeks (25 sessions total) on the AMES device, which combines repeated movement with targeted vibration to the antagonist muscle., Main Outcome Measures: Strength and active motion tests on the AMES device; International Standards for the Neurological Classification of SCI (ISNCSCI) motor and sensory examinations; Modified Ashworth Scale (MAS); grasp and release test (GRT); Van Lieshout Test (VLT); and Capabilities of Upper Extremity questionnaire (CUE)., Results: The AMES strength test scores improved significantly in metacarpophalangeal flexion (P=.024) and extension (P=.007) and wrist flexion (P=.001) and extension (P<.000). The AMES active motion scores improved in the hand (P=.001) and wrist (P=.001). The MAS and ISNCSCI scores remained unchanged, whereas the GRT scores increased (P=.025). Post hoc analysis showed a trend from pre- to posttreatment (P=.068) and a significant change from pretreatment to 3-month follow-up (P=.046). There was no significant change in the VLT (P=.951) or the CUE (P=.164). Five of the 10 participants reported a return of sensation to the digits after the first, second, or third treatment session., Conclusions: People with chronic, incomplete tetraplegia may experience improvements in impairments and function after treatment on a device combining assisted movement and proprioceptive stimulation. Further investigation is warranted., (Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To assess the reliability of the Test of Wheeled Mobility (TOWM) and the Wheelie test., Design: Cohort study., Setting: Gymnasium., Participants: Manual wheelchair users (N=30, age 23-53y) with a spinal cord injury., Intervention: Participants performed the 30 skills of the TOWM and the 8 skills of the Wheelie test twice. Ability, time, and anxiety scores were assessed on field. Quality scores were assessed by video analysis., Main Outcome Measures: Test-retest reliability was evaluated for the ability, time, anxiety, and quality scores of both tests. Intrarater and interrater reliability were determined on the basis of quality scores of 20 participants. Intraclass coefficient and nonparametric statistics were applied, as well as standard error of measurement, method error (ME), coefficient variation of ME, minimal detectable change (95% confidence), and technical error of measurement., Results: Test-retest reliability: no significant differences between t1 and t2 in the ability, quality, and time scores, except for anxiety scores. Standard error of measurement, ME, coefficient variation of ME, and minimal detectable change (95% confidence) values were low for the ability and quality total score and higher for the time and anxiety total score. Intrarater and interrater reliability interclass correlation coefficients of both tests ranged between .91 and .99. Interrater relative technical error of measurement for the TOWM and the Wheelie test total quality score was 3.7% and 6.3%, respectively, and intrarater relative technical error of measurement was 4.3% and 6.1%, respectively. Interclass correlation coefficients per individual tasks ranged between .88 and 1.00, except for "level propulsion forward," which showed low interclass correlation coefficient scores (interrater: .49; intrarater: .44; test-retest: .43)., Conclusions: Based on ability and quality total scores, the TOWM and the Wheelie test are reliable when assessing the wheeled mobility of manual wheelchair users with spinal cord injury. The quality criteria of 1 task from the TOWM and 3 tasks from the Wheelie test need to be refined., (Copyright © 2013 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To identify the nature of the changes of respiratory mechanics in patients with middle cervical spinal cord injury (SCI) and their correlation with posture., Design: Clinical trial., Setting: Acute SCI unit., Participants: Patients with SCI (N=34) at C4-5 level studied within 6 months of injury., Interventions: Patients were assessed by the negative expiratory pressure test, maximal static respiratory pressure test, and standard spirometry., Main Outcome Measures: The following respiratory variables were recorded in both the semirecumbent and supine positions: (1) tidal expiratory flow limitation (TEFL); (2) airway resistances; (3) mouth occlusion pressure developed 0.1 seconds after occluded inspiration at functional residual capacity (P(0.1)); (4) maximal static inspiratory pressure (MIP) and maximal static expiratory pressure (MEP); and (5) spirometric data., Results: TEFL was detected in 32% of the patients in the supine position and in 9% in the semirecumbent position. Airway resistances and P(0.1) were much higher compared with normative values, while MIP and MEP were markedly reduced. The ratio of forced expiratory volume in 1 second to forced vital capacity was less than 70%, while the other spirometric data were reduced up to 30% of predicted values., Conclusions: Patients with middle cervical SCI can develop TEFL. The presence of TEFL, associated with increased airway resistance, could increase the work of breathing in the presence of a reduced capacity of the respiratory muscles to respond to the increased load. The semirecumbent position and the use of continuous positive airway pressure can be helpful to (1) reduce the extent of TEFL and avoid the opening/closure of the small airways; (2) decrease airway resistance; and (3) maintain the expiratory flow as high as possible, which aids in the removal of secretions., (Copyright © 2012 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To assess the test-retest reliability and discriminative validity of a 14-item manual wheelchair circuit adapted from previous research (AMWC)., Design: Two AMWC trials per subject completed within 15 days., Setting: Two clinical research and 3 rehabilitation centers., Participants: Convenience sample of individuals with spinal cord injury (N=50) from centers in the United States (n=38) and the Netherlands (n=12). Mean age ± SD was 46±13 years, and mean injury duration ± SD was 12±11 years. Fifteen had cervical injuries, and 42 were men., Interventions: An existing 8-task manual wheelchair circuit was modified to remove the need for a wheelchair treadmill and expanded to 14 tasks to attenuate floor and ceiling effects: 5 original tasks-figure-of-8, .012-m doorstep crossing, .10-m platform, 15-m sprint, and making a level transfer; 3 modified tasks-3% and 6% ramp, and 3-minute overground wheeling; and 6 new tasks-.04-m doorstep crossing, propelling over artificial grass, opening/closing a door, 3% side slope, holding a wheelie for 10 seconds, and propelling in a wheelie., Main Outcome Measures: Reliability of the primary outcomes, sum ability score (sum of all tasks; 0-14 [no.]) and sum performance time (figure-of-8 + sprint + grass; 0-360 [s]), was determined by intraclass correlation coefficients (ICCs) for the whole sample and paraplegia (PP) and tetraplegia (TP) subsets. Independent t tests compared PP and TP trial 1 sum ability score and sum performance time., Results: Sum ability and sum performance time ICCs exceeded .90 for the full sample and the PP/TP subsets. Sum ability was higher for PP than TP (PP, 12.9±1.2; TP, 9.8±2.8; P<.00), and sum performance times were lower for PP than TP (20.0±4.0s vs 32.0±1.97s, P<.00)., Conclusions: AMWC primary outcomes, sum ability score and sum performance time, are reliable and discriminate between TP and PP., (Copyright © 2011 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To explore how respiratory impairment after cervical spinal cord injury affects vocal function, and to explore muscle recruitment strategies used during vocal tasks after quadriplegia. It was hypothesized that to achieve the increased respiratory support required for singing and loud speech, people with quadriplegia use different patterns of muscle recruitment and control strategies compared with control subjects without spinal cord injury., Design: Matched, parallel-group design., Setting: Large university-affiliated public hospital., Participants: Consenting participants with motor-complete C5-7 quadriplegia (n=6) and able-bodied age-matched controls (n=6) were assessed on physiologic and voice measures during vocal tasks., Interventions: Not applicable., Main Outcome Measures: Standard respiratory function testing, surface electromyographic activity from accessory respiratory muscles, sound pressure levels during vocal tasks, the Voice Handicap Index, and the Perceptual Voice Profile., Results: The group with quadriplegia had a reduced lung capacity (vital capacity, 71% vs 102% of predicted; P=.028), more perceived voice problems (Voice Handicap Index score, 22.5 vs 6.5; P=.046), and greater recruitment of accessory respiratory muscles during both loud and soft volumes (P=.028) than the able-bodied controls. The group with quadriplegia also demonstrated higher accessory muscle activation in changing from soft to loud speech (P=.028)., Conclusions: People with quadriplegia have impaired vocal ability and use different muscle recruitment strategies during speech than the able-bodied. These findings will enable us to target specific measurements of respiratory physiology for assessing functional improvements in response to formal therapeutic singing training., (Copyright © 2011 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To determine whether nabilone, a synthetic cannabinoid, alleviates spasticity in people with spinal cord injury (SCI)., Design: A double-blind, placebo-controlled crossover study., Setting: Outpatient rehabilitation clinics., Participants: We recruited volunteers (N=12) with SCI and spasticity. One subject, a paraplegic man, dropped out of the study because of an unrelated cause. Eleven subjects completed the study; all subjects were men with an average age of 42.36 years; 6 of them were persons with tetraplegia, and 5 were persons with paraplegia., Interventions: The subjects received either nabilone or placebo during the first 4-week period (0.5mg once a day with option to increase to 0.5mg twice a day), and then outcome measures were assessed. After a 2-week washout, subjects were crossed over to the opposite arm., Main Outcome Measures: The primary outcome was the Ashworth Scale for spasticity in the most involved muscle group, in either the upper or lower extremities, chosen by the subject and clinician. The secondary outcomes included the sum of the Ashworth Scale in 8 muscle groups of each side of the body measured by the clinician; Spasm Frequency Scale and visual analog scale, reported by the subject; Wartenberg Pendulum Test, in order to quantify severity of spasticity; and the Clinician's and Subject's Global Impression of Change., Results: One subject dropped out during the placebo arm because of an unrelated urinary stricture, and 11 subjects completed the study. There was a significant decrease on active treatment for the Ashworth in the most involved muscle (mean difference +/- SD, .909+/-.85; P=.003), as well as the total Ashworth score (P=.001). There was no significant difference in other measures. Side effects were mild and tolerable., Conclusions: Nabilone may be beneficial to reduce spasticity in people with SCI. We recommend a larger trial with a more prolonged treatment period and an option to slowly increase the dosage further.

Objective: To examine menopause transition characteristics and symptom bother in women with spinal cord injury (SCI)., Design: Prospective cohort (4 data collection periods across 4 years)., Setting: Community., Participants: Women (n=62) with SCI (injury levels C6-T12, nonambulatory, >36mo postinjury; 86.1% retention) and women without SCI (n=66; 92.9% retention) with intact ovaries, not using hormone therapy, and between the ages of 45 and 60 years volunteered. A total of 505 observations were collected and analyzed., Interventions: None., Main Outcome Measures: Age at final menstrual period (FMP), transitions through menopause status classifications, and menopause symptom bother (vasomotor, somatic, psychologic symptoms)., Results: The number of women transitioning through a menopause status classification over the course of the study did not significantly vary by group (P=.263), nor did age at FMP (P=.643). Women with SCI experienced greater bother of somatic symptoms (a subscale, P<.001), bladder infections (P<.001), and diminished sexual arousal (P=.012). Women without SCI had significantly greater bother of vasomotor symptoms (P=.020). There were no significant group by menopause status interactions; main effects for menopause status were significant only for vasomotor symptoms and vaginal dryness., Conclusions: Results suggested that women with SCI experience greater symptom bother in certain areas, but that patterns of symptom bother across menopause, transition through menopause, and age at FMP are similar to those of their peers. Larger studies are needed to examine menopause outcomes with respect to level of injury and completeness of injury. These findings provide a framework that women with SCI and their health care providers can use to address the menopause transition and highlight the importance of multidisciplinary involvement to maximize health and well being during this transition., (Copyright 2010 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To compare spatio-temporal propulsion characteristics and shoulder muscle electromyographic activity in persons with cervical spinal cord injury propelling a standard pushrim wheelchair (WC) and a commercially available pushrim-activated power assisted wheelchair (PAPAW) design on a stationary ergometer., Design: Repeated measures., Setting: Motion analysis laboratory within a rehabilitation hospital., Participants: Men (N=14) with complete (American Spinal Injury Association grade A or B) tetraplegia (C6=5; C7=9)., Intervention: Participants propelled a standard pushrim WC and PAPAW during 3 propulsion conditions: self-selected free and fast and simulated 4% or 8% graded resistance propulsion., Main Outcome Measures: Median speed, cycle length, cadence, median and peak electromyographic activity intensity, and duration of electromyographic activity in pectoralis major, anterior deltoid, supraspinatus, and infraspinatus muscles were compared between standard pushrim WC and PAPAW propulsion., Results: A significant (P<.05) decrease in electromyographic activity intensity and duration of pectoralis major, anterior deltoid, and infraspinatus muscles and significantly reduced intensity and push phase duration of supraspinatus electromyographic activity at faster speeds and with increased resistance were seen during PAPAW propulsion., Conclusions: For participants with complete tetraplegia, push phase shoulder muscle activity was decreased in the PAPAW compared with standard pushrim WC, indicating a reduction in demands when propelling a PAPAW.

Objective: To study the effect of posture on the hypercapnic ventilatory responses (HCVR)., Design: Nonrandomized controlled study., Setting: Rehabilitation hospital and a pulmonary institute., Participants: Patients with neurologically stable C(5-8) tetraplegia (n=12) and healthy control subjects (n=7)., Interventions: Not applicable., Main Outcome Measures: Supine and seated forced vital capacity (FVC) and HCVR, and supine and erect blood pressure., Results: FVC in the sitting position was reduced in patients with tetraplegia (52+/-13% predicted); supine FVC was 21% higher (P=.0005). In the sitting position, HCVR was lower in patients than in controls (0.8+/-0.4 vs 2.46+/-0.3 L/min/mmHg, P<.001). Supine HCVR was not significantly different between the groups. When HCVR was normalized to FVC, there was still a significant difference between patients and controls in the sitting position. Patients with tetraplegia were orthostatic (mean supine blood pressure 91+/-13 mmHg vs mean erect blood pressure 61+/-13 mmHg, respectively, P<.0001). The magnitude of the orthostatism correlated with that of the postural change in HCVR (r=.93, P<.0001)., Conclusions: Respiratory muscle weakness may contribute to the attenuated HCVR in tetraplegia. However, the observation that supine HCVR is still low even when normalized to FVC suggests a central posture-dependent effect on the HCVR, which may be linked to the postural effect on arterial blood pressure.

Objectives: To explore and quantify the physical and functional effects of stabilizing the torso with electrical stimulation of the paralyzed hip and trunk musculature after motor complete tetraplegia., Design: Single-subject case study with repeated measures and concurrent controls., Setting: Academic outpatient rehabilitation center., Participants: Forty-four-year-old man with C4 American Spinal Injury Association grade A tetraplegia 20 years postspinal cord injury., Intervention: A surgically implanted multichannel pulse generator and intramuscular stimulating electrodes to activate lumbar erector spinae, quadratus lumborum, and gluteus maximus muscles bilaterally., Main Outcome Measures: Outcomes assessed with and without stimulation included (1) spinal alignment and pelvic orientation, (2) pulmonary function and ventilatory volumes, (3) forward bimanual reaching distance, (4) seated stability and resistance to externally applied disturbances, (5) maximal force and speed of rowing-like movements, and the ability to (6) independently return to an erect seated position from full forward or lateral flexion and (7) roll in bed without assistance., Results: Stimulation improved spinal convexity and kyphosis by 26 degrees and 21 degrees , reduced posterior pelvic tilt by 11 degrees , increased forced expiratory volume and vital capacity by 10% and 22%, and improved forward reach by more than 7cm. Average resistance to sagittal disturbances increased by more than 40% (P<.002), and mean force exerted during underhanded pulling more than doubled (P=.014) with stimulation. Restoration of upright sitting in both sagittal and coronal planes and bed turning was made possible through appropriately timed activation of the hip and trunk muscles., Conclusions: A neuroprosthesis for controlling the paralyzed torso can positively impact spinal alignment, seated posture, pulmonary function, trunk stability, and reach. Stimulation of hip and trunk muscles can improve performance of activities of daily living as well as enable independent wheelchair and bed mobility.

Scleroderma or systemic sclerosis (SSc) is a relatively uncommon disease. Although well-known for many years, research on appropriate physical therapy during all stages of myositis due to scleroderma is limited. We report the functional outcome in a patient with an acute quadriparesis secondary to diffuse SSc associated with extensive myositis. This 35-year-old black woman progressed to almost complete functional recovery in the course of 16 days of acute rehabilitation with combined physical therapy including resistive exercises. This case strongly suggests that a patient with diffuse SSc and associated myositis can undergo aggressive physical therapy in a monitored environment with good functional improvement and no worsening of the myositis.

Objectives: The first objective was to assess group differences for specific airway conductance (sGaw) among subjects with tetraplegia, high paraplegia (HP: T2-T6), and low paraplegia (LP: T10-L4). The second objective was to determine the significance of responsiveness to ipratropium bromide (IB) by the assessment of the inherent variability of baseline measurements for impulse oscillation (IOS), body plethysmography, and spirometry., Design: Prospective cross-sectional intervention study., Setting: James J. Peters Veterans Administration Medical Center., Participants: Subjects (N=43): 12 with tetraplegia (C4-8), 11 with HP, 11 with LP, and 9 controls., Interventions: Not applicable., Main Outcome Measures: Measurement of IOS, body plethysmography, and spirometry parameters at baseline and 30 minutes after IB., Results: Baseline sGaw was significantly lower in tetraplegia (0.14+/-0.03) compared with HP (0.19+/-0.05) and LP (0.19+/-0.04) patients. By use of minimal difference to evaluate IB responsiveness in tetraplegia, 4 of 12 and 12 of 12 subjects had significant increases in forced expiratory volume in 1 second and sGaw, respectively, whereas 11 of 12 and 10 of 12 subjects had significant decreases in respiratory resistances measured at 5 and 20 Hz (R5 and R20), respectively., Conclusions: The finding of group differences for baseline sGaw supports the hypothesis that human lung contains functional sympathetic innervation. Body plethysmography and IOS were comparable in detecting IB-induced bronchodilation in tetraplegia and significantly more sensitive than spirometry.

Objective: To investigate the influence of hand cycling on outcome measures of physical capacity during and after rehabilitation in persons with paraplegia and tetraplegia in The Netherlands., Design: A longitudinal cohort study with measurement moments at the start (t1) and end (t2) of clinical rehabilitation and 1 year after discharge (t3). Hand cycle use was assessed by means of questionnaires at t2 and t3., Setting: Eight rehabilitation centers in The Netherlands., Participants: Subjects (N=162) with a recent spinal cord injury., Interventions: All subjects followed the regular rehabilitation program., Main Outcome Measures: Peak oxygen uptake (Vo(2)peak) and peak power output (POpeak) determined in a handrim wheelchair peak exercise test, peak muscle strength of the upper extremities, and pulmonary function., Results: A significantly larger increment in Vo(2)peak, POpeak, and elbow extension strength was found in subjects with paraplegia during clinical rehabilitation. No such effect was found in subjects with tetraplegia. In the postrehabilitation period, no influence of hand cycling on any outcome measure was found in subjects with paraplegia or subjects with tetraplegia., Conclusions: After correction for baseline values and confounders, regular hand cycling (once a week or more) appeared to be beneficial for improving aerobic physical capacity in persons with paraplegia during clinical rehabilitation. The small and heterogeneous study groups may have hampered the finding of positive results of hand cycling in persons with tetraplegia.

The loss of elbow extension power is particularly disabling for the nonambulatory patient. Reconstruction of elbow extension can be performed by a deltoid to triceps transfer or by a biceps to triceps transfer provides the most satisfying reconstruction for patients. Although the overall time for rehabilitation can be lengthy, the functional gain is substantial, predictable, and easily appreciated by the patient. Furthermore, the risks to residual preoperative function are practically nil.

Measurement of upper limb function in persons with tetraplegia poses significant issues for clinicians and researchers. It is crucial that measures detect the small but significant improvements in hand function that may or may not occur as a result of our interventions. Before determining how we measure changes from upper limb interventions, we must establish what outcomes are of greatest interest, and for whom. Many issues have an impact on both the measurement and interpretative process.

Despite improved surgical techniques and postoperative management protocols for tetraplegic patients undergoing upper extremity functional reconstruction, recent studies have shown that these procedures are profoundly underutilized in the United States. The complex disabilities of tetraplegic patients limit their ability to independently obtain treatment information and travel to medical destinations to receive reconstructive procedures, thus making them a vulnerable patient population susceptible to physician influence regarding treatment decisions. Based on the results of previous research, we believe that increased collaboration among treating physician specialties will enhance patient access to surgical reconstruction.

Patients with incomplete cervical spinal cord injuries present unique challenges for the reconstructive surgeon. For example, their patterns of injury don't easily fit into the International Classification system familiar to surgeons; they don't lend themselves to a "recipe" approach to surgical decision-making; and they frequently have developed upper limb deformities that must be addressed before any consideration is made for functional surgery. Meanwhile, little has been published regarding surgery for these patients. This article summarizes issues related to evaluating and planning surgical procedures for the upper limb in incomplete lesions of the cervical spinal cord.

Objective: To examine the relationship between psychologic cues of somatic stress and physiologic responses to exercise in persons with paraplegia and tetraplegia., Design: Repeated measures with 2 comparison groups., Setting: Academic medical center., Participants: Forty-two subjects between 18 and 69 years of age with motor-complete spinal cord injury (SCI) resulting in paraplegia or tetraplegia (American Spinal Injury Association grades A and B)., Interventions: Not applicable., Main Outcome Measures: Subjects underwent peak graded arm ergometry during which heart rate, oxygen consumption (VO2), minute ventilation (VE), and ratings of perceived exertion (RPE) (Borg Categorical 6-20 Scale) were measured at successive work rate increments from baseline to fatigue., Results: There were inconsistent associations among the outcomes. For subjects with tetraplegia, RPE related positively to heart rate at the initial work rate, but there were no other significant correlations. For subjects with paraplegia, RPE did not correlate significantly with heart rate, VO2, or VE. VO2 and Ve related positively at the first and last work rates. In general, heart rate, VO2, and Ve increased as the exercise intensity increased, and were more pronounced in subjects with paraplegia. While RPE values increased with increasing work rates for each group, we found no differences between groups., Conclusions: Our findings contradict the well-accepted relationships between RPE and both heart rate and VO2 during exercise by people without disabilities, and challenge the use of RPE as a valid psychophysiologic index of perceived exertion in persons with SCI.

Objective: To investigate the relieving effect on interface pressure of an alternate sitting protocol involving a sitting posture that reduces ischial support., Design: Repeated measures in 2 protocols on 3 groups of subjects., Setting: Laboratory., Participants: Twenty able-bodied persons, 20 persons with paraplegia, and 20 persons with tetraplegia., Interventions: Two 1-hour protocols were used: alternate and normal plus pushup. In the alternate protocol, sitting posture was alternated every 10 minutes between normal (sitting upright with ischial support) and with partially removed ischial support (WO-BPS) postures; in the normal plus pushup protocol, sitting was in normal posture with pushups (lifting the subject off the seat) performed every 20 minutes., Main Outcome Measure: Interface pressure on seat and backrest., Results: In WO-BPS posture, the concentrated interface pressure observed around the ischia in normal posture was significantly repositioned to the thighs. By cyclically repositioning the interface pressure, the alternate protocol was superior to the normal plus pushup protocol in terms of a significantly lower average interface pressure over the buttocks., Conclusions: A sitting protocol periodically reducing the ischial support helps lower the sitting load on the buttocks, especially the area close to ischial tuberosities.

Objectives: To describe the course of gross motor function over 2 years in children with cerebral palsy (CP) aged 9 to 15 years, and to investigate its relationship with impairments and age., Design: Prospective cohort study., Setting: Rehabilitation department of a university medical center in the Netherlands., Participants: Seventy boys and 40 girls with CP (mean age +/- standard deviation, 11.2+/-1.7y)., Interventions: Not applicable., Main Outcome Measure: The Gross Motor Function Measure (GMFM)., Results: GMFM item scores were stable over the 2 years for the whole group. No difference was found in the course of GMFM item scores between the Gross Motor Function Classification System (GMFCS) levels. We found significant differences in the course of GMFM item scores (corrected for GMFCS) for the different levels of limb distribution, selective motor control, muscle strength, range of motion in the hip and knee, spasticity of the hamstrings, and type of education. There were significantly larger decreases in the more severely affected children. Multivariable analysis showed that a poor selective motor control was the most important determinant of a less favorable course of gross motor function., Conclusions: Some impairment characteristics may be used to identify children who are at risk for deterioration in gross motor function, and may serve as a guide for interventions.

Objectives: To investigate acute changes in the biceps tendon after a high-intensity wheelchair propulsion activity and to determine whether these changes are related to subject characteristics., Design: The biceps tendon was imaged with ultrasound before and after wheelchair basketball or quad rugby. The average diameter of the tendon was calculated as well as the echogenicity ratio (the pixel intensity ratio of the biceps tendon to a reference just superficial to the tendon sheath)., Setting: National Veterans Wheelchair Games in 2004 and 2005., Participants: Forty-two subjects who participated in wheelchair basketball or quad rugby at the Veterans Games., Interventions: Not applicable., Main Outcome Measures: Biceps tendon diameter and biceps echogenicity., Results: The echogenicity ratio of the tendon significantly decreased from 1.97 to 1.73 after the event (P=.038). The diameter of the biceps tendon increased from 4.60 to 4.82 mm (P=.178). Also, it was found that the change in tendon diameter positively correlated with the time of play (P=.004)., Conclusions: Acute changes in biceps tendon properties after exercise were found and likely represent edema, a first sign of overuse injury. The significance of continuous activity was shown by the fact that subjects who had more playing time showed a larger increase in tendon diameter.

Objectives: To develop the construct, content, and criterion validity of the Salford Gait Tool (SF-GT) and to evaluate agreement between gait observations using the SF-GT and kinematic gait data., Design: Tool development and comparative evaluation., Setting: University in the United Kingdom., Participants: For designing construct and content validity, convenience samples of 10 children with hemiplegic, diplegic, and quadriplegic cerebral palsy (CP) and 152 physical therapy students and 4 physical therapists were recruited. For developing criterion validity, kinematic gait data of 13 gait clusters containing 56 children with hemiplegic, diplegic, and quadriplegic CP and 11 neurologically intact children was used. For clinical evaluation, a convenience sample of 23 pediatric physical therapists participated., Interventions: We developed a sagittal plane observational gait assessment tool through a series of design, test, and redesign iterations. The tool's grading system was calibrated using kinematic gait data of 13 gait clusters and was evaluated by comparing the agreement of gait observations using the SF-GT with kinematic gait data., Main Outcome Measures: Criterion standard kinematic gait data., Results: There was 58% mean agreement based on grading categories and 80% mean agreement based on degree estimations evaluated with the least significant difference method., Conclusions: The new SF-GT has good concurrent criterion validity.

Objective: To evaluate the inter- and intraobserver repeatability of the Salford Gait Tool (SF-GT), a new observation-based gait assessment tool for evaluating sagittal plane cerebral palsy (CP) gait., Design: Masked comparative evaluation., Setting: University in the United Kingdom., Participants: A convenience sample of 23 pediatric physical therapists with varying degrees of clinical experience recruited from the Greater Manchester area., Intervention: Participants viewed videotapes of the sagittal plane gait of 13 children and used the SF-GT to analyze their 13 different gait styles on 2 occasions. Eleven children had hemiplegic, diplegic, or quadriplegic CP and 2 were neurologically intact., Main Outcome Measures: Inter- and intraobserver repeatability of hip, knee, and ankle joint positions at 6 different phases of the gait cycle., Results: The SF-GT demonstrated good interobserver (77%) and intraobserver (75%) repeatability., Conclusions: We have established that the SF-GT is a repeatable clinical assessment tool with which to guide the diagnosis, treatment planning, and evaluation of interventions by pediatric physical therapists of sagittal plane gait deviations in CP.

Objectives: To relate locomotor function improvement, within the first 6 months after spinal cord injury (SCI), to an increase in Lower Extremity Motor Score (LEMS) and to assess the extent to which the level of lesion influenced the outcome of ambulatory capacity., Design: Longitudinal and cross-sectional analyses., Setting: Seven SCI rehabilitation centers., Participants: Patients (N=178) were analyzed longitudinally (group A, motor complete; group B, motor incomplete; nonwalking or group C, motor incomplete and able to stand). The cross-sectional analysis included 86 patients (paraplegic, n=46; tetraplegic, n=40; group 1 with limited and group 2 with unrestricted walking function 6 mo after SCI)., Interventions: Not applicable., Main Outcome Measures: Walking Index for Spinal Cord Injury (WISCI), gait speed, and LEMS., Results: For group A, 24.8% of the patients improved in LEMS (median range, 0-10) and 7.7% in walking function (WISCI median range, 0-8; mean gait speed range, 0 to .14+/-.10 m/s). For group B, LEMS improved in 93.5% of the patients (median range, 14-28) and walking function in 84.8% of the patients (WISCI median range, 0-10; mean gait speed range, 0 to .41+/-.45 m/s) (P<.001). For group C, LEMS and walking function improved in 100% of the patients (LEMS median range, 29-41; WISCI median range, 8-16; mean gait speed range, .36+/-.29 m/s to .88+/-.44 m/s) (P=.001). In groups B and C, the improvement of walking function was greater than in LEMS. The cross-sectional analysis showed that group 1 patients with tetraplegia had more muscle strength (median LEMS, 31.5), and equal walking function (WISCI, 8; walking speed, 0.4+/-0.3 m/s) compared with patients with paraplegia (LEMS, 23; P<.01; WISCI, 12; P=0.6; speed, 0.4+/-0.3 m/s; P=.68). In group 2, patients with tetraplegia had slightly more strength (LEMS, 48) and equal walking function (WISCI, 20; walking speed, 1.4+/-0.3 m/s) compared with patients with paraplegia (LEMS, 45; P<.05; WISCI, 20; P=1.0; speed, 1.4+/-0.3 m/s; P=.89)., Conclusions: An improvement in locomotor function does not always reflect an increase in LEMS, and LEMS improvement is not necessarily associated with improved locomotor function. LEMS and ambulatory capacity are differently associated in patients with tetra- and paraplegia. Functional tests seem to complement clinical assessment.

Objective: To assess the effect of chronic deconditioning on cardiac dimensions and function in subjects with high-level spinal cord injury (SCI), who represent a human in-vivo model of extreme inactivity., Design: Cross-sectional study., Setting: University medical center., Participants: Seven men with tetraplegia and 7 able-bodied controls., Interventions: Not applicable., Main Outcome Measures: Echocardiographic measurements of resting cardiac dimensions, systolic function, and global and long-axis diastolic function., Results: Left ventricular mass index was significantly lower in the subjects with SCI than in the controls (90.8+/-26 g/m(2) vs 122+/-28.9 g/m(2); P=.05). In addition, dimensions of left ventricle, left atrium, and vena cava inferior were all significantly reduced in the subjects with SCI compared with controls (P<.05). There were no differences between the groups for any of the parameters reflecting systolic and global and long-axis diastolic function., Conclusions: Tetraplegia is associated with a reduction in cardiac mass and dimensions. Resting diastolic and systolic function is not altered with continued exposure to inactivity, however, which suggests a remodeling of the heart as a physiologic adaptive process.

Objective: To compare excitabilities of spinal stretch reflex among clinically complete spinal cord injury (SCI), incomplete SCI, elderly healthy, and young healthy subjects., Design: Case comparison., Setting: Research laboratory., Participants: Volunteer sample of 12 complete SCI, 10 incomplete SCI, 10 elderly, and 11 young subjects., Intervention: Mechanically induced stretch reflex, H-reflex, and M response in electromyographic activity of the soleus muscle were recorded in all subjects., Main Outcome Measures: Absolute peak-to-peak stretch reflex amplitude and maximum H-reflex (Hmax), and those values relative to the maximum M response (Mmax) amplitude (relative peak-to-peak stretch reflex amplitude) and H/M ratio., Results: Both the absolute and relative peak-to-peak stretch reflex amplitudes showed the greatest values in incomplete SCI among the 4 groups. Although absolute and relative peak-to-peak stretch reflex amplitudes of the incomplete SCI group were greater than those of the complete SCI group, the H/M ratios of both groups were comparable, and were greater than those of the younger and elderly groups., Conclusions: The results suggest that the greater absolute and relative peak-to-peak stretch reflex amplitudes of incomplete SCI were mostly due to the greater maximum motor potential (Mmax), while the elevated spinal motoneuronal excitability shown by the increased H/M ratio was maintained in the chronic stage after both complete and incomplete SCIs.

Objectives: To assess preference of reconstructive treatment of upper extremities in subjects with tetraplegia compared with preference of treatment of 3 other impairments and to determine the effect of subjects' characteristics on preference of upper-extremity reconstruction., Design: Survey., Setting: Two specialized spinal cord injury centers in the Netherlands., Participants: A consecutive sample of 47 patients with tetraplegia in stable condition., Interventions: Not applicable., Main Outcome Measure: The quality weight of 5 tetraplegic health states determined with the time trade-off technique and expressed as a single value (the "utility") on a scale between 0 (worst possible situation) and 1 (best possible situation)., Results: The response rate was 92%. The utility of tetraplegia +/- standard deviation was .57+/-.30. The utilities of tetraplegia without impairment in one of the following functions were .69+/-.33 for sexuality, .69+/-.33 for standing/walking, .63+/-.31 for bladder and bowel function, and .65+/-.32 for upper-extremity function. The differences between these utilities and the utility of tetraplegia were significant (P<.05). No significant differences were found between the utilities of the impairments. Improvement of a specific impairment contributed between 14% and 28% to the potential overall gain in the tetraplegic health state utility., Conclusions: The combination of impairments determines the low utility of the tetraplegic health state. No priority for improvement of any of the investigated impairments was found. This emphasizes the need for the meticulous selection of patients for treatment of specific conditions. Further research should try to determine the crucial factors in the decision-making process of patients for specific interventions.

Objectives: To determine whether the muscle strength, as measured with break-technique handheld dynamometry (HHD), is dependent on the angular velocity achieved during testing and to compare reliability at different angular velocities., Design: Repeated-measures study. Participants underwent HHD by using make-technique (isometric) and break-technique (eccentric) dynamometry at 3 prespecified angular velocities. Elbow movement was recorded with an electrogoniometer., Setting: Inpatient spinal cord injury unit., Participants: Convenience sample of 20 persons with tetraplegia with weakness of elbow flexors or extensors., Interventions: Not applicable., Main Outcome Measures: Elbow angular velocity and muscle strength recorded during HHD., Results: With the break technique, angular velocities averaging 15 degrees , 33 degrees , and 55 degrees /s produced 16%, 30%, and 51% greater strength measurements, respectively, than velocities recorded by using the make technique (all P < .006 for comparisons between successive techniques). The intraclass correlation coefficient for intrarater reliability was .89 or greater for all testing techniques., Conclusions: Greater strength is recorded with faster angular velocities during HHD. Differences in angular velocity may explain the wide range previously reported for break- versus make-technique strength measurements. Variation in angular velocity is a potential source of variability in serial HHD strength measurements, and for this reason the make technique may be preferable.

Objective: To determine whether application of functional electric stimulation (FES) to lower-limb muscles during postural tilting improves orthostatic tolerance in people with tetraplegia., Design: A crossover design., Setting: A rehabilitation hospital., Participants: Sixteen acute and chronic subjects with tetraplegia (15 men, 1 woman) with complete motor function loss at the C3-7 levels were recruited. Time since injury ranged from 2 to 324 months (mean, 118.9+/-104.2 mo)., Intervention: Subjects were tested on a progressive head-up tilting maneuver with and without the application of FES at 0 degrees , 15 degrees , 30 degrees , 45 degrees , 60 degrees , 75 degrees , and 90 degrees continuously for up to 1 hour. FES was administered to 4 muscle groups including the quadriceps, hamstrings, tibialis anterior, and gastrocnemius muscles bilaterally at an intensity that provided a strong, visible, and palpable contraction. This was to produce a muscle pumping mechanism during the tilting maneuver., Main Outcome Measures: Systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate, perceived presyncope score, and the overall duration of orthostatic tolerance, that is, the time that subjects could tolerate the tilting maneuver without developing severe hypotension or other intolerance symptoms., Results: When the tilt angle was increased, the subjects' SBP and DBP tended to decrease, whereas the heart rate tended to increase in both testing conditions. Adding FES to tilting significantly attenuated the drop in SBP by 3.7+/-1.1 mmHg (P = .005), the drop in DBP by 2.3+/-0.9 mmHg (P = .018), and the increase in heart rate by 1.0+/-0.5 beats/min (P = .039) for every 15 degrees increment in the angle of the tilt. FES increased the overall mean standing time by 14.3+/-3.9 min (P = .003)., Conclusions: An FES-induced leg muscle contraction is an effective adjunct treatment to delay orthostatic hypotension caused by tilting; it allows people with tetraplegia to stand up more frequently and for longer durations.

Objective: To estimate the differences in glenohumeral contact forces and shoulder muscle forces between able-bodied subjects and subjects with paraplegia and tetraplegia during wheelchair-related activities of daily living (ADLs)., Design: Kinematics and external forces were measured during wheelchair ADLs (level propulsion, weight-relief lifting, reaching) and processed by using an inverse dynamics 3-dimensional biomechanical model., Setting: Biomechanics laboratory., Participants: Five able-bodied subjects, 8 subjects with paraplegia, and 4 subjects with tetraplegia (N = 17)., Interventions: Not applicable., Main Outcome Measures: Glenohumeral contact forces and shoulder muscle forces., Results: Peak contact forces were significantly higher for weight-relief lifting compared with reaching and level propulsion (P < .001). High relative muscle force of the rotator cuff was seen, apparently needed to stabilize the joint. For weight-relief lifting, total relative muscle force was significantly higher for the tetraplegia group than for the able-bodied group (P = .022)., Conclusions: Glenohumeral contact forces were significantly higher for weight-relief lifting and highest over the 3 tasks for the tetraplegia group. Without taking paralysis into account, more muscle force was estimated for the subjects with tetraplegia during weight-relief lifting.

Objective: To investigate the course of mechanical efficiency of handrim wheelchair propulsion during rehabilitation of subjects with (in)complete paraplegia and tetraplegia., Design: Subjects were tested at the start of active rehabilitation (t1), 3 months later (t2), and when discharged from inpatient rehabilitation (t3). They performed two 3-minute submaximal treadmill exercise blocks in a wheelchair., Setting: Eight rehabilitation centers in the Netherlands., Participants: Ninety-two people with (in)complete paraplegia and tetraplegia., Interventions: Not applicable., Main Outcome Measures: Mechanical efficiency values were calculated for each block. The course of mechanical efficiency was investigated using test occasions (t1 -t3), completeness and level (paraplegia or tetraplegia) of the lesion, and power output as independent variables in a multilevel regression analysis., Results: Mechanical efficiency significantly increased between t1 and t2 only. After adding level and completeness of the lesion and their interactions with time to the model, block 2 showed that subjects with paraplegia had a significantly higher mechanical efficiency than subjects with tetraplegia. Subjects with tetraplegia improved more between t1 and t2 . Differences in mechanical efficiency between subjects with paraplegia and tetraplegia could not be explained by differences in absolute and relative power output levels., Conclusions: Results showed a significant improvement in mechanical efficiency during the first 3 months of active rehabilitation. Subjects with paraplegia showed a higher mechanical efficiency than did subjects with tetraplegia, whereas the latter showed more improvement between t1 and t2 .

Objective: To determine whether a custom girdle, designed to provide truncal stability and abdominal support, will improve pulmonary function, enhance inspiratory muscle activity, and reduce the sensation of respiratory effort in patients with spinal cord injury (SCI)., Design: Pulmonary function, transdiaphragmatic pressure time product (PTP di ), twitch (Tw Pdi) and maximal transdiaphragmatic pressures (Pdi), and perception of respiratory effort (Borg Rating of Perceived Exertion score) were measured with and without an abdominal girdle in a seated position., Setting: Rehabilitation hospital., Participants: Ten patients with posttrauma SCI (injury level, C5-T6)., Intervention: Application of the abdominal girdle., Main Outcome Measures: Borg score and measures of lung volumes, dynamic abdominal compliance, and Tw Pdi and maximal Pdi., Results: Wearing of the girdle was associated with a lower Borg score (P = .002) and reduced functional residual capacity (P = .006) but increased inspiratory capacity (P = .02) and forced vital capacity (P = .02). Although there was a decrease in dynamic abdominal compliance (P < .001) and an increase in PTP di (P = .02), this was accompanied by an increase in both Tw Pdi (P = .02) and maximal Pdi (P = .03). CONCLUSIONS The custom girdle reduced the sensation of respiratory effort in patients with SCI by optimizing the operating lung volumes and decreasing abdominal compliance, which enhanced diaphragm performance.

Although an increasing number of women are becoming pregnant and rearing children after spinal cord injury (SCI), scant literature exists on breastfeeding after injury. In particular, it is unclear whether women with SCI above T7 can sustain breastfeeding in a manner similar to neurologically intact nursing mothers. A functional let-down reflex is required to provide adequate milk to a nursing infant. Infant suckling activates tactile receptors in the breast, and this signal is carried via afferent nerves in the T4-6 dorsal roots to the spinal cord and then to neurons in the hypothalamus, which release oxytocin into the bloodstream. Oxytocin triggers milk ejection from the breast. Suckling-induced afferent stimuli are absent in women with SCI above T4 and are reduced if the injury is between T4 and T6. This report describes the breastfeeding practices of 3 tetraplegic women and shows that breastfeeding can be maintained for extended periods (12-54 wk) after delivery. Two women required active mental imaging and relaxation techniques, or oxytocin nasal spray, to facilitate the let-down reflex. These findings suggest that although an absence of suckling-induced afferent stimuli may impair the let-down reflex, long-term breastfeeding can be maintained.