INTRODUCTION
Over the first year after a spinal cord injury (SCI) whole body lean mass markedly declines while trunkal fat increases significantly. These deleterious changes in body composition result from the forced immobility and the limitations on exercise capacity imposed by SCI. Individuals with SCI have difficulty achieving and maintaining intensities of aerobic training that can beneficially impact body composition. Upper body exercise in SCI involves a small active muscle mass, precluding the ability to achieve more than modest exercise demands on the body. However, few studies have explored the potential effects of moderate to high intensity whole body exercise on body composition in the acute phase (<2 years) after SCI.
METHODS
Individuals aged 20-40 yrs within 24 months of an SCI (C5-T10; AIS A, B, C) were randomized to 6 months of wait-list (WL, N=6), arms only rowing (AO, N=6), or hybrid FES-rowing training (FESRT, N=11; 2 females) exercise. The goal of training was to perform 3 exercise sessions per week for 26 weeks and to achieve an exercise intensity of 70-85% maintained for a continuous 30-40 min. Aerobic capacity was measured before and after 6 months. Dual x-ray absorptiometry was used to derive body composition measures, including regional fat. Visceral adiposity was measured from a 5 cm slice placed across the entire abdomen above the iliac crest at the 4th lumbar vertebrae. Subcutaneous fat over the visceral cavity was estimated from that on each side of the abdominal cavity and subtracted from total abdominal fat to provide a value for visceral fat content.
RESULTS
WL did have a longer time since injury than AO (0.99+/-0.32 vs. 0.56+/-0.14 yrs p=0.02), but the two groups did not differ in any baseline value or change over 6 months; therefore, data from the two groups were combined for comparison to FESRT. Aerobic capacity increased significantly only in FESRT (14%, p=0.03). Body weight did not change in either WL/AO or FESRT, though fat mass tended to increase in both groups (3.1+/-1.4 kg, p=0.04; 1.8+/-1.2 kg, p=0.17). However, visceral adiposity increased significantly in WL/AO (2149+/-924 cm3, p=0.04), whereas the increase in FESRT was less and did not reach significance (938+/-742 cm3, p=0.25). Moreover, lean mass declined in WL/AO (-1.3+/-0.3, p=0.03), whereas it increased in FESRT (1.7+/-0.66 kg, p=0.03). Although leg lean mass was unchanged in WL/AO (-0.3+/-0.3 kg, p=0.39), it increased in FESRT (1.1+/-0.4, p=0.02).
CONCLUSIONS
Hybrid FES exercise training that allows for moderate to high intensity whole body exercise may provide an avenue to prevent increased fat and decreased lean mass in the first two years after an SCI. Early introduction of this form of exercise into rehabilitation for those with SCI could provide pronounced lifelong health benefits.

Introduction: Shoulder pain can develop at any time after a spinal cord injury (SCI), but frequently occurs within the first 5 years post-injury. Previous research found that half of adults with SCI have pain in both shoulders, and often the pain will last longer than 1 year and interfere with daily activities. The extent of this interference in people with SCI living in Australia is unknown. Therefore, the aim of the study is to describe the incidence of shoulder pain, associated patient characteristics and related levels of interference with daily functioning and activities in people with SCI.

Method: The problem of “shoulder pain” was included as a sub-domain of interest in the Australian module of the International Spinal Cord Injury (Aus-InSCI) Community Survey, conducted in 2018. Participants living in the community were invited to participate from SCI units in four Australian states, NSW government insurance agency and three consumer organisations. The “shoulder pain” sub-domain included 6 key questions related to shoulder pain presence, duration, interference with daily activity, treatments/strategies and their effectiveness. Patient characteristics were also recorded.

Results: 1583 adults (18 years or older) with traumatic or non-traumatic SCI at least 12 months post-injury were recruited. The demographic profile of the whole cohort was: age 58 ± 14 years; male 73%; paraplegia 61%; incomplete lesions 68%; duration post-injury 17 + 14 years (range: 23% < 5 years and 21% > 30 years). Seventy-eight percent of the cohort experienced a type of pain that interfered with their daily life and nearly half of the cohort (48%) experienced shoulder pain in previous 3 months lasting for more than a day. The presence of pain in both shoulders (25%) was twice that for right (12%) or left (10%) shoulder pain alone. Nearly, one-third of the cohort (32%) reported shoulder pain lasting from 1 to 5 years. General activities (46%) and self-care (22%) were impacted the most by presence of shoulder pain. Surprisingly, the two most common treatments/strategies for managing shoulder pain was to eat a healthy diet and keep a healthy weight (29%) and attend manual therapy (20%). Interestingly, a VAS mean score of 6 (out of 10, higher value depicting better outcome) was given for treatment effectiveness. Compared to one year ago, most participants rated their function and independence as about the same (63%), with a smaller proportion being better (18%) or worse (19%).

Conclusions: Aus-InSCI represents the largest and most comprehensive survey about the ’lived experience’ with SCI in Australia. Shoulder pain is recognised as the most common and incapacitating upper limb problem in individuals following SCI. Conservative therapies incorporating exercise can significantly reduce shoulder pain in people with SCI. However, pain can persist and have a major impact on functioning and independence. Given these findings, the development of preventive and management strategies to decrease the prevalence of painful shoulder would be beneficial to this population. National and international organisations should encourage policy and decision makers to tackle the challenging and important issue of shoulder pain in people with SCI.

Aims
To explore the unique intersection between arm/hand surgical reconstructions, timing of intervention, current clinical assessments and the life impacts described by individuals with tetraplegia, in light of innovative nerve transfer (NT) surgeries becoming more commonplace world-wide.

Methods/Design
A mixed methods convergent design was utilized for concurrent analysis of the data from the assessment of all individuals considering arm/hand reconstructive surgery, regardless of their final decision. For the surgery group, analysis involved three main patient-reported outcome measures (PROMs), which have been collected since 2010, when the international upper limb registry was launched in New Zealand. In parallel, a qualitative case series explored the lived experience of tetraplegia at various time points between the onset of tetraplegia and making a decision to either accept or decline arm/hand reconstruction surgeries. The International Classification of Functioning, Disability and Health (ICF) taxonomy was used as an analytical lens to guide data interpretation.

Results
From 2010, 90 individuals were assessed as clinically suitable for arm/hand recontructions, of whom 55 accepted surgery and received up to three surgical tendon transfer (TT) reconstructions: key pinch, grasp and elbow. Sixteen individuals received NTs with or without TT procedures at less than 12 months following their SCI. The most common cause of injury was transport (n = 41), with remainder accounted for by sports, falls and other trauma (n = 48) and one unknown cause. Based on the NZ census data where 15% of the population self-identify as indigenous Maori, there was over-representation of Maori in this sample (n = 30). To date, 18 semi-structured interviews have been completed, consisting of seven participants who declined surgery, five participants who received late TT surgery and six early NT surgery participants. Preliminary content analysis using ICF linking reveals self-care activities associated with the construct of looking after one’s health (d570) dominated, although driving (d475) was the most frequent single pre-surgery goal. Identified self-care tasks include changing basic body position (d410), eating (d550), drinking (d560) and dressing (d560). Undertaking a single task (d210) was most frequently linked to ADL.

Conclusion
First, the pursuit of independence was greatest in the newly-injured group, while alternative views of independence emerged based on the actual lived experience and the daily demands of tetraplegia. This was in the presence of improvements in arm/hand function for all surgery participants. The alternatives were to ‘live a meaningful life' and/or 'well-being' based. This is not to say independence has no importance or value, just that its dominant positioning may need to be questioned. Second, from this sample, young indigenous Maori appear at higher risk of tetraplegia and also are more likely to decline TT reconstructions. However, these individuals show stronger acceptance of early surgery options offered during their post-acute rehabilitation. A mixed methods approach allows for greater appreciation of both participant characteristics and surgery uptake, and the relativity of arm/hand function than can be achieved by either quantitative or qualitative inquiry, particularly in a country with a low population such as New Zealand.

Introduction:
Wheelchair users with spinal cord injury (SCI), who are dependent on their upper limbs for mobility, show a high prevalence of shoulder pain (up to 69%).1,2 The occurrence of shoulder
pain detrimentally affects functioning, independence, participation and quality of life. It is generally assumed that shoulder pathology is causing shoulder pain, however results from previous studies are conflicting and most studies included only patients with shoulder pain. 3,4
The objective of our study was to describe the association between reported shoulder pain and shoulder pathology to understand a possible causal relationship between shoulder pathologies and shoulder pain. The aims of this study were:
1. to describe present shoulder pathologies in wheelchair users with SCI, assessed by MRI.
2. to evaluate the association between shoulder pathologies and the presence of shoulder pain.

Design: cross-sectional between-group analysis

Participants: a convenience sample of 51 shoulders (51 participants) of wheelchair dependent persons (44 males, 7 females, median age 50 years (IQR 14), median time since injury (TSI) of 24 years (IQR 16) and median Wheelchair User Shoulder Pain Index (WUSPI) of 13 (IQR 39) with a chronic SCI. Participants were grouped according to prevalence of shoulder pain: no-pain (NP) group included participants with WUSPI 0-15, pain (P) group participants with WUSPI >15.

Method: All persons underwent MRI imaging of the shoulder. Pathologies were scored (number and severity) by two blinded and experienced radiologists. The included pathologies were atrophy, tendon pathologies and calcifications in the rotator cuff, pathologies of the long biceps tendon, arthrosis of the acromioclavicular and glenohumeral joint, subacromial and subcoracoidal bursitis and calcifications, subchondral cysts on the glenoid and/or the caput humeri and labrum lesion.
Participants characteristics and number and severity of shoulder pathologies were analyzed descriptively. Univariate logistic regression was performed to evaluate the association between shoulder pathologies and shoulder pain. To evaluate the clustering of shoulder pathologies the Jaccard binary similarity coefficient was used.

Results:
The NP group included 27 persons (15 with paraplegia, 12 with tetraplegia) with a median WUSPI score of 0 (IQR 5). The P group included 24 persons (15 with paraplegia, 9 with tetraplegia) with a median WUSPI score of 42 (IQR 34).
The number of co-occurring MRI findings in the participants’ shoulder ranged from 0 to 17 (out of 28 possible findings), with a median of 7 (IQR 5). The most frequent findings were arthrosis of the acromioclavicular joint (NP 74%, P 87%) and findings on the supraspinatus (NP 78%, P 92%), subscapularis (NP 52%, P 81%) and long biceps tendons (NP 66%, P 77%).
There was no statistical difference of present shoulder pathologies between the P and NP group in any of the MRI findings. Typical clusters of shoulder pathologies in both groups were: supraspinatus tears, subscapularis tears, acriomioclavicular arthrosis, subchondral cysts and biceps lesions.

Conclusion:
Shoulder pathologies are common in persons with and without shoulder pain. Interventions, therefore should be carefully planned considering clinical symptoms and findings and not be solely based on MRI findings of shoulder pathology.

Introduction:
Repetitive contractions are often used in an attempt to increase the voluntary strength of very weak muscles in people with spinal cord injuries (SCI). However, it is unknown whether this is an effective training paradigm. The aim of this trial is to compare the effectiveness of repeated contractions of isolated muscles combined with usual care, versus usual care alone for increasing strength in the very weak muscles of people with recent SCI. That is, in muscles with grade 1 or 2 strength on the traditional 6-point manual muscle test scale.

Methods:
One hundred and twenty people with recent SCI undergoing inpatient rehabilitation participated in this trial. Participants were randomised to either an experimental or control group. One target muscle group with grade 1 or 2 strength was selected from the following muscles: the elbow flexors, elbow extensors, wrist flexors, wrist extensors, knee flexors, knee extensors, ankle dorsiflexors or ankle plantarflexors. Participants allocated to the Treatment group performed 200 repetitions of isolated contractions of the target muscle as well as usual care. Participants allocated to the Control group received usual care alone. Participants were assessed at baseline and 8 weeks by a blinded assessor. The primary outcome was voluntary muscle strength, and the secondary outcomes were participants’ perceptions of strength and function, and therapists’ expectation of final strength.

Results:
There were three dropouts. The mean between-group difference for the primary outcome of voluntary strength at 8 weeks was 0.4 on a 13-point scale (95% confidence interval -0.5 to 1.3). This is less than the clinically worthwhile treatment effect of 1 point set a priori. The mean between-group difference for participants’ perception of change in strength and function were 0.8 points (95% CI 0.1 to 1.4) and 0.6 points (95% CI -0.04 to 1.3), respectively on a 15-point scale.

Conclusion:
The results indicate that two hundred repetitions of isolated muscle contractions per day does not increase the strength of very weak muscles directly affected by spinal cord injury. However, participants may perceive an increase in strength with repetitive exercise.

Introduction: Triceps is paralyzed in patients with C5 tetraplegia, while the deltoid and elbow flexors are preserved. Elbow extension restoration surgery aims to reconstruct the paralyzed extension by transferring the tendon of a preserved muscle, either the posterior deltoid or the biceps brachii, to the distal tendon of the triceps brachii. Several months of rehabilitation are then necessary, during which the transferred muscle adapts to its new function. The purpose of this study was to explore the muscle synergies during elbow flexion-extensions in a patient with a C5 tetraplegia, who underwent a surgical restoration of elbow extension.
Methods: A patient with C5 tetraplegia 5 (ASIA impairment scale B) was recruited to follow a movement analysis protocol of his upper limb movements before an elbow extension restoration surgery with a posterior deltoid transfer (Moberg technique) associated with a medialization of the anterior deltoid (Buntine technique), and throughout the rehabilitation period. The protocol consisted in performing elbow flexion / extensions with the shoulder abducted at 30°, 60°, 80°, 90° and 120°. Kinematics and muscle activation were measured using 29 retroreflective markers, 11 electromyographic surface electrodes and 2 intramuscular electrodes. Muscle synergies were extracted from EMG signals using Non-Negative Matrix Factorization.
Results: The posterior deltoid was exclusively activated during elbow extension, from 6 weeks post-surgery for the elbow flexion-extension trials with the shoulder abducted at 30° and 60°, from 14 weeks post-surgery at 80°, and from 18 weeks post-surgery at 90°. From 18 weeks post-surgery, elbow extension against gravity was possible, however only still with a permanent activation of the posterior deltoid during the extension-flexion cycle. Throughout rehabilitation, the anterior deltoid became more and more synergistic with the posterior deltoid, while the middle deltoid, supraspinatus and trapezius muscles had a permanent activation during the movement cycle.
Conclusions: The transferred muscle acquired its elbow extensor function at 90° of shoulder abduction from week 18 after surgery. Recruitment of the deltoid posterior during extension became more and more efficient with rehabilitation time. However, co-contraction of the posterior deltoid remained during elbow flexion-extensions above the shoulder level. The medialization of the anterior deltoid seemed to be efficient to ensure shoulder stabilization during elbow extension, with the help of middle deltoid, supraspinatus and trapezius muscles. More patients with a posterior deltoid’s and a biceps brachii’s transfer will be recruited in this study. We expect these results to provide a better comprehension of muscle adaptation after elbow extension restoration surgery and to guide the rehabilitation for each patient.