Neuromotor prostheses (NMPs) aim to replace or restore lost motor functions in paralysed humans by routeing movement-related signals from the brain, around damaged parts of the nervous system, to external effectors. To translate preclinical results from intact animals to a clinically useful NMP, movement signals must persist in cortex after spinal cord injury and be engaged by movement intent when sensory inputs and limb movement are long absent. Furthermore, NMPs would require that intention-driven neuronal activity be converted into a control signal that enables useful tasks. Here we show initial results for a tetraplegic human (MN) using a pilot NMP. Neuronal ensemble activity recorded through a 96-microelectrode array implanted in primary motor cortex demonstrated that intended hand motion modulates cortical spiking patterns three years after spinal cord injury. Decoders were created, providing a ‘neural cursor’ with which MN opened simulated e-mail and operated devices such as a television, even while conversing. Furthermore, MN used neural control to open and close a prosthetic hand, and perform rudimentary actions with a multi-jointed robotic arm. These early results suggest that NMPs based upon intracortical neuronal ensemble spiking activity could provide a valuable new neurotechnology to restore independence for humans with paralysis. The cover shows Matt Nagle, first participant in the BrainGate pilot clinical trial. He is unable to move his arms or legs following cervical spinal cord injury. Researchers at the Department of Neuroscience at Brown University, working with biotech company Cyberkinetics and 3 other institutions, demonstrate that movement-related signals can be relayed from the brain via an implanted BrainGate chip, allowing the patient to drive a computer screen cursor and activate simple robotic devices. Such neuromotor prostheses could pave the way towards systems to replace or restore lost motor function in paralysed humans. Prior to this advance, this type of work has been performed chiefly in monkeys. The latest example of such research has achieved a large increase in speed over current devices, enhancing the prospects for clinically viable brain-machine interfaces.

Neuronal ensemble control of prosthetic devices by a human with tetraplegia

In the United States alone, there are more than 200,000 individuals living with a chronic spinal cord injury (SCI). Healthcare for these individuals creates a significant economic burden for the country, not to mention the physiological, psychological, and social suffering these people endure everyday. Regaining partial function can lead to greater independence, thereby improving quality of life. To ascertain what functions are most important to the SCI population, in regard to enhancing quality of life, a novel survey was performed in which subjects were asked to rank seven functions in order of importance to their quality of life. The survey was distributed via email, postal mail, the internet, interview, and word of mouth to the SCI community at large. A total of 681 responses were completed. Regaining arm and hand function was most important to quadriplegics, while regaining sexual function was the highest priority for paraplegics. Improving bladder and bowel function was of shared importance to both injury groups. A longitudinal analysis revealed only slight differences between individuals injured 3 years. The majority of participants indicated that exercise was important to functional recovery, yet more than half either did not have access to exercise or did not have access to a trained therapist to oversee that exercise. In order to improve the relevance of research in this area, the concerns of the SCI population must be better known and taken into account. This approach is consistent with and emphasized by the new NIH roadmap to discovery.

/pdf/targeting-recovery-priorities-of-the-spinal-cord-injured-1sllg7pz60.pdf

Targeting recovery: Priorities of the spinal cord-injured population

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140673602076031.pdf

Spinal-cord injury

Objective. —To compare the efficacy of methylprednisolone administered for 24 hours with methyprednisolone administered for 48 hours or tirilazad mesylate administered for 48 hours in patients with acute spinal cord injury. Design. —Double-blind, randomized clinical trial. Setting. —Sixteen acute spinal cord injury centers in North America. Patients. —A total of 499 patients with acute spinal cord injury diagnosed in National Acute Spinal Cord Injury Study (NASCIS) centers within 8 hours of injury. Intervention. —All patients received an intravenous bolus of methylprednisolone (30 mg/kg) before randomization. Patients in the 24-hour regimen group (n=166) received a methylprednisolone infusion of 5.4 mg/kg per hour for 24 hours, those in the 48-hour regimen group (n=167) received a methylprednisolone infusion of 5.4 mg/kg per hour for 48 hours, and those in the tirilazad group (n=166) received a 2.5 mg/kg bolus infusion of tirilazad mesylate every 6 hours for 48 hours. Main Outcome Measures. —Motor function change between initial presentation and at 6 weeks and 6 months after injury, and change in Functional Independence Measure (FIM) assessed at 6 weeks and 6 months. Results. —Compared with patients treated with methylprednisolone for 24 hours, those treated with methylprednisolone for 48 hours showed improved motor recovery at 6 weeks (P=.09) and 6 months (P=.07) after injury. The effect of the 48-hour methylprednisolone regimen was significant at 6 weeks (P=.04) and 6 months (P=.01) among patients whose therapy was initiated 3 to 8 hours after injury. Patients who received the 48-hour regimen and who started treatment at 3 to 8 hours were more likely to improve 1 full neurologic grade (P=.03) at 6 months, to show more improvement in 6-month FIM (P=.08), and to have more severe sepsis and severe pneumonia than patients in the 24-hour methylprednisolone group and the tirilazad group, but other complications and mortality (P=.97) were similar. Patients treated with tirilazad for 48 hours showed motor recovery rates equivalent to patients who received methylprednisolone for 24 hours. Conclusions. —Patients with acute spinal cord injury who receive methylprednisolone within 3 hours of injury should be maintained on the treatment regimen for 24 hours. When methylprednisolone is initiated 3 to 8 hours after injury, patients should be maintained on steroid therapy for 48 hours.

https://jamanetwork.com/journals/jama/articlepdf/416377/jama_277_20_029.pdf

Administration of Methylprednisolone for 24 or 48 Hours or Tirilazad Mesylate for 48 Hours in the Treatment of Acute Spinal Cord Injury Results of the Third National Acute Spinal Cord Injury Randomized Controlled Trial

Task-oriented repetitive movements can improve motor performance in patients with neurological or orthopaedic lesions. The application of robotics and automation technology can serve to assist, enhance, evaluate, and document neurological and orthopedic rehabilitation. This paper deals with the application of "patient-cooperative" techniques to robot-aided gait rehabilitation of neurological disorders. We define patient-cooperative to mean that, during movement, the technical system takes into account the patient's intention and voluntary efforts rather than imposing any predefined movements or inflexible strategies. It is hypothesized that such cooperative robotic approaches can improve the therapeutic outcome compared to classical rehabilitation strategies. New cooperative strategies are presented that detect the patient's voluntary efforts. First, this enables the patient increased freedom of movement by a certain amount of robot compliance. Second, the robot behavior adapts to the existing voluntary motor abilities. And third, the robotic system displays and improves the patient contribution by visual biofeedback. Initial experimental results are presented to evaluate the basic principle and technical function of proposed approaches. Further improvements of the technical design and additional clinical testing is required to prove whether the therapeutic outcome can be enhanced by such cooperative strategies.

Patient-cooperative strategies for robot-aided treadmill training: first experimental results

International Standards for Neurological and Functional Classification of Spinal Cord Injury

/pdf/international-standards-for-neurological-and-functional-5ehs1y6y0w.pdf

The ®rst edition of the International Standards for Neurological and Functional Classi®cation of Spinal Cord Injury, ie neural disturbances (`Spinal Cord Injury') whether from trauma or disease, was published in 1982 by the American Spinal Injury Association (ASIA). Reference was made to the 1992 Revision of the International Standards and published in Paraplegia (the former title of Spinal Cord) in 1994, Volume 32, pages 70 ± 80 by JF Ditunno Jr, W Young, WH Donovan and G Creasey. Since then there have been three revisions, the most recent being in 1996. Dr Frederick M Maynard Jr in his Preface to this Fourth Revision said:-

Thomas B. Ducker

Papers

International Standards for Neurological and Functional Classification of Spinal Cord Injury

International Standards for Neurological and Functional Classi®cation of Spinal Cord Injury