CONTEXT:Obesity after spinal cord injury (SCI) is a major healthcare concern due to its associated increased morbidity and mortality. Veterans with SCI constitute the largest single group of individuals with SCI nationwide, and have high prevalence of obesity (>75%) and cardiometabolic dysfunction (≥50%) - a fact that highlights the importance of studying Veterans specifically. Daily eating patterns, such as the time between the first and last eating activity ("eating window"), are understudied in this group. These patterns are critical to understanding determinants of obesity and potential targets for treatment, and informing future studies comparing SCI and non-SCI populations. OBJECTIVE:We sought to quantify eating windows of Veterans with SCI and obesity and study baseline demographic data associated with these eating windows, leveraging the unique VA SCI / Disorders Registry. METHODS:We recruited Veterans with chronic SCI (≥ 1 year post-injury), paraplegia (injury levels T1 - S5), and obesity (body mass index (BMI) > 22 kg/m2, an SCI-specific cutoff), from a single Veterans Affairs SCI Center. Veterans tracked start and stop times of eating and drinking (>0 kcals) over two consecutive weeks. RESULTS:Forty-five Veterans participated in the study. Participants were predominantly older (>60 years old), male, white, with a BMI of 31 kg/m2 (IQR 11). The median eating window was 10.8 h (IQR 3.5). Eating windows were shorter on weekends (p = 0.037), for rural residents (p < 0.001), those with caregivers (p < 0.001), and those not working (p < 0.001). In adjusted, multivariable analyses, eating windows were shorter only for those not working (p = 0.042). CONCLUSION:In a sample of Veterans with SCI and obesity, the median eating window was 10.8 h. Lower employment levels may be associated with shorter eating windows - are a potential factor to be explored that may contribute to this overall eating pattern. SCI profoundly impacts metabolism, and a better understanding of how eating windows induce additional metabolic effects and potentially increases risk of obesity after SCI is needed.

Flexibility training involving stretching aims to increase the range of motion (ROM) about a joint and mitigate factors that limit mobility. Stretching has been used for improving human performance and preventing injuries. Further, stretching can be used as spasticity treatment in people with spinal cord injury to provide relief from muscle spasms and improve passive ROM. Therapists apply manual stretching to participants; however, providing personalized and repeatable stretching forces is caregiver intensive. This paper describes the methods to apply three stretching techniques and determines the feasibility of implementing their protocols using a powered device and open-loop Functional Electrical Stimulation (FES) patterns. This paper develops a robust kinematic closed-loop controller to emulate the static, activeisolated (AIS), and proprioceptive neuromuscular facilitation (PNF) stretching techniques targeting the hamstring complex in which the human lies in a supine position. The robust electric motor controller rotates the leg from its initial position through a desired ROM using a rigid pivot arm actuated by a Bowden cable. When the leg reaches the target end ROM, FES inputs are applied for AIS and PNF stretching. Experiments were safely conducted in two able-bodied individuals to demonstrate the device's feasibility of implementing each stretching technique on the hamstring complex. A Lyapunov stability analysis ensures exponential tracking of the motor controller.

Functional electrical stimulation (FES) and motorized cycles have the potential to recover lost function and mobility in people with neurological disorders. However, the human-robot system is uncertain, nonlinear, and time-varying, posing technical challenges to customizing the interaction across participants. In this paper, a closed-loop switching adaptive controller is designed to achieve cadence tracking using a powered FES-cycling system. The adaptive design copes with the parametric uncertainty of the cycle-rider dynamics and the unknown switching muscle control effectiveness by computing estimates of the uncertain parameters. A saturated state-feedback controller activates the quadriceps muscle groups, whereas an integral concurrent learning technique activates the electrical motor and leverages input-output data to estimate the parametric uncertainty and achieve cadence tracking. A switching Lyapunov-based stability analysis is developed in two phases. The initial phase ensures bounded tracking and estimation when a learning condition has not been attained; in the second phase, global exponential tracking and estimation convergence is ensured, given an online-verified finite excitation condition is satisfied. The developed controller was tested during three FES-cycling trials with different cadence trajectories and learning conditions in eight able-bodied individuals and three participants with neurological conditions (NCs) during ten-minute and five-minute experiments, respectively. The system achieves an average RMS cadence tracking error of $2.49\pm0.42$ , $2.66\pm0.36$ , and $2.69\pm0.58$ revolutions per minute (RPM) with the able-bodied participants, while an average RMS cadence tracking error of $3.15\pm0.97$ , $2.60\pm0.17$ , $3.47\pm1.43$ RPM for the participants with NCs in three cycling trials. Note to Practitioners —FES-Cycling is a rehabilitation strategy recommended to recover muscle capacity and improve cardiovascular function in people with neurological disorders. Although significant progress has been made on the closed-loop control of FES-cycling systems, a critical need exists to develop adaptive strategies to comply with the nonlinear, time-varying muscle responses to FES, cope with the uncertain parameters of the cycle-rider system, and improve tracking performance. This paper develops a decoupled control design for muscles and motor. The FES controller is tuned using minimal parameters to yield bounded muscle responses with a tunable saturation limit. The electric motor control is designed using an adaptive-based method that estimates the uncertain parameters in the cycle-rider system and strategically exploits the muscle input to improve tracking performance. Results from cycling trials in able-bodied individuals and participants with neurological conditions demonstrate the feasibility of the adaptive control design to tracking different trajectories with the same set of control parameters across all participants despite the inherent variability in human subjects. The adaptive controller requires minimal tuning and copes with the rider’s uncertainty while obtaining predictable, satisfactory performance, potentially paving the way for the widespread implementation of adaptive closed-loop controllers for FES-cycling systems at the clinic and community.

You have accessJournal of UrologyCME1 Apr 2023MP52-10 CHRONIC, NON-INVASIVE NERVE STIMULATION THERAPY TO TREAT INCONTINENCE IN PEOPLE WITH NEUROGENIC BLADDER Seth Meade, Dennis Bourbeau, Steven Brose, Kenneth Gustafson, Cesar Colasante, and Kevin Suarez Seth MeadeSeth Meade More articles by this author , Dennis BourbeauDennis Bourbeau More articles by this author , Steven BroseSteven Brose More articles by this author , Kenneth GustafsonKenneth Gustafson More articles by this author , Cesar ColasanteCesar Colasante More articles by this author , and Kevin SuarezKevin Suarez More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003300.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Reduction of urinary urgency and incontinence is a top priority for individuals with neurogenic bladder (NB). Multiple clinical studies show non-invasive genital nerve stimulation (GNS) can modulate sympathetic reflexes to inhibit bladder contractions acutely and is well-tolerated. To translate GNS as an effective adjunct therapy for managing neurogenic bladder, further evidence of chronic efficacy and feasibility is needed. METHODS: In this “before-and-after” prospective cohort study, participants acted as their own controls. 9 individuals with NB were enrolled (8/9 (88.9%) male) and confirmed to: 1) have NB by urodynamics examination and 2) have bladder contractions inhibited by GNS. 5 participants (100% male) who tolerated GNS without additional medications and were adherent to voiding diaries tested the efficacy of at-home, self-administered GNS using a commercial TENS unit. Participants completed voiding diaries, each detailing at least 1 continuous week of tracked voiding, leak, and urgency events. Diaries were completed once at study initiation during a control period without GNS or medications, and then for 3 separate periods during prolonged use of GNS to manage incontinence (baseline, 6 months, 1 year). Participants also completed a bladder-related quality of life questionnaire (Qualiveen) at their initial evaluation, as well as 6 and 12 months later. RESULTS: Preliminary findings show that GNS increased bladder capacity for all 9 individuals tested by an average of 58%, and 3/5 individuals tested chronically maintained an increased bladder capacity after 6 months of GNS. 4/5 individuals reported increased bladder-related QOL by total Qualiveen after 6 months of at-home GNS. Of 2 individuals who experienced leakage with chronic voiding data one reduced their leaks/day by 90% at 6 months of use and the other by 30% at 1 year of GNS. Of 2 individuals with the primary goal of reducing bladder urgency, neither was able to reduce their urgency events/day but were able to reduce their voiding frequency by 65% and 15% after more than 1 month of use. The primary reason individuals reported for dropping from the study was difficulty placing the electrodes and keeping them in place. CONCLUSIONS: GNS can provide a durable reduction in leakage events for individuals with incontinence due to neurogenic bladder up to 6 months. Multiple subjects reported issues with electrode placement and adhesion as well as associated wires from the TENS unit leading to less-than-ideal GNS for some. Source of Funding: -RX002512 Department of Veterans Affairs -642810 Craig H. Neilsen Foundation (CHNF) © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e706 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Seth Meade More articles by this author Dennis Bourbeau More articles by this author Steven Brose More articles by this author Kenneth Gustafson More articles by this author Cesar Colasante More articles by this author Kevin Suarez More articles by this author Expand All Advertisement PDF downloadLoading ...

Context: To counteract cumulative weight gain, a female veteran with multiple sclerosis with spinal cord involvement initiated a program of time restricted eating (TRE), eating all calories within a daily 6-hour window. Findings: The patient experienced significant weight loss and improved cardiometabolic markers. Conclusion/Clinical Relevance: Additional research is warranted to study TRE to mitigate obesity.

Context: Individuals with SCI typically live with neurogenic bowel dysfunction and impaired colonic motility that may significantly impact health and quality of life. Bowel management often includes digital rectal stimulation (DRS) to modulate the recto-colic reflex to promote bowel emptying. This procedure can be time-consuming, caregiver-intensive, and lead to rectal trauma. This study presents a description of using electrical rectal stimulation as an alternative to DRS to help manage bowel emptying in a person with SCI. Methods: We conducted an exploratory case study with a 65-year-old male with a T4 AIS B SCI who normally relies on DRS as the main component of his regular bowel management strategy. In randomly selected bowel emptying sessions during a 6-week period, the participant received burst-pattern electrical rectal stimulation (ERS) (50 mA, 20 pulses/s at 100 Hz), via a rectal probe electrode until bowel emptying was achieved. The primary outcome measure was number of cycles of stimulation required to complete the bowel routine. Results: 17 sessions were performed using ERS. In 16 sessions, a bowel movement was produced after only 1 cycle of ERS. In 13 sessions, complete bowel emptying was achieved with 2 cycles of ERS. Conclusions: ERS was associated with effective bowel emptying. This work represents the first time ERS has been used to affect bowel emptying in someone with SCI. This approach could be investigated as a tool to evaluate bowel dysfunction, and it could be further refined as a tool for improving bowel emptying.

Restoring and improving the ability to walk is a top priority for individuals with movement impairments due to neurological injuries. Powered exoskeletons coupled with functional electrical stimulation (FES), called hybrid exoskeletons, exploit the benefits of activating muscles and robotic assistance for locomotion. In this paper, a cable-driven lower-limb exoskeleton is integrated with FES for treadmill walking at a constant speed. A nonlinear robust controller is used to activate the quadriceps and hamstrings muscle groups via FES to achieve kinematic tracking about the knee joint. Moreover, electric motors adjust the knee joint stiffness throughout the gait cycle using an integral torque feedback controller. For the hip joint, a robust sliding-mode controller is developed to achieve kinematic tracking using electric motors. The human-exoskeleton dynamic model is derived using Lagrangian dynamics and incorporates phase-dependent switching to capture the effects of transitioning from the stance to the swing phase, and vice versa. Moreover, low-level control input switching is used to activate individual muscles and motors to achieve flexion and extension about the hip and knee joints. A Lyapunov-based stability analysis is developed to ensure exponential tracking of the kinematic and torque closed-loop error systems, while guaranteeing that the control input signals remain bounded. The developed controllers were tested in real-time walking experiments on a treadmill in three able-bodied individuals at two gait speeds. The experimental results demonstrate the feasibility of coupling a cable-driven exoskeleton with FES for treadmill walking using a switching-based control strategy and exploiting both kinematic and force feedback.

Context Amyotrophic lateral sclerosis (ALS) is a group of rare neurological diseases which cause progressive loss of upper and lower motor neurons at the spinal or bulbar level. ALS affects voluntary muscles of the body which control eating, talking, and moving. Individuals with ALS manifest difficulty breathing on their own due to weakness of the respiratory system. The average life expectancy of individuals with ALS is 2–5 years from the time of diagnosis, with death resulting from respiratory failure. There is no cure for ALS. At present, riluzole and edaravone are the only FDA-approved treatments that impact survival. Adverse reactions to edaravone include hypoxia and respiratory failure. To date, there are no published reports describing isolated dramatic respiratory improvement in ALS with continued global clinical worsening including limb and face function, particularly following edaravone use.Findings We present a case report of late stage bulbar ALS, in which a dramatic respiratory improvement is seen following edaravone use, and subsequent cessation.Conclusion/Clinical Relevance Isolated pulmonary decline and subsequent recovery following cessation of edaravone in the setting of continued systemic neurologic decline has not yet been described and may suggest potential for reversibility of edaravone-related pulmonary decline. Research is needed to evaluate this possibility further, and this case report may lead to further investigation to evaluate this possibility. Alternatively, although less likely, it is possible the observed that pulmonary improvement may either be beneficially attributed to edaravone, or unrelated to edaravone entirely – representing an undescribed phenomenon of isolated pulmonary decline and improvement in the setting of systemic continued ALS progression, possibly related to the bulbar subtype. Further investigation is warranted to evaluate both the role of edaravone in causing in a potentially reversible pulmonary decline upon cessation of the medication, and the possibility of other undefined variables including various subtypes of ALS contributing to this phenomenon.

Objective: Persons with spinal cord injury (SCI) have a higher prevalence of being overweight than the general population, which is thought to be due to a variety of metabolic, physiologic and psychological changes. The quality improvement project described in this work was designed to help overweight persons with SCI lose bodyweight through nutrition, exercise, and behavioral management strategies.Methods: Eighteen persons with SCI who were overweight were enrolled in a 12-week interdisciplinary weight management program. Participants were limited to persons at least one-year post-acute SCI with an established overweight status. Measurements, including a person's weight, body mass index, and waist circumference (WaC), were taken at the program's start, at its end, and six months post program.Results: Seventeen out of 18 participants experienced weight loss, (WaC) decreased (P < 0.001), and the program was effective at reducing weight (P < 0.001). Six months following participation in the program participants did experience a significant change in weight or waist size six months post program, thus indicating that subjects did not regain weight after completion of the program.Conclusion: This quality improvement project provided indications of the benefits of an SCI-specific interdisciplinary weight management program. Clinical research evaluating methods for helping persons with SCI achieve a healthy bodyweight is indicated.

BACKGROUND:The increasing use of prescription opioids has contributed to the epidemic of opioid abuse in the United States. Efforts to reduce opioid prescriptions and offer alternatives for pain management are needed.OBJECTIVE:To determine the success of a multidisciplinary project to manage chronic pain while reducing reliance on opioids in a population of patients with spinal cord injury (SCI).DESIGN:Retrospective analysis.SETTING:This study was conducted in an SCI system of care in northeast Ohio.PARTICIPANTS:Individuals with SCI receiving outpatient care were included.INTERVENTIONS:Clinicians in SCI and pain management specialties developed a plan to manage individuals with SCI, particularly for individuals using opioids, including physical, occupational, recreational, and vocational therapy. These services worked closely with the SCI physicians when chronic pain was identified to help better medically manage their pathology and support efforts to decrease opioid use in a multipronged approach.MAIN OUTCOMES:The primary outcome measures from opioid prescription data from 2008 to 2016 were the percent of outpatients receiving opioids, opioid prescription rates, and opioid prescription doses over time.RESULTS:The percentage of outpatients receiving opioids and the number of opioid prescriptions through the outpatient service significantly decreased, from 39% to 16% and from 2.5 to 1.5 prescriptions per patient per quarter, respectively, correlating with the introduction of the multidisciplinary interventions. The total morphine equivalent quantities of prescription medications, particularly nonmethadone opioids, also decreased significantly.CONCLUSIONS:The multidisciplinary interventional approach was associated with marked decreases in the percentage of patients receiving opioids and the amounts of opioids being prescribed. This reduction could have a significant impact on the opioid crisis.LEVEL OF EVIDENCE:IV.

OBJECTIVES:Most individuals with spinal cord injury have neurogenic bowel dysfunction, which includes slowed colonic motility and has a significant impact on their health and quality of life. Bowel management typically includes mechanical rectal distension to evoke a recto-colic reflex and promote bowel emptying. Electrical stimulation could replace this mechanical distension. The purpose of this study was to determine the feasibility of evoking colonic activity using electrical stimulation.MATERIALS AND METHODS:Acute experiments were conducted in eight neural-intact cats under chloralose anesthesia. Patterned electrical stimulation was administered via electrodes placed on the surface of the distal colon or proximal colon. Distal and proximal colon pressures were measured using saline-filled balloon catheters. Outcome measures included peak colonic pressure; time to onset of response; and time to peak pressure compared to baseline without stimulation.RESULTS:Stimulation elicited colonic activity in all animals. Peak colon pressures were 15 ± 28 cmH2 O and were proportional to stimulation amplitudes. Time to onset and time to peak pressure were 13 ± 19 s and 37 ± 49 s, respectively, and were not significantly affected by stimulus parameters. Proximal colon stimulation only resulted in pressure responses from the proximal colon, but distal colon stimulation resulted in both proximal and distal responses in 40% of trials. Adding isoflurane anesthesia removed this proximal response to distal stimulation.CONCLUSIONS:Distal colon stimulation evoked colonic activity. The dependence of this response on stimulation location and anesthesia suggests that responses were reflex mediated. Colonic stimulation may have the potential to improve colonic motility for individuals with neurogenic bowel dysfunction.

Individuals with spinal cord injury (SCI) usually develop neurogenic detrusor overactivity (NDO), resulting in bladder urgency and incontinence, and reduced quality of life. Electrical stimulation of the genital nerves (GNS) can inhibit uncontrolled bladder contractions in individuals with SCI. An automated closed-loop bladder neuromodulation system currently does not exist but could improve this approach. We have developed a custom algorithm to identify bladder contractions and trigger stimulation from bladder pressure data without need for abdominal pressure measurement. The goal of this pilot study was to test the feasibility of automated closed-loop GNS using our custom algorithm to identify and inhibit reflex bladder contractions in real time. Experiments were conducted in a single session in a urodynamics laboratory in four individuals with SCI and NDO. Each participant completed standard cystometrograms without and with GNS. Our custom algorithm monitored bladder vesical pressure and controlled when GNS was turned on and off. The custom algorithm detected bladder contractions in real time, successfully inhibiting a total of 56 contractions across all four subjects. There were eight false positives, six of those occurring in one subject. It took approximately 4.0 ± 2.6 s for the algorithm to detect the onset of a bladder contraction and trigger stimulation. The algorithm maintained stimulation for approximately 3.5 ± 1.7 s, which was enough to inhibit activity and relieve feelings of urgency. Automated closed-loop stimulation was well-tolerated and subjects reported that algorithm decisions generally matched with their perceptions of bladder activity. The custom algorithm automatically, successfully identified bladder contractions to trigger stimulation to inhibit bladder contractions acutely. Closed-loop neuromodulation using our custom algorithm is feasible, but further testing is needed refine this approach for use in a home environment.

Background Blood flow restriction (BFR) exercise, which already has shown promise in the able‐bodied population, may be a novel method for improving muscle function in the incomplete spinal cord injury (iSCI) population. However, the feasibility and tolerance for BFR exercise in this population is unknown. Objective To determine the feasibility and safety of BFR exercise in the iSCI population, with special attention paid to acute hemodynamic changes and the risk of deep vein thrombosis (DVT). Design Within‐subjects repeated measures design. Setting Outpatient SCI rehabilitation unit in a Veterans Affairs medical center. Participants Nine individuals with varying levels of iSCI and varying functional abilities. Methods Subjects performed a trial of unilateral BFR knee extension (3 × 10) with, and without, BFR (125% of venous occlusion pressure) in a counterbalanced order. Main Outcome Measurements Acute autonomic dysreflexia risk, total work, pain, perceived difficulty, muscle activation, lactate, hemodynamics, and tissue oxygenation were compared between conditions. Each subject was screened for a DVT at baseline and returned for a quantitative D‐dimer assessment 3‐4 days after the protocol. Results All subjects were able to complete each BFR trial without showing signs of autonomic dysreflexia or DVT formation. No differences were observed for pain, perceived effort, muscular activation, or lactate between BFR and control exercise. Mean arterial pressure and systolic pressure both increased with exercise (18.8% and 17.6% in BFR, and 19.4% and 19.6% in control, respectively; P < .05) but were not different between conditions. Oxyhemoglobin and deoxyhemoglobin saturation both increased during BFR exercise (+12.3 ± 96.7 and +105.4 ± 76.7, respectively), whereas tissue oxygenation index decreased (–6.5 ± 3.0%; P < .05 for all comparisons). Conclusions Results suggest that controlled BFR exercise can be safely performed by individuals with iSCI without added cardiovascular strain or heightened pain. Level of Evidence IV

OBJECTIVE:Neurogenic bladder dysfunction, including neurogenic detrusor overactivity (NDO) is one of the most clinically significant problems for persons with spinal cord injury (SCI), affecting health and quality of life. Genital nerve stimulation (GNS) can acutely inhibit NDO-related reflex bladder contractions and increase bladder capacity. However, it is unknown if GNS can improve urinary continence or help meet individuals' bladder management goals during sustained use, which is required for GNS to be clinically effective.DESIGN:Subjects maintained voiding diaries during a one-month control period without stimulation, one month with at-home GNS, and one month after GNS. Urodynamics and quality of life assessments were conducted after each treatment period, and a satisfaction survey was taken at study completion.SETTING:Subject screening and clinical procedures were conducted at the Louis Stokes Cleveland VA Medical Center. Stimulation use and voiding diary entries were conducted in subjects' homes.PARTICIPANTS:Subjects included five men with SCI and NDO.INTERVENTIONS:This study tested one month of at-home portable non-invasive GNS.OUTCOME MEASURES:The primary outcome measure was leakage events per day. Secondary outcome measures included self-reported subject satisfaction, bladder capacity, and stimulator use frequency.RESULTS:GNS reduced the number of leakage events from 1.0 ± 0.5 to 0.1 ± 0.4 leaks per day in the four subjects who reported incontinence data. All study participants were satisfied that GNS met their bladder goals; wanted to continue using GNS; and would recommend it to others.CONCLUSIONS:Short term at-home GNS reduced urinary incontinence and helped subjects meet their bladder management goals. These data inform the design of a long-term clinical trial testing of GNS as an approach to reduce NDO.

Background: Neurogenic detrusor overactivity after spinal cord injury (SCI) causes urinary incontinence and reduces bladder capacity. Surface electrical genital nerve stimulation (GNS) acutely inhibits reflex bladder contractions. The stimulation amplitude selected for GNS is typically twice the amplitude that is required to evoke the pudendal-anal reflex. There is concern about the ability of persons with sensation to comfortably tolerate effective levels of GNS. The objective of this work is to determine if persons with incomplete SCI are able to tolerate acute GNS for bladder inhibition. Methods: Twenty-four subjects with neurogenic detrusor overactivity, SCI, and pelvic sensation were enrolled in this case series. The setting was the Spinal Cord Injury Service of a Veterans Affairs Medical Center. Primary outcome measures were sensation threshold and tolerable stimulation amplitude; secondary outcome measures were bladder capacity and bladder contraction inhibition. Results: GNS was tolerable up to 30 +/- 16 mA (range 8 mA to >= 60 mA) at amplitudes greater than twice the pudendal-anal (PA) reflex threshold, which was 8 +/- 5 mA (range 4 mA to 20 mA). Twelve subjects tolerated GNS at greater than twice the PA, six tolerated 1-1.5 times the PA, and five had no identifiable PA. GNS at tolerable amplitudes inhibited reflexive bladder contractions or increased bladder capacity 135 +/- 109 mL (n=23). GNS did not cause autonomic dysreflexia or intolerable spasticity. Conclusions: GNS is tolerable at amplitudes that effectively inhibit neurogenic detrusor overactivity in individuals with pelvic sensation. GNS therefore is a tool with potential clinical applications for persons with preserved sensation.

From the perspective of a multidisciplinary team, the authors describe the first reported use of ultrasound guidance for steroid injection into the pisotriquetral joint to relieve wrist pain of a person with spinal cord injury undergoing acute inpatient rehabilitation. Musculoskeletal ultrasound guidance was used to improve the accuracy of a corticosteroid injection of the pisotriquetral joint and the basal thumb in a 70-year-old man with paraplegia experiencing multifocal degenerative wrist pain. There was no bleeding or bruising after the injections, and the patient reported complete pain resolution 1 wk after the injections, which continued for over 1 yr. A multidisciplinary team was key in diagnosis, selection of treatment, and evaluation of treatment effect. Corticosteroid injection of the pisotriquetral joint under ultrasound guidance can be used as a treatment modality for managing wrist pain stemming from that joint. Further investigation and studies evaluating the use of ultrasound versus other imaging modalities for injection of the wrist are indicated.

Background Lack of an effective cough may result in the frequent aspiration of airway secretions and foreign material and the development of recurrent respiratory tract infections. In persons with spinal cord injury, lower thoracic low frequency spinal cord stimulation (conventional LF‐SCS, 50Hz, 15mA) results in large positive airway pressure generation (P), and is a useful method to restore an effective cough mechanism. Unfortunately, activation of the expiratory muscles via LF‐SCS requires high stimulus amplitudes, which may also cause unwanted side effects including stimulation of sensory fibers and therefore cannot be applied in patients with intact sensation. Objective To evaluate the effectiveness a novel method of expiratory muscle activation, which involves the application of high frequency spinal cord stimulation with low stimulus amplitudes (HF‐SCS; 500Hz, 1mA). Methods Studies were performed on 13 anesthetized dogs. Multi contact stimulating electrodes were positioned over the dorsal surface of the lower thoracic and upper lumbar spinal cord. In one group of animals the effects of HF‐SCS and LF‐SCS on P were evaluated. SCS was applied at functional residual capacity (FRC) and also over a wide range of lung volumes. Given our previous success with LF‐SCS, these values were used as our gold standard to which all comparisons were made. In a second group of animals, the mechanism of expiratory muscle activation during HF‐SCS was evaluated. P and EMG recordings from the external oblique (EO) before and after spinal cord section at the T12 level were evaluated. Internal intercostal muscle (II) activation at the level of the stimulating electrode was also assessed via II EMG recordings, before and after T9 root section. Results For both HF‐SCS and LF‐SCS, the optimum site for pressure generation was in the region of T9 spinal level (62±5 and 66±8cmH 2 O). P declined progressively at more rostral and caudal levels. In response to increasing lung volume, P increased in linear fashion during both HF‐SCS and LF‐SCS over the entire vital capacity range. For both HF‐SCS and LF‐SCS, bilateral dorsal column section significantly reduced EO EMG activity recorded below the level of spinal section and also resulted in a substantial fall in P (from 56±6 to 28±1cmH 2 O, p<0.05). Subsequent lateral funiculi section completely abolished those activities and resulted in further reductions in P. However, onset time of II EMG activity during HF‐SCS was significantly longer than obtained during direct T9 motor root activation (p<0.05). Conclusion These results suggest that HF‐SCS produces a comparable level of expiratory muscle activation to that achieved with conventional stimulus parameters, but with much lower stimulus amplitudes and is more dependent upon synaptic pathways rather than direct motor root activation. Support or Funding Information Support : VA RR&D A1488‐R and NIH‐NINDS R01NS064157

In persons with spinal cord injury, lower thoracic low-frequency spinal cord stimulation (LF-SCS; 50 Hz, 15 mA) is a useful method to restore an effective cough. Unfortunately, the high-stimulus-amplitude requirements and potential activation of pain fibers significantly limit this application in persons with intact sensation. In this study, the mechanism of the expiratory muscle activation, via high-frequency SCS (HF-SCS; 500 Hz, 1 mA) was evaluated in dogs. In group 1, the effects of electrode placement on airway pressure generation (P) was evaluated. Maximal P occurred at the T9-T10 level with progressive decrements in P at more rostral and caudal levels for both LF-SCS and HF-SCS. In group 2, electromyographic (EMG) latencies of internal intercostal muscle (II) activation were evaluated before and after spinal root section and during direct motor root stimulation. Onset time of II EMG activity during HF-SCS was significantly longer (3.84 ± 1.16 ms) than obtained during direct motor root activation (1.61 ± 0.10 ms). In group 3, P and external oblique (EO) EMG activity, before and after sequential spinal section at the T11-T12 level, were evaluated. Bilateral dorsal column section significantly reduced EO EMG activity below the section and resulted in a substantial fall in P. Subsequent lateral funiculi section completely abolished those activities and resulted in further reductions in P. We conclude that 1) activation of the expiratory muscles via HF-SCS is dependent entirely on synaptic spinal cord pathways, and 2) HF-SCS at the T9 level produces a comparable level of muscle activation with that achieved with LF-SCS but with much lower stimulus amplitudes. NEW & NOTEWORTHY The findings in the present study suggest that lower thoracic high-frequency spinal cord stimulation with low stimulus currents results in sufficient activation of the expiratory muscles via spinal circuitry to produce large positive airway pressures sufficient to generate an effective cough mechanism. This method, therefore, may be applied in patient populations with intact sensation such as stroke and amyotrophic lateral sclerosis to restore an effective cough.

BACKGROUND:Neurogenic detrusor overactivity (NDO) often results in decreased bladder capacity, urinary incontinence, and vesico-ureteral reflux. NDO can trigger autonomic dysreflexia and can impair quality of life. Electrical stimulation of the genital nerves (GNS) acutely inhibits reflex bladder contractions and can increase bladder capacity. Quantifying the effect of GNS on bladder capacity and determining what study factors and subject factors influence bladder capacity improvements will inform the design of clinical GNS interventions.METHODS:We measured bladder capacity in 33 individuals with NDO, with and without GNS. These data were combined with data from seven previous GNS studies (n=64 subjects). A meta-analysis of the increase in bladder capacity and potential experimental factors was conducted (n=97 subjects total).RESULTS:Bladder capacity increased 131±101 ml with GNS across subjects in all studies. The number of individuals whose bladder capacity was greater than 300 ml increased from 24% to 62% with GNS. Stimulus amplitude was a significant factor predicting bladder capacity gain. The variance of the bladder capacity gain significantly increased with increasing infusion rate. Other factors did not contribute to bladder capacity gain.CONCLUSION:GNS acutely increases bladder capacity in individuals with NDO. The consistent increase in magnitude of bladder capacities across the eight studies, and the lack of dependence on individual-specific factors, provide confidence that GNS could be an effective tool for many individuals with NDO. Studies of the chronic effect of GNS on bladder control, with clinical measures such as urinary continence, are needed.