835

NeuroRehabilitation 35 (2014) 835–840 DOI:10.3233/NRE-141158 IOS Press

The application of somatosensory evoked potentials in spinal cord injury rehabilitation Xie Caizhonga,∗ , Shan Chunleib , Liu Beibeia , Ding Zhiqinga , Ding Qinnenga and Wang Tongb,∗ a Department

of Rehabilitation Medicine, Jinling Hospital, Nanjing Medical University, Nanjing, Jiangsu, China

b Department of Rehabilitation Medicine, the First Affiliated Hospital of Nanjing Medical University, Jiangsu, China

Abstract. BACKGROUND: For a therapeutic intervention after spinal cord injury (SCI), it is important to take accurate and objective assessment tools. OBJECTIVE: To explore the practicability of somatosensory evoked potentials (SEPs) and Modified Barthel Index (MBI) scale and describe the rehabilitation value of SEPs in different degrees of SCI. METHODS: Thirty-six SCI patients were enrolled in this study. All the patients received comprehensive rehabilitation treatment, such as physical therapy, occupational therapy, functional electrical stimulation, and psychotherapy. The nerve function of the spinal cord was assessed by SEPs, the activities of daily living (ADL) was evaluated by MBI scale, and SEP recordings and MBI scores were obtained before and after treatment. RESULTS: There were statistically significant differences in SEPs latency among different grades of SCI before treatment. The SEPs latency after treatment was better than that before treatment in every grade (p < 0.05). Comparable differences among different grades were also detected by MBI scores before treatment (p < 0.05), and the MBI scores increased significantly after treatment (p < 0.05), higher in each group than another from grade A to B, C, and D. There was a linear correlation between SEPs latency and MBI scores before and after treatment. CONCLUSION: SEPs combined with MBI scale could objectively reflect the SCI degree and accurately monitor therapeutic intervention in SCI. SEPs have a greater value in monitoring SCI than MBI and their rehabilitation value varies in different grades of SCI. Keywords: Spinal cord injury, somatosensory evoked potentials, Modified Barthel Index, activities of daily living, rehabilitation treatment, outcome

1. Introduction With the development of medicine, the survival rate of SCI is increasing. Basic research and clinical medicine aim to treat SCI using a variety of strategies (Lalwani et al., 2011; Wang et al., 2011). Recent studies show that a combination of clinical medicine and ∗ Address for correspondence: Dr. Xie Caizhong, Department of Rehabilitation Medicine, Jinling Hospital, Zhongshan East Road No. 305, Nanjing, Jiangsu province, China. Tel.: +02580860311; E-mail: [email protected]; Wang Tong, PhD, Department of Rehabilitation Medicine, the First Affiliated Hospital of Nanjing Medical University, Jiangsu 210029, China. E-mail: [email protected].

rehabilitation medicine can obviously lower the complications of SCI, and greatly improve the sufferers’ quality of life (Christine Fekete, & Alexandra Rauch, 2012; Arif Jetha et al., 2011). Great progress has been made in the diagnosis and treatment of SCI, but objective and effective methods are yet to be developed for its evaluation (Alexander et al., 2009). Besides, adequate studies are required on the changes of the nervous function after SCI. Many authors have reported SEPs to be a useful neurophysiological approach to detect the objective functional abnormality of the spinal cord. SEPs receive input from sensory pathways originating in the limbs, which can be used to assess the integrity of neural processing capabilities in SCI patients. We

1053-8135/14/$27.50 © 2014 – IOS Press and the authors. All rights reserved

836

X. Caizhong et al. / The application of somatosensory evoked potentials in spinal cord injury rehabilitation

previously utilized MBI scale to measure ADL in SCI patients, but its significance was uncertain. In this study, we employed the posterior tibial nerve SEPs and MBI to evaluate the therapeutic effect in 36 SCI patients, explored the practicability of SEPs and MBI, and investigated their value of rehabilitation for different degrees of SCI.

2. Method 2.1. Participants This retrospective study was carried out in the Department of Rehabilitation Medicine, Jinling Hospital, Nanjing, Jiangsu Province, China from October 2009 to May 2012. The experiment was performed after obtaining patient informed consent, and ethical approval from the Ethics Committee of Jinling Hospital. This study included 36 SCI patients, 22 males and 14 females, aged 35 to 67 years, and diagnosed by MRI. Among them, there were 23 cases of lumbar vertebral damage and 13 cases of thoracic vertebral damage. The causes of SCI varied from falling from high altitude to traffic accident and disease-induced spinal cord compression. And the disease course was from 15 days to 1 year. All the patients received surgical treatment with inside fix, followed by a month of rehabilitation therapy. Based on ASIA classification (Eriks Hoogland et al., 2011), the patients were graded as A, B, C, D and E. Grade A (n = 8) referred to complete SCI, including those without any sensory and motor function in the Mao department; B (n = 9) incomplete SCI, including those with Sensory Function but no Motor Function; C (n = 9) incomplete SCI, including those with half of the key muscles above grades 1–2; D (n = 10) incomplete SCI, including those with half of the key muscles above grade 3; and E (n = 0) with normal sensory and motor function. The patients of grades A, B, C and D were grouped together and separated by the motor level to determine the remaining four categories. The data including SEPs recordings and MBI scales were collected during hospital stay and after rehabilitation treatment. 2.2. Rehabilitation treatment All the patients had stable vital signs and normal spinal column. According to the locations of nervous lesions and clinical stages of SCI, we established different rehabilitation protocols and adopted different

strategies for the SCI patients (Natale et al., 2009; Ozelie et al., 2009; Wilson et al., 2009; Johnson et al., 2009; Abeyta et al., 2009). Rehabilitation treatment was performed once a day, 5 times a week for 4 weeks. The followings are rehabilitation strategies for the SCI patients. In the acute unstable phase of SCI for 2–4 weeks, the patients received bed-side rehabilitation treatment, the main measures taken included proper positioning of extremities, axial turning-over of the body, passive and active range of on-bed motion, breathing exercise, functional electrical stimulation (FES), bladder and bowel function training, and strength training. In the acute stable phase of SCI for 5–8 weeks, the patients carried on functional training. The main rehabilitation measures included range of motion, strength training, FES to improve the functions of the paralyzed extremities and the bladder and bowel, a chest-waist for standing, sitting and posture balance, transfer training for moving from bed to wheelchair or from wheelchair to toilet, and bladder and bowel function training. In the intermediate phase of recovery from SCI for 8–12 weeks, when the fractured part, injured nerves, compression symptoms and breathing became stable, rehabilitation treatment focused on further improvement of muscle strength, muscles of the arms and shoulders trained for those with complete SCI, while the remaining muscles strengthened for those with incomplete SCI. Patients who needed the use of assistive device practiced standing and walking inside Gang in addition to wheelchair, ADL and hand-function training. In the late phase of recovery from SCI of over 12 weeks, when the patients no longer stayed in hospital, we continued all the training contents of the intermediate phase, and instructed the patients’ family members about the prevention of complications and methods of rehabilitation, so that the patients could complete the training program at home. 2.3. Effect assessment Activities of daily living (ADL) assessment. Evaluation of ADL using MBI scale revealed the locomotor performance and rehabilitation efficacy in the patients with different grades of SCI. The individual performance of 10 daily function activities was measured by MBI scale concerning self-care, continence and locomotion, and the scores on the 10 items were based on the amount of physical assistance required to

X. Caizhong et al. / The application of somatosensory evoked potentials in spinal cord injury rehabilitation

perform the task. Each item with 5 categories (Hetz, Latimer, & Ginis, 2009). The maximal score of each item represented the weight of that item for its relative contribution to the total score. For example, personal hygiene constituted a maximum 5 of 100 points, dressing 10 of 100 points, and chair/bed transfer 15 of 100 points. SEPs Monitoring. Assessment of spinal cord function using posterior tibial nerve SEPs revealed the injury severity and the pattern of recovery of SCI. The electrophysiological monitoring system (MEB9102, Neuropacki, NIHON KOHDEN, Japan) was used to elicit and record SEPs (Cardini, Longo, & Haggard, 2011). SEPs of the leg were recorded by using surface electrodes on the scalp overlying the primary sensory area in the parietal lobe contralateral to the stimulated limb at Cz’ (2 cm behind the Cz location) and FPz (International 10–20 system). In addition, before every SEPs recording, the electrode impedance was tested to make sure that it was within the acceptable range. The posterior tibial nerve was stimulated at each ankle by square-wave electrostimulation at 2 Hz and with 0.2 ms duration. The input impedance of stimulating and recording electrodes were maintained below 5000. Stimulus intensity was adjusted to produce a visible twitch in the toe without causing any discomfort. To confirm the reproducibility of the SEPs, each measurement was carried out at least three times. Data from the SEPs were obtained before and after rehabilitation treatment for one month, and the latency was evaluated for all the patients. 2.4. Statistical analysis The statistical package SPSS, version 13.0 was used for all the statistical analyses, and the P values of less than 0.05 were considered statistically significant. Data on SEPs and MBI were subjected to the analysis of variance (ANOVA), using SEPs latency or MBI score as the input and the ASIA impairment scale as the independent variable. Pairwise multivariate t-tests were done using Fisher’s least significant difference method and compensation for multiple comparisons. Multivariate contrasts were also performed with reference to the baseline measurement. The ASIA impairment scales were compared among different groups of SCI by ANOVA. The correlation of the changes in SEPs with the improvement in the MBI score was analyzed statistically before and after treatment using the Mann-Whitney U test.

837

3. Results 3.1. MBI scores ADL findings of the MBI score recovery were presented in Table 1. As shown in Table 1, there existed significant between-group differences in the MBI scores on the four injury severities before treatment (p < 0.05), and also compared with before treatment the MBI score increased apparently after treatment (p < 0.05). The MBI score of the grade A group was low after rehabilitation. There was a more gradual improvement in the MBI score of the grade B group after rehabilitation. A significant improvement in MBI scores of the grade C group was detected after rehabilitation. While the MBI scores of the grade D group increased most apparently after rehabilitation. The data depicted that rehabilitation improved the functional outcome or activities of daily living. 3.2. SEPs latency The SEPs latency change could accurately reflect the degree of SCI. Lower-extremity SEPs data were presented in Table 2. In the four injury groups, the N-P SEPs latency from lower-extremity increased corresponding to the increase in injury severity before treatment. Whereas, a reduction of the N-P SEPs latency appeared at the graded levels of ASIA after treatment. Statistical analysis of the SEPs data showed significant between-group differences in the four injury severities (p < 0.05). Different recovery patterns were observed after treatment in the four groups, with a higher rehabilitation value in each group than another, from grade D to C, B, and A. 3.3. Relationship between MBI scores and SEPS The relationships between MBI score and SEPS for SCI patients before and after rehabilitation were shown in Table 3. Convergent criterion-related validity was demonstrated by relating the MBI score to the SEPs Table 1 ADL of the SCI patients before and after rehabilitation treatment Grade

Before treatment

After treatment

t

P

A (n = 8) B (n = 9) C (n = 9) D (n = 10)

30.9 ± 2.2 46.4 ± 2.0 53.7 ± 2.2 66.1 ± 2.8

37.5 ± 4.2 58.7 ± 3.4 69.5 ± 4.1 84.2 ± 4.6

8.52 18.46 24.23 27.53

0.000∗ 0.000∗ 0.000∗ 0.000∗

∗ Statistically

significant at p ≤ 0.05.

838

X. Caizhong et al. / The application of somatosensory evoked potentials in spinal cord injury rehabilitation Table 2 Posterior tibial nerve SEP latency in the SCI patients before and after rehabilitation treatment N wave Grade A (n = 8) B (n = 9) C (n = 9) D (n = 10) ∗ Statistically

P wave

Before treatment

After treatment

t

P

Before treatment

After treatment

t

P

63.4 ± 4.5 42.0 ± 1.9 36.1 ± 1.8 29.5 ± 1.5

57.3 ± 5.9 35.4 ± 1.8 30.3 ± 2.0 25.2 ± 1.4

7.44 13.44 37.21 18.04

0.000∗ 0.000∗ 0.000∗ 0.000∗

72.0 ± 5.1 47.7 ± 1.8 41.5 ± 1.8 33.4 ± 1.6

63.5 ± 6.6 39.3 ± 2.0 33.8 ± 1.9 27.8 ± 1.8

10.90 19.63 25.65 36.15

0.000∗ 0.000∗ 0.000∗ 0.000∗

significant at p ≤ 0.05.

Table 3 Relationship between ADL and SEPs in the SCI patients Before rehabilitation SEPs N P

After rehabilitation

MBI (r)

P

MBI (r)

P

0.966 0.968

0.000∗ 0.000∗

0.953 0.955

0.000∗ 0.000∗

∗ Statistically significant co-efficient (r).

at

p ≤ 0.05.

Pearson’s

correlation

latency, with a significant correlation between SEPs latency and MBI scores before and after rehabilitation. Spearman’s correlation coefficients were 0.966 and 0.968 before rehabilitation and 0.953 and 0.955 after rehabilitation. SEPs provided an objective assessment of spinal nerve function, and the outcome of rehabilitation could be accurately evaluated by the association of SEPs with ADL. 4. Discussion SCI triggers a series of complex pathophysiological mechanisms, which can result in different effects on the conduction of axonal pathways, locomotion and tissue morphology (Abeyta et al., 2009). SCI is a devastating neurological trauma, often resulting in the impairment of bladder, bowel, and sexual function as well as the loss of voluntary control of muscles innervated by spinal cord segments below the lesion site. The degree of neurological dysfunction after SCI largely depends on the nature and the level of injury. Based on the nature and location of injury, SCI is divided into complete and incomplete types. In recent years, significant development has been made in the clinical diagnosis and treatment of SCI (Gassaway, Whiteneck & Dijkers, 2009; Bamford & Mushahwar, 2011; Whiteneck et al., 2011; Forrest et al., 2008; Cahow et al., 2009; Sally et al., 2011; Teresa et al., 2011). MRI contributes to the understanding of the severity and prognosis of the injury; and electrophysiological measurement provides objective data, such as latency and amplitude,

for assessing spinal conductivity. Current treatment of SCI focuses on surgical stabilisation of the spine, intensive neurological rehabilitation, and the prevention and treatment of acute and chronic complications. However, how to improve overall neurological function remains a challenge in the treatment of SCI. Recent studies show that a combination of drug therapy, surgical intervention and rehabilitation can yield some clinical benefits, such as the improvement in functional outcomes or quality of life, and meanwhile help build evidence for the importance of rehabilitation for SCI. Even slight neurological recovery can have a high impact on the daily functioning of severely handicapped patients. For a therapeutic intervention after SCI, it is important to take accurately and objectively assessment tools (Aubrey et al., 2010). Clinical measures for the recovery of motor and sensory function have been evaluated for their effects in tracing preserved residual and/or recovered function after SCI (Wirz et al., 2011). The ASIA Impairment Scale (AIS) has become a standardized and routinely applied neurological assessment and classification scale for patients suspected of SCI, but it may be insensitive or highly variable as an outcome measure for assessing the possible benefits of an intervention. Currently there is no method for measuring upper cervical, thoracic, or sacral motor function. SCI is often associated with the deficits of spinal sensory pathways. SEPs are elicited by electrical stimuli administered randomly to any point of sensory organ, sensory nerve or sensory pathways, which can be use to assess the integrity of neural processing capabilities in patients with spinal cord injury. SEPs, first described in 1947, provide a reliable, reproducible and objective in-vivo assessment of the functional integrity of the ascending sensory pathways that project in the dorsal spinal cord (Garcia & Larrea, 2012). Their utility in SCI studies has been previously demonstrated in both animal studies and in humans (Kirshblum et al., 2011). Therefore, we investigated the utility of monitoring SEPs. In addition to determining injury severities utilizing ASIA standards and sensory testing using SEPs,

X. Caizhong et al. / The application of somatosensory evoked potentials in spinal cord injury rehabilitation

evaluating functional outcome measures is being considered to address these gaps. The application of MBI requires no special equipment, no particular training, little time, and little expense. The MBI scale has been utilized to measure an individual’s performance on 10 activities of daily living, as in self-care, continence, and locomotion, evaluate functional outcomes after SCI rehabilitation, and evaluate the relationships between functional ability and fitness. But its responsiveness has not been compared with that of other measures after SCI. A combination of ASIA, SEPs and MBI can provide information about spinal cord function that is not retrievable by other clinical means and may have additional value in predicting the outcome. The current study examined both posterior tibial nerve SEPs and MBI scores before and after rehabilitation treatment, evaluated the rehabilitation effects for patients with various grades on ASIA, and sought to depict the association between SEPs and MBI scores. As outlined in Table 1 and Table 2, the current results provide the documentation of the amount of SEPs and MBI scores in treating four subgroups of people with SCI differentiated by level and completeness of injury. The grade A group showed functional deficits of highest severity before treatment, indicating the absence of motor and sensory function; grade B, significant functional deficits, indicating the absence of motor function and the presence of sensory function; grade C, moderate functional deficits, indicating some motor function; grade D, the least functional impairment, indicating weight supported motor function. SEPs and MBI scores revealed statistically significant differences among the four neurologic injury groups before and after rehabilitation. The current results demonstrated that rehabilitation was required and effective for patients with AIS A, B, C, and D. Furthermore, SEPs and MBI scores indicated a differential recovery pattern after rehabilitation treatment in the four injury groups. One clinical implication of these findings would be that the order of rehabilitation values with various grades on ASIA was from grade D to grade A. These data provided the opportunity to study the relationships among AIS, SEPs and MBI. SEPs are significantly correlated with MBI scores before and after rehabilitation treatment, and they are both very sensitive to SCI. In particular, the measurement of SEPs, as a noninvasive technique, has a great value in monitoring spinal cord function. In conclusion, we characterized different levels and completeness of SCI using electrophysiological

839

responses measured by SEPs, and compared these responses with ADL scores after rehabilitation treatment. Clearly, the combination of SEPs and MBI, as two different but complementary measures, objectively reflected the degree of SCI. In this regard, the assessment of SEPs would be crucial in clinic to evaluate therapeutic efficacy against spinal cord injury. Acknowledgments The authors are grateful to the participants for their collaboration and wish to express their gratitude to our corporate partners for their assistance. Ethical approval The experiment was performed after obtaining patient informed consent, and ethical approval from the Ethics Committee of Jinling Hospital. Declaration of interest The authors declare that there is no conflict of interest. References Abeyta, N., Freeman, E.S., Primack, D., Hammond, F.M., Dragon, C., Harmon, A., & Gassaway, J. (2009). SCIRehab Project series: The social work/case management taxonomy. J Spinal Cord Med, 32, 336-342. Alexander, M.S., Anderson, K.D., Biering-Sorensen, F., Blight, A.R., Brannon, R., Bryce, T.N., Creasey, G., Catz, A., Curt, A., Donovan, W., Ditunno, J., Ellaway, P., Finnerup, N.B., Graves, D.E., Haynes, B.A., Heinemann, A.W., Jackson, A.B., Johnston, M.V., Kalpakjian, C.Z., Kleitman, N., Krassioukov, A., Krogh, K., Lammertse, D., Magasi, S., Mulcahey, M.J., Schurch, B., Sherwood, A., Steeves, J.D., Stiens, S., Tulsky, D.S., van Hedel, H.J., & Whiteneck, G. (2009). Outcome Measures in Spinal Cord Injury: Recent Assessments and Recommendations for Future Directions. Spinal Cord, 47, 582-591. Arif Jetha, Guy Faulkner, Paul Gorczynski, Kelly ArbourNicitopoulos, Kathleen, A., Martin, & Ginis, (2011). Physical activity and individuals with spinal cord injury: Accuracy and quality of information on the Internet. Disability and Health Journal, 4, 112-120. Aubrey, A., Webb, Sybil Ngan, David,& Fowler, (2010). Spinal cord injury II: Prognostic indicators, standards of care, and clinical trials. Can Vet J, 51, 598-604. Bamford, J.A., & Mushahwar, V.K. (2011). Intraspinal microstimulation for the recovery of function following spinal cord injury. Prog-Brain-Res, 194, 227-239.

840

X. Caizhong et al. / The application of somatosensory evoked potentials in spinal cord injury rehabilitation

Cahow, C., Skolnick, S., Joyce, J., Jug, J., Dragon, C., & Gassaway, J. (2009). SCIRehab Project series: The therapeutic recreation taxonomy. J Spinal Cord Med, 32, 298-306. Cardini, F., Longo, M.R., & Haggard, P. (2011). Vision of the body modulates somatosensory intracortical inhibition. Cereb-Cortex, 21, 2014-2022. Christine Fekete, Alexandra, & Rauch, (2012). Correlates and determinants of physical activity in persons with spinal cord injury: A review using the International Classification of Functioning, Disability and Health as reference framework. Disability and Health Journal, 5, 140-150. Eriks Hoogland, I., Cieza, A., Post, M., Hilfiker, R., van Hedel, H., Cripps, R., Chen, Y., Boldt, C., & Stucki, G. (2011). Category specification and measurement instruments in large spinal cord injury studies: A comparison using the International Classification of Functioning, Disability, and Health as a reference[J]. Am J Phys Med Rehabil, 90, 39-49. Forrest, G.F., Sisto, S.A., Barbeau, H., Kirshblum, S.C., Wilen, J., Bond, Q., Bentson, S., Asselin, P., Cirnigliaro, C.M., & Harkema, S. (2008). Neuromotor and musculoskeletal responses to locomotor training for an individual with chronic motor complete AIS-B spinal cord injury. J Spinal Cord Med, 31, 509-521. Garcia-Larrea, L. (2012). Objective pain diagnostics: Clinical neurophysiology. Neurophysiol Clin, 42, 187-197. Gassaway, J., Whiteneck, G., & Dijkers, M. (2009). SCIRehab: Clinical taxonomy development and application in spinal cord injury rehabilitation research. J Spinal Cord Med, 32, 260-269. Hetz, S.P., Latimer, A.E., & Ginis, K.A. (2009). Activities of daily living performed by individuals with SCI: Relationships with physical fitness and leisure time physical activity. Spinal Cord, 47, 550-554. Johnson, K., Bailey, J., Rundquist, J., Dimond, P., McDonald, C., Reyes, I.A., Thomas, J., & Gassaway, J. (2009). SCIRehab Project series: The supplemental nursing taxonomy. J Spinal Cord Med, 32, 329-335. Kirshblum, S., Botticello, A., Lammertse, D.P., Marino, R.J., Chiodo, A.E., & Jha, A. (2011). The impact of sacral sensory sparing in motor complete spinal cord injury. Arch Phys Med Rehabil, 92, 376-383.

Lalwani, S., Mathur, P., Jain, N., Behera, B., & Misra, M.C. (2011). Spinal cord injury. J Neurosurg Spine, 15, 576-577. Natale, A., Taylor, S., LaBarbera, J., Bensimon, L., McDowell, S., Mumma, S.L., Backus, D., Zanca, J.M., & Gassaway, J. (2009). SCIRehab Project series: The physical therapy taxonomy. J Spinal Cord M, 32, 270-282. Ozelie, R., Sipple, C., Foy, T., Cantoni, K., Kellogg, K., Lookingbill, J., Backus, D., & Gassaway, J. (2009). SCIRehab Project series: The occupational therapy taxonomy. J Spinal Cord Med, 32, 283297. Sally Taylor-Schroeder, Jacqueline LaBarbera, Shari McDowell, Jeanne, M., Zanca4, Audrey Natale, Sherry Mumma, Julie Gassaway, Deborah, & Backus. (2011). Physical therapy treatment time during inpatient spinal cord injury rehabilitation. J Spinal Cord Med, 34, 149-161. Teresa Foy, Ginger Perritt, Deepa Thimmaiah, Lauren Heisler, Jennifer Lookingbill Offutt, Kara Cantoni, Ching-Hui Hseih, Julie Gassaway, Rebecca Ozelie, Deborah, & Backus. (2011). Occupational therapy treatment time during inpatient spinal cord injury rehabilitation. J Spinal Cord Med, 34, 162-175. Wang, Y.T., Lu, X.M., Zhu, F., Huang, P., Yu, Y., Zeng, L., Long, Z.Y., & Wu, Y.M. (2011). The use of a gold nanoparticle-based adjuvant to improve the therapeutic efficacy of hNgR-Fc protein immunization in spinal cord-injured rats. Biomaterials, 32, 7988-7998. Whiteneck, G., Gassaway, J., Dijkers, M., Backus, D., Charlifue, S., Chen, D., Hammond, F., Hsieh, C.H., & Smout, R.J. (2011). SCIRehab: Inpatient treatment time across disciplines in spinal cord injury rehabilitation. J Spinal Cord Med, 34, 135-150. Wilson C., Huston T., Koval J., Gordon S., Schwebel A.,& Gassaway J. SCIRehab Project series: The psychology taxonomy. (2009). J Spinal Cord Med, 32, 319-328. Wirz, M., Bastiaenen, C., de Bie, R., & Dietz, V. (2011). Effectiveness of automated locomotor training in patients with acute incomplete spinal cord injury: A randomized controlled multicenter trial. BMC Neurol, 11, 60.

Copyright of NeuroRehabilitation is the property of IOS Press and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.

The application of somatosensory evoked potentials in spinal cord injury rehabilitation.

For a therapeutic intervention after spinal cord injury (SCI), it is important to take accurate and objective assessment tools...
66KB Sizes 0 Downloads 11 Views