Background
Weight gain is a common problem in patients with spinal cord injury, which could increase the risk of metabolic syndrome and related morbidity. This could be attributed to overestimation of energy requirements, despite a tendency for reduction in energy expenditure compared to pre-injury levels, loss of voluntary muscle use below the spinal cord lesion and reduction in lean tissue mass.

Study design
Prospective Cohort Study

Population
Persons with acute Spinal Cord Injury admitted for inpatient rehabilitation.

Intervention
None

Objectives
To determine the quantum of differences between measured Energy Expenditure (m-EE) and predicted energy expenditure (p-EE) during different stages of acute spinal cord injury rehabilitation, in order to estimate sample size for a future definitive study.

To assess the feasibility related to recruitment and clinical assessment for outcome measures

Setting
Inpatient wards of Princess Royal Spinal Injuries Centre, Sheffield Teaching Hospitals, UK

Methods
All patients completed their rehabilitation program as per existing protocols in the centre for bed-rest and mobilization following acute spinal cord injury. After recruitment, demographic data and outcome measures were completed at bed-rest phase, early mobilization phase, and before discharge. Estimated resting and total daily energy expenditure were calculated using the Henry Equations. Actual energy requirements were measured under standard conditions by indirect calorimetry (GE Healthcare metabolic oxygenator). Other parameters recorded included anthropometric and metabolic syndrome measurements, and fasting venous blood samples for blood sugars and cholesterol levels.

Results
Ninety-one patients were screened for this study, of which 29 were recruited between 9th September 2015 and 17th July 2018 which resulted in a recruitment rate of 0.85 patients per month. Out of the 29 recruited patients three (10%) withdrew from the study, one (3%) died, one (3%) was withdrawn, one (3%) was lost to follow up and 11(38%) were not followed up.

Across all timepoints and injury groups, m-EE was lower than p-EE, mean -711 Kcal/day (95% CI -821, -601). m-EE in paraplegic patients was lower than p-EE by a greater magnitude, mean difference – 871 Kcal/day, (95% CI -1000, -634), than in tetraplegic patients, mean difference -604 Kcal/day (95% CI -724, -484).

Though 29 participants were recruited, fewer contributed complete data sets than anticipated (13 at bed rest and mobilization, 10 at discharge) which would have introduced greater uncertainty around our estimates. This was a result of multiple factors, including staffing schedules, practical difficulties with performing certain anthropometric measurements, and delay in admission for rehabilitation within the bed-rest phase due to acute management of spine injuries at major trauma centres.

Conclusion
Measured Energy Expenditure was less than predicted Energy Expenditure by an average of 711 Kcal/day in this cohort of patients during the course of their acute spinal cord injury rehabilitation. The quantum of difference was greater in those with paraplegia compared to tetraplegia. Recruitment rates and data measurements were influenced by constraints on staffing schedules, measurement techniques for certain outcome measurements, and admission pathways for Spinal Cord Injury rehabilitation.

Protocol
https://clinicaltrials.gov/ct2/show/NCT03661294

Introduction: Cardiorespiratory fitness generally is reduced in wheelchair users with a spinal cord injury (SCI), resulting in high risks of cardiovascular complications. Therefore, exercise interventions such as handcycling training are important. The HandbikeBattle event (HBB) is an annual uphill handcycling race in Austria among teams of twelve Dutch rehabilitation centers, which is preceded by a 5-month training period. The HBB was created to promote handcycling and an active lifestyle among former rehabilitation patients. Previous research has shown positive effects of participation in the HBB on cardiorespiratory fitness and health. Associations among training load and the change in cardiorespiratory fitness are, however, unknown. The aim of the study was to examine: 1) associations between training load and change in cardiorespiratory fitness, 2) occurrence of musculoskeletal shoulder pain during the training period.
Methods: 62 Wheelchair users (age 40 ± 12 years, 41 men; of which 28 SCI, 7 spina bifida, 27 other) participated. The training period was only monitored by the researchers, i.e. no specific training regime was imposed. A handcycling/arm crank graded exercise test was performed at the beginning (T1) and end (T2) of the training period. Peak power output per kg (POpeak/kg) and peak oxygen uptake per kg (VO2peak/kg) were primary outcome measures for cardiorespiratory fitness. For each training session, participants filled out the rating of perceived exertion (sRPE, scale 0-10) and the duration of the session in minutes. Training load was defined as the Training Impulse (TRIMP); which is sRPE multiplied by duration of the session, in arbitrary units (AU). All training sessions were summed to define total TRIMPsRPE for each participant. Shoulder pain was assessed with a questionnaire (range 1 – 6) at T1 and T2. Having moderate-severe pain was defined as ≥4 (moderate pain) at one or both shoulders. Multilevel regression analyses were used to investigate the association between training load and change in cardiorespiratory fitness. Shoulder pain was assed descriptively.
Results: A total of 4787 training sessions were analyzed. Participants trained for 21 ± 6 weeks with an average of 4 ± 1 training sessions per week. Mean weekly TRIMPsRPE was 1642 ± 630 AU. POpeak/kg showed a significant increase from 1.52 ± 0.51 W/kg at T1 to 1.81 ± 0.56 W/kg at T2 (∆POpeak/kg 0.28 ± 0.25 W/kg, 21%, p<0.001, ES=0.53). VO2peak/kg showed a significant increase from 24.82 ± 7.80 ml/kg/min at T1 to 28.91 ± 7.93 ml/kg/min at T2 (∆VO2peak/kg 3.97 ± 3.41 ml/kg/min, 18%, p<0.001, ES=0.50). Total TRIMPsRPE was not significantly associated with change in cardiorespiratory fitness. At T1, 20% of participants reported moderate-severe shoulder pain, at T2 14% reported moderate-severe shoulder pain (p=0.51).
Conclusions: Cardiorespiratory fitness significantly increased during the training period. Shoulder pain showed no significant change. Training load (total TRIMPsRPE) was not significantly associated with change in cardiorespiratory fitness. To understand the dose-response relationships between cardiorespiratory outcomes and training load better, associations between training load and change in submaximal responses; such as mechanical efficiency, lactate curves and ventilatory thresholds, might be an interesting focus for future studies.

Introduction:
Most robotic overground gait training devices require users to use crutches to keep balance, which is a clear limitation on their use in everyday life.

We present the results of the first prospective clinical study on a newly developed self-balancing robotic exoskeleton (Atalante®, Wandercraft) that enables individuals with spinal cord injury (SCI) to perform ambulatory functions without technical aids.

Design/Methods:
Inclusion criteria were patients with a chronic motor complete SCI (AIS A or B) ranging from T5 to T12, with stable medical conditions. The study protocol included 12 one-hour training sessions during 3 weeks. Patients walked on the floor with the robotic assistance connected to a mobile suspension system (without weight bearing) to prevent falling.
Patients were recruited from 2 rehabilitation centres as part of a protocol for CE marking.

Main outcome was the ability to walk 10 meters unassisted, secondary outcomes were assessment of other ambulatory functions, of bladder and bowel functions, pain and spasticity.

Results:
Twelve patients were enrolled: 11 completed the protocol and one withdrew for personal reasons. There were 9 men and 2 women, mean age 33.9 years, mean time since injury was 8.3 years. Six patients had T6 levels of lesion, 5 had lesions at or below T10. Eight patients had lower limbs spasticity.

Seven patients passed the 10mWT unassisted at the 12th session (mean walking speed 0,13m/s), while 4 required some human help. All 11 patients succeeded the other ambulatory tests (stand-up, sit-down, balance, turn).

We did not observe any significant change on the bladder function (Qualiveen score) or neuropathic pain (NPSI, NPRS). Five patients described an improvement of the bowel function (VAS), which was not correlated with the NBD score. Assessment of spasticity with the Ashworth scale showed heterogeneous results depending on the muscles examined. Ischial skin erosion was seen in patient that needed local dressing.

Conclusion:
This is the first study that demonstrates the effectiveness and safety of a dynamic self-balancing robotic exoskeleton for walking in persons with SCI. Besides the obvious advantage of freeing the upper limbs for use in the everyday life (lifting or carrying loads and objects…), it also mimics a person’s natural gait. The mean walking speed observed was higher than that obtained with other self-supporting robotic devices (1). This new technology opens new perspective in the field of assistance for persons with high level of dependence.

(1) Barbareschi G, Richards R, Thornton M, Carlson T, Holloway C. Statically vs dynamically balanced gait: Analysis of a robotic exoskeleton compared with a human. Conf Proc IEEE Eng Med Biol Soc.2015;2015:6728-31.

Introduction: People living with spinal cord injury (SCI) who ambulate (i.e., SCI ambulators) participate in half as much leisure-time physical activity (LTPA) as wheelchair-users with SCI. Although preliminary research has identified some of the barriers and facilitators to LTPA participation for SCI ambulators (e.g., pain, fatigue), there has not been a systematic examination of factors related to physical activity participation in this population. The Theoretical Domains Framework (TDF) is one methodological approach that can be used to systematically investigate these factors. The TDF synthesizes constructs from 33 theories of behaviour change into 11 domains of behavioural influences. The TDF is used to identify domains/factors (e.g., social influences, motivation and goals) that are most relevant for explaining and changing a particular behaviour, thus indicating opportunities and factors to target in PA-enhancing interventions. Therefore, the objectives of this study were to (1) identify barriers and facilitators to LTPA as identified by SCI ambulators, (2) categorize these factors using the TDF and (3) establish the strength of the relationships between TDF factors and LTPA among SCI ambulators.
Methods: Twenty-one SCI ambulators (100% AIS-D; Mage=39 years; Mpost-injury=8.38 years; 52% male; 24% tetraplegic) participated in this study; 62% used mobility aids (e.g., orthotics, walker). The LTPA Questionnaire for People with SCI (LTPAQ-SCI) was used to assess the total number of minutes per week spent on LTPA (inclusive of mild, moderate, and heavy intensity LTPA). TDF factors related to LTPA were measured by the Determinants of Physical Activity Questionnaire through 33-items rated on 7-point Likert scales (1 = strongly disagree; 7 = strongly agree). Descriptive statistics were used to identify and categorize TDF factors. Two-tailed bivariate Pearson correlations were calculated between TDF factor ratings and min/week of LTPA.
Results: ‘Knowledge’ (M=3.97; SD=1.76), ‘Coping Planning’ (M=4.56; SD=1.25), and ‘Beliefs in Capabilities’ (M=4.79; SD=1.58) were rated the lowest, suggesting their absence may act as the greatest barriers to LTPA. Factors positively correlated with min/week of LTPA were: having the sports/exercise skills to do physical activity, r=.77, p<.01; not being easily distracted from the physical activity planned, r=.59, p=.01; and being prepared to give up things done in leisure time for physical activity, r=.53, p<.05. No other TDF factors were significantly correlated with LTPA.
Discussion: Although SCI ambulators lack knowledge on LTPA and have reduced beliefs in their capabilities to do LTPA, these factors are not associated with min/week of LTPA. Rather, beliefs relating to skills, coping planning, and goal conflict are significantly associated with LTPA min/week. Interventionists are advised to develop interventions that provide information on how SCI ambulators can be active and how to develop coping plans to overcome barriers to activity. Self-efficacy enhancing interventions would also be beneficial to bolster beliefs in one’s ability to be active.

Introduction
Loss of upper extremity function after cervical spinal cord injury (SCI) impacts heavily on independence. Nerve transfer surgery offers an exciting new option for re-animation of arm and hand function in tetraplegia.

Methods
This study was a prospective case series, consecutively recruiting people with early, traumatic, cervical SCI referred to a single centre for upper extremity reanimation. Goals were restoration of elbow extension, grasp, pinch and hand opening. Participants were assessed at 12 and 24 months post-surgery. Primary outcome measures were the Action Research Arm Test (ARAT), Grasp Release Test (GRT) and the Spinal Cord Independence Measure (SCIM).

Results
Sixteen participants (27 limbs) with mid level cervical SCI were recruited and 59 nerve transfers performed. At 24 months, there was a significant improvement in ARAT (mean difference -14·36, CI -18·76 to -9·97 p=0·001) and GRT (mean difference – 74·89, CI -96·04 to -53·73 p=0·001). SCIM subscales improved by more than the minimal detectable change (MDC) and the minimal clinically important difference for total SCIM score and ‘mobility in the room/toilet’, and the MDC for self-care. Median triceps strength was grade 3 (IQR-2-3) and digital extensor strength was 4 (IQR-4-4). Mean grasp strength, in a subgroup of participants with nerve transfers, was 3.2kg (SD 1·5). Adverse events were few, with no functional consequences.

Conclusion
Nerve transfer surgery is a safe and effective addition to surgical techniques for upper limb reanimation in tetraplegia. Nerve transfers resulted in significant functional improvement in all standardised outcome measures utilised.

Funding
Institute for Safety, Compensation and Recovery Research, Victoria, Australia