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International Symposium on Autonomic Dysfunctions following Spinal

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International Symposium on Autonomic Dysfunctions following Spinal Powered By Docstoc
					           International Symposium on
Autonomic Dysfunctions following Spinal Cord Injury
                 Wednesday, February 23, 2011
                  Blusson Spinal Cord Centre
                        09:00 to 19:00




                       FACULTY OF MEDICINE
                       DIVISION OF PHYSICAL MEDICINE
                             AND REHABILITATION
                                                Location

                           Blusson Spinal Cord Centre
                 818 West 10th Avenue, Vancouver, British Columbia


           All events will take place on the ground floor. Talks will be held in the Lecture Hall.
                            Lunch and refreshments will be served in the Atrium.


                                             Blusson Spinal Cord Centre
                                             Ground Floor Guide


                                            Gym

                                                                                           ACCESS lab
             VWR /
             Stores
                                                                               card access only




                                                      Lecture Hall
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                             nlo
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          Bike Room
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                                                                                                  Exit to 10th Ave.
                       ac
                      rd
                      ca




                                                                                                      Café
                                            Janitor    Servery   Storage /
                                                                 Electrical


                                                                                                          main (north)
                                                                             io +
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    south entrance                                                                                        entrance
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                                                                       fo tr
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    (sliding doors)                                                                                       (sliding doors)
                                                                        R




                 Reception
                   desk            Atrium




2
                                              Welcome


Dear Participants,

Welcome to Vancouver and the recently opened Blusson Spinal Cord Centre, home of the International
Collaboration on Repair Discoveries (ICORD) and Rick Hansen Institute.

For many years, motor and sensory abnormalities have been the main focus of spinal cord injury (SCI) related
research. However, SCI is associated with not only devastating paralysis, but also with various autonomic
dysfunctions, including disordered cardiovascular control, bowel, bladder and sexual dysfunctions. On a daily
basis, individuals with SCI experience these devastating conditions which limit their activities of daily living,
participation in sport and frequently result in life-threatening medical emergencies. Individuals with SCI
recently rated the recovery of autonomic functions as a top priority, higher than finding a cure for paralysis.

Until recently, the impact of SCI on a person’s neurological function was only evaluated through the use of
the International Standards for the Neurological Classification of Spinal Cord Injury (motor and sensory
evaluation). Unfortunately, these standards do not provide information about the status of a person’s autonomic
function. As a result of an elaborate international process that included consultation and cooperation by
members of the International Autonomic Committee, a joint collaboration between the American Spinal
Injury Association (ASIA) and the International Spinal Cord Society (ISCoS), the Autonomic Standards for
documentation of remaining functions following SCI were created in 2009. This document was followed by
numerous international data sets that addressed various autonomic dysfunctions following SCI. However,
these actions only mark the beginning of our process in standardizing clinical tools for evaluating complex and
still poorly understood autonomic dysfunctions among individuals with SCI.

This unique symposium, with an international panel of speakers with expertise in autonomic dysfunctions
following SCI, will address the latest basic science and clinical evidence in the field. The panel will include
internationally renowned physiatrists, urologists, exercise physiologists, sexual health clinicians, and basic
scientists.

It is my hope that the symposium provides you with a better understanding of the autonomic dysfunctions
associated with SCI, so that you will be able to implement this knowledge in your research or clinical
practice.

Sincerely,


Andrei Krassioukov MD, PhD, FRCPC
Chair of Symposium Organizing Committee
Professor, Dep. Medicine, Div. Phys. Med. & Rehab.
Associate Director and Scientist, ICORD, University of British Columbia,
Staff physician, Spinal Cord Program, GF Strong Rehabilitation Centre,
Chair of ASIA/ISCoS International Autonomic Committee

                                                                                                                    3
                       Schedule at a Glance

    8:30 – 9:00     Registration
                    Coffee/Tea provided.


    9:00 – 9:20     Opening Remarks
                    Dr. Andrei Krassioukov, Dr. Tom Oxland.


    9:20 – 9:40     Introduction to the Autonomic Nervous System
                    Dr. Matt S. Ramer.


    9:40 – 10:40    SESSION #1: Sexual Health following SCI
                    Dr. Frédérique J. Courtois, Dr. Marca S. Alexander, Dr. Stacy Elliott.


    10:40 – 11:00   Break

    11:00 – 12:00   SESSION #2: Bowel & Bladder Function following SCI
                    Dr. Klaus Krogh, Dr. Claes Hultling, Dr. Mark Nigro.


    12:00 – 13:40   LUNCH
    12:50 – 13:30   Research Poster Competition

    13:40 – 14:40   SESSION #3: Cardiovascular Health following SCI
                    Dr. Lawrence P. Schramm, Dr. Jill Wecht, Dr. Andrei Krassioukov.

    14:40 – 15:00   Break

    15:00 – 16:00   SESSION #4: Special Topics
                    Dr. William A. Bauman, Dr. Susan Harkema, Dr. Fin Biering-Sørensen.

    16:00 – 16:30   Break

    16:30 – 17:30   SESSION #5: Plenary Lecture
                    Dr. Lawrence P. Schramm, Introduction by Dr. Andrea Townson.


    17:30 – 19:00   Evening Reception
                    Wine and hors d’oeuvres.




4
                                   Program Details


INTRODUCTION

(9:20 – 9:40) Peripheral sympathetic axons and neurotrauma.
Matt S. Ramer, PhD. ICORD. University of British Columbia.



SESSION #1: Autonomic Functions and Sexual Health following SCI

(9:40 – 10:00) Sexual Sensations, Pleasure and Orgasm Following Spinal Cord
Injury: The Role of Autonomic Stimulation.
Frédérique J. Courtois, PhD. Université du Québec à Montréal.


(10:00 – 10:20) Using the Neurologic Examination to Promote Sexual
Sustainability after SCI.
Marca S. Alexander, MD. Renown Rehabilitation Hospital, Reno, NV.


(10:20 – 10:40) Sexual and Fertility Rehabilitation: The important role of ANS
in clinical and research practice.
Stacy Elliott, MD. ICORD. University of British Columbia.


SESSION #2: Autonomic Functions and Bowel & Bladder following SCI

(11:00 – 11:20) Neurogenic Bowel Dysfunction.
Klaus Krogh, MD, PhD, DMSc. University Hospital of Aarhus, Aarhus, Denmark.


(11:20 – 11:40) Autonomic Dysreflexia from a 25 year Perspective of Personal
Experience with Tetraplegia — Surprised that I´m Still Alive.
Claes Hultling, MD, PhD. Spinalis SCI Unit, Karolinska Institutet, Stockholm, Sweden.


(11:40 – 12:00) Neurogenic Bladder - Management of High Detrussor Pressures.
Mark Nigro, MD, FRCSC. ICORD, University of British Columbia.




                                                                                        5
                                            Program Details


    SESSION #3: Autonomic Functions and Cardiovascular Health following SCI

    (13:40 – 14:00) The Recovery of Cardiovascular Regulation After Spinal Cord Injury.
    Lawrence P. Schramm, PhD. The Johns Hopkins University School of Medicine, Baltimore, MD.


    (14:00 – 14:20) The Cognitive Impact of Autonomic Cardiovascular Dysregulation in
    Persons with SCI.
    Jill Wecht, EdD. Mount Sinai School of Medicine, New York, NY.


    (14:20 – 14:40) Autonomic Evaluation as a Missing Component in Paralympics
    Classification of Athletes with Spinal Cord Injury.
    Andrei Krassioukov, MD, PhD, FRCPC. ICORD, University of British Columbia.


    SESSION #4: Autonomic Functions following SCI: Special Topics

    (15:00 – 15:20) Metabolic and Endocrine Disorders in Individuals with Chronic
    Spinal Cord Injury.
    William A. Bauman, MD. Mount Sinai School of Medicine, New York, NY.


    (15:20 – 15:40) Functional Recovery in Individuals with Chronic Incomplete Spinal
    Cord Injury with Intensive Activity-based Rehabilitation.
    Susan Harkema, PhD. University of Louisville, Louisville, KY.


    (15:40 – 16:00) International Spinal Cord Injury Data Sets with focus on Autonomic
    Data Sets.
    Fin Biering-Sørensen, MD, DMSc. Rigshospitalet and University of Copenhagen, Denmark.


    SESSION #5: Plenary Lecture

    (16:30 – 17:30) The CNS Localization of Metabolic Regulation: Fact or Fiction?
    Lawrence P. Schramm, PhD. The Johns Hopkins University School of Medicine, Baltimore, MD.




6
                                   Plenary Lecture




             The CNS Localization of Metabolic Regulation:
                           Fact or Fiction?
                                    Lawrence P. Schramm, Ph.D.
                                Professor of Biomedical Engineering
                                     Professor of Neuroscience
                          The Johns Hopkins University School of Medicine


 “Are we justified in selecting some component of metabolic regulation, calling it a ‘function’, and
 then expecting to find a discrete locus in the central nervous system that subserves that function?”


Dr. Schramm will trace the history of CNS localization of somatic and metabolic functions from
phrenology in the early 19th century, through “vasomotor centers” and “fight or flight” in the early-to-
mid 20th century, to recent physiological and anatomical localizations.




                                                                                                           7
    Matt S. Ramer, PhD
    Matt Ramer completed his B.Sc. in Life Sciences in 1995 (Queen’s University), and his Ph.D. in
    Physiology in 1998 (Queen’s) under the supervision of Dr. Mark Bisby. He carried out post-doctoral
    fellowship work at King’s College London with Profs. Stephen McMahon and John Priestley. Both his
    Ph.D. and fellowship work concerned plasticity and regeneration of sympathetic and sensory neurons
    in the wake of neurotrauma. Dr. Ramer came to UBC in 2001, and is currently an Associate Professor
    (Zoology, Neurosurgery), and a member of ICORD.


    Peripheral sympathetic axons and neurotrauma
    The majority of peripheral sympathetic neurons are situated in ganglia of the two sympathetic chains,
    which lie ventral and lateral to the spinal column. During development, their axons join mixed nerves
    and travel exclusively toward peripheral targets. This ‘compartmentation’ of sympathetic axons is evident
    in adult animals, in which dorsal root ganglia, dorsal roots and ventral roots are devoid of sympathetic
    axons. Trauma to peripheral nerves and to the spinal cord results in the violation of this developmentally-
    established compartmentation, and to the formation of pericellular sympathetic baskets surrounding some
    DRG neurons. This is of particular interest since both peripheral nerve injury and spinal cord injury result
    in abnormal communication between sympathetic and sensory neurons. This presentation will review
    the basic anatomy of the sympathetic nervous system, the normal growth of sympathetic axons during
    development and aberrant sprouting which follows neurotrauma. Putative mechanisms underlying
    sympathetic sprouting, as well as possible functional correlates will also be discussed.




     Introduction to the Autonomic Nervous System                                               9:20 – 9:40

8
Frédérique J. Courtois, PhD
PhD graduate from McGill University (1989) on an animal model of sexual function following spinal
cord injury. Post doctoral fellowship (1989-91) in Lyon-France generalizing the results to humans with
SCI. University research fellow at Université de Montréal (1991-1994) and Université du Québec à
Montréal (1994-1999). Director of the graduate program in sexology (1999-2005) and chair of the
FRSQ Grant Committee on Health population (2001-2002 and 2007-2011). Clinical consultant
at the Institut de réadaption Gingras-Lindsay de Montréal since 1992 and Institut de réadaption en
déficience physique de Québec since 1996. Currently full professor in Sexology at Université du Québec
à Montréal.


Sexual Sensations, Pleasure And Orgasm Following Spinal Cord Injury: The
Role Of Autonomic Stimulation
Courtois FJ, Charvier K, Morel Journel N, Vézina JG, Côté I, Boulet M, Carrier S, Jacquemin G, Fournier C.

Spinal cord injuries (SCI) involve sensory deficits affecting sexual sensations. Yet, individuals with SCI
report orgasm despite complete lesions and men with SCI describe sensations upon ejaculation. While the
somatic afferents normally conveying sensations are impaired, autonomic afferents can bypass the lesion
though peripheral pathways. This study describes the sensations perceived by SCI individuals at ejaculation
and characterizes them according to lesion levels and extent of autonomic stimulation.
Material and methods: 122 men with SCI undergoing ejaculation tests (natural, vibrostimulation,
midodrine) assessed on their perception of cardiovascular, muscular and autonomic responses. Participants
further subdivided into those experiencing and those not experiencing autonomic hyperreflexia.
Results: Subjects perceive significantly more cardiovascular, muscular and autonomic sensations
upon ejaculation compared to sexual stimulation alone. Individuals with autonomic hyperreflexia
(SBP>20mmHg) report significantly more sensations in each category than those failing to experience
autonomic hyperreflexia. Stimulation modality influences the extent of sensations perceived, natural
stimulation triggering the least sensations and autonomic stimulation the most.
Discussion: Individuals with SCI can perceive sexual sensations despite even complete lesions, including
cardiovascular, muscular and various degrees of autonomic arousal. The combined responses appear to
become climactic when autonomic hyperreflexia is triggered. The results are interpreted to suggest that
climax is related to the phenomenon of autonomic hyperreflexia, but that sensations can be perceived
whether climax is reached or not. The findings have important implications to help individuals identifying
and cognitively reframing bodily sensations into sexual arousal. They also suggest that some degree
autonomic hyperreflexia may be desired during sexual activity.


 SESSION #1: Sexual Health                                                                      9:40 – 10:00

                                                                                                               9
     Marca S. Alexander, MD
     Marcalee Sipski Alexander, MD has studied sexuality and SCI for over 20 years. She has focused on
     documenting the impact of the neurologic examination on sexual responses to arousal and orgasm and
     developing treatments for women and men with SCIs and MS. She was also a major driving force be-
     hind the development of the International Standards for the Classification of Autonomic Function post
     SCI and was involved in the development of Sexual Function International Data Sets. Dr. Alexander has
     worked at 5 US Model Systems and is currently Medical Director at Renown Rehabilitation Hospital in
     Reno, Nevada.


     Using the Neurologic Examination to Promote Sexual Sustainability after SCI
              Many people with SCIs would like to stay sexually active throughout their lifetime.
     Unfortunately, aside from a handful of specialized centers, there little consistency in the education
     or promotion of optimal sexual health for persons with SCIs; thus, it is uncertain whether practices
     are optimized. Moreover, when education is available, it is often broadbased, rather than tailored to
     specific patterns of injury. In this presentation, a basic recipe for SCI clinicians is provided utilizing the
     neurologic exam to maximize the SCIs patient’s potential for sexual sustainability.
              As early as the ICU, it is important to let patients and partners know that sexual concerns
     are a part of rehabilitation. Preexisting sexual problems should be documented. Next a complete AIS
     examination with attention to the T11-L2 and sacral areas will provide an assessment of the anticipated
     impact of the SCI on sexual responses. Information from the examination is used for specific patient
     education. Patients are then encouraged to experiment with what works based upon their potential
     function. The autonomic standards and the international data sets are tailored for documentation of
     expected versus actual sexual responses and allow determination of potential areas requiring treatment.
              Despite the importance of the autonomic nervous system in sexual responses, treatments
     should begin with rectifying iatrogenic or partner causes. Once these issues are addressed, use of
     targeted therapies based upon the patient’s neurologic assessment and autonomic dysfunction is
     recommended. Finally, regular cycling back and reassessment of the patient’s desires and treatment needs
     is recommended.




      SESSION #1: Sexual Health                                                                 10:00 – 10:20

10
Stacy Elliott, MD
Stacy Elliott, MD is a Clinical Professor in the Departments of Psychiatry and Urological Sciences in the
Faculty of Medicine, University of British Columbia. She specializes in tertiary outpatient care of persons
with sexual dysfunctions associated with medical, surgical or traumatic problems. She is the Director of
the BC Center for Sexual Medicine, a consultant to the GF Strong Sexual Health Rehabilitation Service,
and Director of the Sexual Assessment and Rehabilitation Clinic at the Men’s Health Initiative. She is
internationally recognized in a leader in the field of SCI sexual and fertility rehabilitation, is an active
faculty member and researcher of ICORD, and is known as an international speaker and author of many
peer reviewed papers and several book chapters.


Sexual and Fertility Rehabilitation: the important role of ANS in clinical and
research practice
Sexual functioning challenges occur after neurological injury along with other autonomic dysfunctions
(including bladder and bowel issues) Successful sexual and fertility rehabilitation is dependant on
complex coordination of remaining autonomic and somatic nervous system function within the
biopsychosocial context of the person. What is known and not known about alterations in sexual
functioning post SCI will be outlined. The use of consumer and professional publications for the
management of persons with disabilities and their research impact will also be discussed. Research in
the area of sexuality after SCI will be discussed, including negatives such as management of autonomic
dysreflexia with ejaculation to the more positive, novel potential of sexual sensory substitution.




 SESSION #1: Sexual Health                                                               10:20 – 10:40

                                                                                                               11
     Klaus Krogh, MD, PhD, DMSc
     Klaus Krogh graduated from Aarhus University, Denmark in 1993. In 2000 he defended his PhD thesis
     on bowel dysfunction after spinal cord injury and in 2004 he defended his doctoral thesis on the same
     topic. In 2008 Klaus Krogh founded the Neurogastroenterology Unit at Aarhus University Hospital.
     The unit combines research, clinical evaluation and treatment of severe gastrointestinal problems in
     individuals with neurological or connective tissue diseases. Since 2010 Klaus has been professor and
     consultant gastroenterologist at Aarhus University Hospital. He has published 65 papers in peer-reviewed
     journals and chaired the ISCoS/ASIA working group on international bowel function SCI data set.

     Neurogenic Bowel Dysfunction
     Spinal cord injury (SCI) has profound effects on bowel function. Approximately 80% of individuals with
     SCI report symptoms of constipation, 66% need digitial stimulation or evacuation of the rectum, 75%
     have episodes of fecal incontinence at least once per year and 20% at least once per month. Symptoms of
     neurogenic bowel dysfunction (NBD) often have severe consequences for quality of life.
     The pathophysiology of NBD depends on the level of SCI. Subjects with supraconal lesions have increased
     tone and reflex activity of the left colon and the rectum while those with conal or cauda equina lesions
     have reduced tone and reflex activity. In complete SCI anorectal sensation and voluntary control of the
     external anal sphincter muscle are lost. Transit time through the colorectum is often severely prolonged
     and recent studies indicate that gastric emptying and small intestinal transit may be delayed too.
     International bowel function basic and extended SCI data set have been developed for description of
     NBD and autonomic standards to document remaining autonomic function after SCI also include brief
     description of bowel function. All need validation in an international setting.
     Basic treatment of NBD includes diet, oral laxatives, suppositories, mini enema and digital stimulation.
     However, evidence for basic treatment modalities is scarce. Subjects not responding to basic treatment
     can be offered transanal irrigation with specially designed catheters, the Malone appendicostomy for
     antegrade colonic irrigation or colostomy.
     New experimental treatment modalities for NBD include sacral nerve stimulation, dorsal genital nerve
     stimulation and surgical creation of a somato-autonomic reflex arch.




      SESSION #2: Bowel & Bladder Function                                                 11:00 – 11:20

12
Claes Hultling, MD, PhD
Dr. Hultling is an Associate Professor at Karolinska Institutet in Stockholm, Sweden. He is the CEO of
the Spinalis Foundation and Medical Officer of the Spinalis SCI Unit at Karolinska Hospital. He is a
member of the Swedish Medical Association, American Spinal Injury Association and the International
Medical Society of Paraplegia. Dr. Hultling established Spinalis, a rehabilitation unit in Sweden in 1991
after his own personal experience of spinal cord impairment. He is a former Paralympian.


Autonomic Dysreflexia from a 25 year Perspective of Personal Experience with
Tetraplegia – Surprised that I´m Still Alive.
What is AD? A number of well established researchers working in spinal cord injury (SCI) have tried to
explain what causes autonomic dysreflexia (AD) and what serious effects it can have on tetraplegic
and high paraplegic patients. Scientific reports point out risk factors and urge care taking staff to look for all
different signs of AD. But what is it like to experience all the classical symptoms of AD? How do you judge
the subjective findings, such as headache, in relation to objective findings such as high blood pressure?
I have lived with my broken neck for soon to be 27 years and have treated a large number of patients – all
suffering from AD – without grasping the true essence of this problem. I am not neglecting the danger but
am sometimes concerned about how the true medical information is conveyed to patients.
I will try to describe from a scientific perspective the reflexogenic bradycardia and how it is perceived
at 4:00 am in the morning when the bladder is full and you can hear your heart beating hard and
irregularly.




 SESSION #2: Bowel & Bladder Function                                                         11:20 – 11:40

                                                                                                                     13
     Mark Nigro, MD, FRCSC
     Dr. Nigro has a full time appointment as Clinical Professor in the Division of Adult Urology
     at Vancouver Hospital. In addition to general Adult Urologic cases, he has a special interest in
     Transplantation, Neurogenic bladder, infertility, and urologic prosthetics. He has been actively involved
     in undergraduate and postgraduate education. He has been Director for the Provincial Organ Retrieval
     Program from 1993 to present. He has been surgical director for renal transplant at VGH from 1998 to
     the present. He is co-director and co-founder of the Vancouver Ejaculatory Dysfunction clinic which is a
     Canadian center for infertility problems to spinal injured males.


     Neurogenic Bladder - Management of High Detrussor Pressures
     Urinary complications from neurogenic bladder continue to be ongoing source of morbidity in the spinal
     cord injury group. These include urinary infection, bladder and renal calculus formation, autonomic
     dysreflexia and upper tract deterioration that can result in reduced renal function. Lesser complications
     such as urinary incontinence have a significant impact on quality of life. It is becoming more apparent
     that the genesis of these complications often arise as a result of high detrussor pressures. Reviewed
     will be the basic physiology involved in the mechanisms resulting in high pressures. Treatment options
     including anticholinergic agents, Botox therapies and surgical management of high bladder pressure will
     be reviewed.




      SESSION #2: Bowel & Bladder Function                                                  11:40 – 12:00

14
Lawrence P. Schramm, PhD
Lawrence Schramm has been on the faculty of the Johns Hopkins School of Medicine since 1970. He
was the first Chairman of the Neural Control and Autonomic Regulation Section of the American
Physiological Society and has served on the editorial board of the American Journal of Physiology and on
NIH review groups. He is a Fellow of the American Institute of Medical and Biological Engineering and
a Fellow of the Biomedical Engineering Society. His research focuses on the role of the spinal cord in
cardiovascular regulation and mechanisms underlying autonomic nervous system dysfunction after spinal
cord injury.


The Recovery of Cardiovascular Regulation After Spinal Cord Injury.
Lawrence P. Schramm, Ph.D. and Mathew R. Zahner, Ph.D.

Orthostatic hypotension associated with postural change and hypertensive crises associated with
autonomic dysreflexia are serious cardiovascular sequelae of spinal cord injury. In patients and
experimental animals with partial spinal lesions, these phenomena are mitigated or prevented by
baroreceptor-mediated regulation of arterial pressure. Although baroreceptor function has been
assessed in spinally injured patients, little is known about the incidence and time-course of recovery
of this function after injury. We used rats to study the pathways necessary for defending against both
hypotension and hypertension after acute, surgical, spinal cord lesions. Then, we studied the time-course
of recovery of these defenses after similar lesions. Experiments were conducted in anesthetized rats
zero to eight weeks after surgical spinal cord lesions. Baroreceptor function was assessed by measuring
the responses of renal sympathetic nerve activity to pharmacologically-generated hypotension and
hypertension. Immediately after selective spinal lesions, diffuse, bilateral pathways were capable of
partially defending against hypotension. However, defense against hypertension appeared to rely on
more localized, ipsilateral, dorsolateral pathways which, in intact rats, prevented spinal inputs from
affecting sympathetic activity. Defenses against both hypotension and hypertension recovered somewhat
eight weeks after spinal hemisections. However, defense against hypertension improved less that defense
against hypotension. If translation of these results to human spinal cord injury is possible, then we might
expect that defense against orthostatic hypotension recovers to a greater extent than defense against
hypertensive crises. Longitudinal studies in patients will be necessary to confirm these predictions.

Supported by NIH Grant HL-16315 to LPS



 SESSION #3: Cardiovascular Health                                                      13:40 – 14:00

                                                                                                              15
     Jill Wecht, EdD
     Dr. Wecht has been investigating the effects of Cardiovascular Autonomic denervation on systemic and
     cerebral hemodynamics for over a decade. She is an Associate Professor of Medicine and Rehabilitation
     Medicine at the Mount Sinai School of Medicine in New York, NY and has been continuously funded
     by the Veterans Affairs Rehabilitation Research & Development Service in the Career Development
     Program since 2000. In addition to her Career Development Awards Dr. Wecht is Program Director of
     the Cardiovascular Autonomic section of Dr. William Bauman’s Center of Excellence for the Medical
     Consequences of SCI and was recently funded by the VA to determine the impact of blood pressure
     dysregulation on health related quality of life in persons with SCI.

     The Cognitive Impact of Autonomic Cardiovascular Dysregulation in Persons
     with SCI
     Spinal cord injury (SCI) results in motor and sensory impairments which can be identified and classified
     according to the American Spinal Injury Association Impairment Scale (AIS); although SCI impacts
     autonomic neural transmission, less is understood regarding the clinical impact of this denervation.
     Cardiovascular regulation is altered following SCI and the degree of impairment may or may not relate
     to the level of AIS injury classification. That said, in general, persons with a cervical lesion (tetrapelgia)
     often present clinically with bradycardia, hypotension and orthostatic hypotension which may significantly
     hamper rehabilitation efforts. Further although many individuals remain overtly asymptomatic to
     significant hypotension, we have documented sub-clinical cognitive deficits in memory and attention
     processing speed in hypotensive individuals with SCI compared to an age-matched non-SCI group. There is
     a growing body of evidence in the non-SCI literature that links deficits in cognition in persons with chronic
     hypotension to inadequate cerebral blood flow responses during testing and we have preliminary evidence
     that this may be the case in individual with SCI. Although individuals with lower level lesions (paraplegia)
     generally present with a normal cardiovascular profile, we and others have documented resting tachycardia
     (heart rate ≥ 84 bpm) and increased arterial stiffness compared to non-SCI controls. Again in the non-SCI
     literature there is significant evidence supporting a link between increased arterial stiffness and accelerated
     cognitive decline. We have preliminary evidence that the proportion of mild to moderate cognitive
     impairment is increased in individuals with paraplegia compared to non-SCI controls and believe that
     vascular cognitive impairment may be present. This presentation will briefly review relevant literature and
     discuss findings on the impact of cardiovascular autonomic dysregulation on cognition in persons with SCI.
     References from this presentation can be found in the participant information package.


      SESSION #3: Cardiovascular Health                                                         14:00 – 14:20

16
Andrei Krassioukov MD, PhD, FRCPC
Dr. Krassioukov is a Professor in the Department of Medicine, Div. of Physical Medicine &
Rehabilitation and a Principal Investigator at the International Collaboration On Repair Discoveries
(ICORD) at the University of British Columbia. He is also a staff physician at the Spinal Cord
Program at the GF Strong Rehabilitation Center in Vancouver, BC. His research involves utilization
of experimental animal models, clinical investigations in human, and is focused on investigation of the
mechanisms of autonomic dysfunctions after spinal cord injury.


Autonomic Evaluation as a Missing Component in Paralympics Classification
of Athletes with Spinal Cord Injury
Individuals with spinal cord injury (SCI), in addition to readily recognized motor deficiencies, often
suffer from various poorly-understood autonomic dysfunctions. Presently established Paralympics
classification does not take into account such factors as autonomic control of the heart and vasculature
that could significantly impact upon an athlete’s performance, thus placing some athletes at a distinct
advantage or disadvantage in comparison to others. In this study we conducted evaluation of the
Paralympic wheelchair Rugby players in order to examine cardiovascular parameters and prevalence of
orthostatic hypotension. Continuous systolic and diastolic blood pressure (SBP, DBP) and heart rate were
recorded at rest and in response to a passive orthostatic test. All athletes were members of Paralympic
wheelchair rugby teams. Twenty-two athletes with cervical SCI were included (average age 32 years;
average time post SCI 13 years). There were ten individuals with complete SCI (AIS A, B) and twelve
with incomplete (AIS C, D). The Paralympic wheelchair rugby classification was similar between the
groups (1.8 complete and 1.89 incomplete). Those with a complete SCI showed an average decline in
SBP of 15-20mmHg and, did not recover their blood pressure within the 15-min of the test. Individuals
with an incomplete SCI showed no changes or only slight decrease in SBP. It is important to note,
however, that symptomatic orthostatic hypotension was seen in both groups and that both groups had an
identical Paralympics classification in wheelchair rugby – emphasizing the need for possible addition of
the autonomic assessment to identify individuals with autonomic dysfunctions to prevent disadvantages.




 SESSION #3: Cardiovascular Health                                                     14:20 – 14:40

                                                                                                           17
     William A. Bauman, MD
     Dr. Bauman is Professor of Medicine and Rehabilitation Medicine at the Mount Sinai School of
     Medicine, New York, NY. Since 1989, he has led clinician-investigators in studying the secondary
     medical consequences of SCI. In 2001, Dr. Bauman established and became Director of the Center of
     Excellence for the Secondary Medical Consequences of Spinal Cord Injury. In 2002, he received the
     Excellence Award from the American Paraplegia Society, and in 2005, the Paul B. Magnuson Award from
     the Department of Veterans Affairs Rehabilitation Research & Development Service. Dr. Bauman has
     been on the Board of Directors of the APS and ASIA.


     Metabolic and Endocrine Disorders in Individuals with Chronic Spinal Cord Injury
     Individuals with chronic spinal cord injury (SCI) have an increased prevalence of abnormalities of
     carbohydrate and lipid metabolism. Diabetes mellitus is more prevalent in persons with SCI compared
     to that in able-bodied persons, and those with higher cord lesions tend to be more insulin resistant.
     Serum HDL cholesterol levels are lower in persons with SCI than the general population, with those with
     the greatest neurological impairment having the lowest serum HDL cholesterol levels; this relationship
     may be due, in part, to autonomic dysfunction, although extreme inactivity and adverse changes in
     body composition (e.g., loss of lean body mass and gain of fat mass) probably play a major role in this
     finding. An inverse relationship has been shown between serum HDL cholesterol values and parameters
     of abdominal fat mass, and a direct relationship has been observed between measures of abdominal
     adiposity and fasting or stimulated serum triglycerides values. Niaspan has been demonstrated to safely
     and effectively raise serum HDL cholesterol levels. Persons with long-standing SCI have been reported
     to have premature coronary heart disease (CHD), and have increased conventional risk factors for
     CHD. Anabolic hormones have been reported to be depressed in persons with chronic SCI. Serum
     growth hormone is reduced to provocative stimulation; insulin-like growth factor is depressed in younger
     individuals with SCI. Serum testosterone levels have also been reported to be depressed. The effect of
     testosterone deficiency and replacement therapy is currently being investigated in persons with chronic
     SCI on cardiovascular autonomic function, body composition, strength, and metabolic parameters.




      SESSION #4: Special Topics                                                          15:00 – 15:20

18
Susan Harkema, PhD
Dr. Harkema is a leading researcher in the field of neurological rehabilitation. She currently holds
the positions of Associate Professor in the Department of Neurological Surgery at the University of
Louisville, Rehabilitation Research Director at the Kentucky Spinal Cord Injury Research Center and
Director of Research at the Frazier Rehab Institute in Louisville. Dr. Harkema is the Director of the
NeuroRecovery Network (NRN)- a revolutionary new program launched by the Christopher and Dana
Reeve Foundation (CDRF).


Functional recovery in individuals with chronic incomplete spinal cord injury
with intensive activity-based rehabilitation
Susan Harkema, Mary Schmidt-Read, Douglas Lorenz, V. Reggie Edgerton, Andrea Behrman

Studies in animals and humans have shown that the functionally isolated human spinal cord maintains
specific properties recognized to generate locomotion in other species. These concepts now have
been translated into the clinic by the Christopher and Dana Reeve NeuroRecovery Network of seven
rehabilitation centers that provide standardized Locomotor Training to individuals with chronic
incomplete spinal cord injury.
An evaluation, using a prospective observational cohort, was conducted on the effect on functional recovery
of an intense standardized activity-based therapy provided during outpatient rehabilitation after incomplete
spinal cord injury (SCI). In seven outpatient rehabilitation centers from the Christopher and Dana Reeve
Foundation NeuroRecovery Network (NRN), 206 individuals ranging from 0.9 to 26 years post injury
were assessed during intensive Locomotor Training, including step training using body weight support and
manual facilitation on a treadmill followed by overground assessment and community integration. Main
outcome measures included the Berg Balance Score; 6 minute walk test and 10 meter walk test.
Outcome measures at enrollment exhibited high variability between AIS C and D patients. While
significant improvement from enrollment to final evaluation was observed in balance and walking
measures for AIS C and AIS D patients, the magnitude of improvement differed significantly between
AIS groups for all measures. It was noted that time since SCI was not significantly associated with the
outcome measures at enrollment but was inversely related with levels of improvement.
These results indicate that rehabilitation that provides intensive activity-based therapy can result in
functional improvements in individuals with chronic incomplete SCI even years after injury.




 SESSION #4: Special Topics                                                              15:20 – 15:40

                                                                                                               19
     Fin Biering-Sørensen, MD, DMSc
     Medical director at Clinic for Spinal Cord Injuries, Rigshospitalet, and Clinical professor with special
     focus on spinal cord injuries at University of Copenhagen, Denmark. Among other duties Assistant
     editor for Spinal Cord and Member of Advisory board for Journal of Rehabilitation Medicine. Scientific
     committee, board memberships include Nordic Medical Society of Paraplegia, President 1993-99;
     Danish Society of Rehabilitation, President 1996-2000; International Spinal Cord Society (ISCoS) 1997-
     2003 Vice-president, 2002-2008 Chairman of the Scientific Committee, 2008-2010 President elect, and
     current President. Published over 450 papers, including more than 215 in peer-reviewed journals, and
     more than 15 chapters in national and international textbooks.


     International Spinal Cord Injury Data Sets with focus on Autonomic Data Sets
     Survival of spinal cord injury (SCI) with a reasonable quality of life has become an expected outcome,
     and there is an increasing need for data pertaining to SCI. Therefore common International SCI Data
     Sets should be collected on individuals with SCI to facilitate comparisons regarding injuries, treatments,
     and outcomes between patients, centers and countries. The process for establishing International SCI
     Data Sets started at an international meeting of experts in SCI data collection and analysis prior to the
     combined meeting of ASIA and ISCoS in Vancouver, Canada in 2002. At this meeting a process was
     developed for selection of data elements to be included in International SCI Data Sets (1).
     International SCI Basic Data Sets are the minimal number of data elements, which should be collected
     in daily clinical practice for a particular topic. Therefore the various Basic Data Sets can be the basis for a
     structured record in centers worldwide caring for persons with SCI. In addition these Basic SCI Data Set
     elements should be included in future SCI research for the relevant topics.
     Examples of International SCI Basic Data Sets related to autonomic functions:
     •	       Lower	Urinary	Tract	Function	(2)
     •	       Urodynamic	(3)
     •	       Bowel	Function	(4)	
     •	       Female Sexual and Reproductive Function (5)
     •	       Male	Sexual	Function	(6)
     •	       Cardiovascular	Function	(7)
     •	       Pulmonary	Function
     •	       Sudomotor/Thermoregulation	Function

     All data sets will be available at the web sites of ISCoS (www.iscos.org.uk), and ASIA (www.asia-spinalinjury.
     org). References from this presentation can be found in the participant information package.


      SESSION #4: Special Topics                                                                 15:40 – 16:00

20
                                Research Poster Competition

1   Skin-derived precursors differentiated into Schwann cells (SKP-SCs) transplanted
    at two months post spinal cord contusion improve recovery of motor and bladder
    function after injury.
    P. L. Assinck1, S. Dworski2, J. S. Sparling1, G. J. Duncan1, D. L. Wu1, Y. Jiang1, R. Church1, A. C. Yung3, J. Liu1, C. K.
    Lam1, F. D. Miller2, W. Tetzlaff1;
    1
      ICORD/UBC, Vancouver, BC, CANADA, 2Hospital for Sick Children/University of Toronto, Toronto, ON,
    CANADA, 3University of British Columbia, Vancouver, BC, CANADA.
    Introduction: Cell transplantation has emerged as a promising candidate therapy for spinal cord injury. However, the
    best candidate cell for a transplantation. SKPs are potentially suitable for autologous transplantation but the therapeutic
    potential of SKP-SCs in the chronic injury environment has not yet been investigated.
    Methods: Here, we transplanted one million cells into the lesion site of rats at 8 weeks post T9/T10 contusion injury
    and allowed survival until week 29.
    Results: Behavioral data indicate that SKP-SC transplantation elicited a trend towards higher BBB locomotion scores,
    which reached significance in week 19, 21, and 23. Up to 18.3% of the transplanted SKP-SC survived for 21 weeks
    post transplantation. Cellular bands of SKP-SCs bridged the lesion in predominantly rostro-caudal orientation and were
    massively filled with axons ensheathed by P0-positive (Schwann cell) myelin of endogenous as well as transplant origins
    as confirmed via immunohistochemistry.
    Conclusion: SKP-SCs transplanted at 8 weeks following spinal cord injury (SCI) and analyzed at 29 weeks post SCI survive
    and bridge the lesion site, modify the glial scar and integrate into the host tissue, create a lesion site permissive to axon growth,
    myelinate axons, improve functional recovery and prevent pathological thickening of the bladder wall. In conclusion, SKP-SCs
    transplantation may become a viable approach to promote repair of the chronically injured spinal cord.


2   A Novel Approach for Monitoring the Autonomic-Cardiac Regulation in Individuals
    with Spinal Cord Injury
    Ataee, P.1, Dumont, G. A. 1, and Krassioukov, A. 2
    Department of Electrical and Computer Engineering, 2ICORD, Dep. of Medicine, The University of British Columbia,
    1

    Vancouver, BC, Canada
    Introduction: Spinal cord injury (SCI) result in loss of supraspinal control of the spinal autonomic neurons causes
    disruption and imbalance in the autonomic regulation of blood pressure (BP) and heart rate (HR). We propose a novel
    approach for monitoring the autonomic-cardiac regulation in individuals with SCI in prevention of heart disease
    and stroke.
    Methods: Using a physiology-based model for the cardiovascular baroreflex, we developed a novel parameter estimation
    technique for identifying cardiac-sympathetic (βH), cardiac-parasympathetic (VH), and arterial-sympathetic (α) tones
    that play important roles in the regulation mechanism of HR and BP. Of 25 international rugby wheelchair athletes who
    underwent a “Sit-up” test, 3 were selected for this study: 1 with complete cervical SCI; 1 with incomplete cervical SCI; 1
    with complete thoracic SCI.
    Results: The values of βH, α, and VH are estimated every 30 seconds, and plotted in a diagram aligned by HR and
    BP signals. We showed that there is a rising trend in the estimated α in an individual with incomplete cervical SCI to
    compensate the orthostatic hypotension. However, there is not any similar α-activation in individuals with complete
    thoracic and cervical SCI. Besides, βH is significantly increased after orthostatic hypotension in an individual with complete
    thoracic SCI in contrary to the one with complete cervical SCI who has no compensatory activation either in βH or α.
    Conclusion: We propose a novel computationally efficient method to estimate sympathetic and vagal tones for the pur-
    pose of autonomic-cardiac regulation monitoring while there is no direct method to measure them. Our method is solely
    based on the HR and BP measurements.




                                                                                                                                            21
                                   Research Poster Competition

     3   Effect of Prazosin on Cardiovascular Control in Men with Spinal Cord Injury
         during Vibrostimulation
         Chang, B.C.1, 7, Elliott, S.E.1-4, McBride, K.M.1, 3, Krassioukov, A.K.1, 4, 5, 6
         1
           ICORD, 2 Vancouver Sperm Retrieval Clinic, 3 G.F. Strong Rehab Center, Sexual Health Rehabilitation Service,
         4
           Departments of Psychiatry and Urology, 5Division of Physical Medicine and Rehabilitation, 6Department of Medicine
         and 7 Department of Biochemistry, UBC, Vancouver, B.C., Canada
         Introduction: Abnormal cardiovascular control with boosts of episodic hypertension, known as autonomic dysreflexia
         (AD), is one of the life threatening events in individuals with spinal cord injury (SCI). Furthermore, ejaculation cannot
         be achieved in men with SCI during sexual intercourse in 90% of the time. To impress upon the significance of this
         concern, a recent study showed regaining sexual abilities as being the most important quality of life issue for paraplegia
         individuals, which was second only to regaining motor functions for quadriplegia individuals. To resolve this severe
         complication, a technique referred to as Penile Vibrostimulation (PVS) has been developed to retrieve sperm in men with
         SCI. However, this procedure is always associated with episodes of AD. Therefore, a possible method of amelioration
         could be to administer Prazosin (Minipress), an alpha adrenergic blocker, on the severity of AD, prior to PVS.
         Methods: 1) N=6, men assessed by ASIA scoring system, 2) Supine position and monitored with a standard ECG
         configuration and BP assessed by finger pulse photoplethysmography, 3) SBP, DBP, and HR were determined and MBP
         calculated, 4) Double blinded, randomized, and crossover trial where each participant served as his own control, 5)
         Each subject underwent the two trials at separate times: received 1mg of Prazosin or identical placebo 10-15hrs prior
         to procedure (pre-loading the night before) and 1mg Prazosin or identical placebo 1.5hrs prior to VS, 6) 10min resting
         period to ensure stable baseline measurements; PVS applied about the glans penis to induce ejaculation, 7) T-test; level
         of statistical significance p=0.05. Results: 1) Difference observed in SBP (p=0.011)and DBP (p=0.014) between Prazosin
         and placebo groups, 2) Difference observed in ΔDBP (p=0.042) upon Prazosin administration. Conclusion: 1) Prazosin
         reduces the severity of elevated blood pressure associated with vibrostimulation, 2)Prazosin administration resulted in a
         significant alteration of autonomic dysreflexia during vibrostimulationbetween the placebo and prazosin procedures.


     4   Electroacupuncture Stimulation on Long-Term Urinary Retention after Spinal
         Cord Injury
         Zhen Chen1 M.D. Ph.D. , Bo Liu2 M.D., Shanghan Wang3 M.D., Weiqun Song M.D. Ph.D.1 Maobin Wang1 M.D.
         1. Rehabilitation Department of Xuanwu Hospital, Capital Medical University, Beijing, China
         2. Guangwai Hospital of Beijing, Beijing, China
         3. Urology Department of Xuanwu Hospital, Capital Medical University, Beijing, China
         Objective: To assess the clinical efficacy of sacral nerve electroacupuncture in patients with long-term urinary retention
         caused by spinal cord injury.
         Methods: A total of 16 patients with urinary retention lasting for more than 6 months after spinal cord injury divided
         into control group and treatment group. The control group was treated with conventional catheterization. The treatment
         group was treated with both electroacupuncture bilaterally at sacral nerve root and conventional catheterization. The
         stimulation lasted for 30 minutes, once per day, and 5 times per week. The sessions lasted 1 to 3 months (depending on
         the patients’ urinary recovery).
         Clinical efficacy was evaluated by voiding diaries, quality of life score and urodynamic investigation. Follow-up
         evaluations were taken after one year.
         Results: Following treatment, 7 patients of the treatment group could micturate voluntarily after electroacupuncture
         stimulation, compared to only 2 patients of the control group. In the treatment group, the maximum detrusor pressure
         increase from 9.21±3.32 cmH2O to 33.57±6.75 cmH2O and the average residual volume decreased from 230.19±40.06
         ml to 42.54±20.91 ml. Average quality of life score declined by 2.2 points.Statistically significant changes in the
         maximum detrusor pressure and average residual volume were observed between the treatment and control group (p <
         .05). No side effects were observed in the treatment of electroacupuncture stimulation.
         Conclusion: Electroacupuncture could be an effective and safe method for patients with long-term urinary retention
         after spinal cord injury.
22
                              Research Poster Competition

5   Management of cardiovascular disease risk factors in the spinal cord injury
    population: an evidence-based clinical review
    Cragg, J and Krassioukov, A
    International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Co-
    lumbia, Canada
    School of Population and Public Health, University of British Columbia
    Introduction. Clinical Scenario: A.C., a 50-year-old male, suffered a spinal cord injury (T1) twenty years ago in a car
    accident. AC is a slightly overweight smoker; he has just celebrated his 50th birthday, and is worried about cardiovascular
    disease. He comes to your office for advice.
    Cardiovascular disease (CVD) is a critical issue for individuals with the spinal cord injury (SCI). CVD-related
    mortality is over 200% more common in patients with SCI compared to able-bodied controls (Kocina, 1997). Death
    from cardiovascular causes is now the leading cause of death in the SCI population. While some patient management
    guidelines for the risk factors of CVD in the SCI population are already in place, they do not rigorously evaluate the
    available clinical evidence and present it in a user-friendly manner.
    Methods. Here, we discuss the management of modifiable CVD risk factors for the chronic SCI population using an
    evidence-based, comprehensive, and systematic approach, highlighting more recent evidence with respect to chronic
    inflammation.
    Results: We identified management recommendations for the following modifiable risk factors: physical inactivity,
    obesity, smoking, dyslipidemia, blood pressure irregularity, glycemic control, and chronic inflammation. We also identified
    a general lack of evidence with respect to examining treatment outcomes specifically within the SCI population.
    Conclusion: For optimal outcomes in SCI patients, healthcare providers should provide treatment for modifiable CVD
    risk factors.




6   Cardiovascular function in rats with spinal cord injury: Using spectral analyses to
    evaluate damage to autonomic pathways
    Inskip, J.A., Ramer, L.M., Ramer, M.S., Krassioukov, A.V. and Claydon, V.E
    Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC.
    Introduction: Spinal cord injury (SCI) can result in profound cardiovascular dysfunction. Many individuals with
    SCI have difficulty controlling their blood pressure (BP) and, as a result, alternately experience periods of very low
    (orthostatic hypotension, OH) and very high (autonomic dysreflexia, AD) blood pressure. These episodes are disruptive
    to daily life and extreme cases can be life threatening; therefore, evaluating cardiovascular control is critical after SCI.
    Spectral analyses have been used to evaluate the severity of injury to cardiovascular autonomic pathways in clinical SCI.
    Whether this technique is suitable for rodents with SCI remains unknown.
    Methods: Arterial BP was recorded from male Wistar rats with high-thoracic SCI (T3, n=11), low-thoracic SCI (T10,
    n=9) and intact controls (n=14). OH was assessed with a 90º head-upright tilt and AD was evaluated using colorectal
    distension. Spectral analyses of cardiovascular parameters were performed; frequency domain variables were correlated
    with OH and AD severity.
    Results: Animals with high-thoracic SCI demonstrated reduced heart rate variability (HRV) and BP variability (BPV)
    compared to intact controls (p<0.05). Individual frequency domains of HRV and BPV in the very-low (VLF), low (LF)
    and high-frequency (HF) ranges were distinct between animals with high- and low-thoracic SCI, and intact controls.
    LF BP oscillations correlated with the severity of OH (r=0.535,p=0.04); HF BP oscillations correlated with AD severity
    (r=0.913,p=0.002).
    Conclusion: Spectral analyses of cardiovascular parameters are sensitive to the differences in cardiovascular autonomic
    function between rodents with high- and low-thoracic SCI. Importantly, several frequency domain measures correlate
    with functional measures of BP control.

                                                                                                                                   23
                                   Research Poster Competition

     7   Modulation of Cutaneous Reflex Response during Manual Wheeling
         Megan MacGillivray1,2, M. Klimstra4, B.J. Sawatzky2,3, E.P. Zehr,2,4 T. Lam1,2
         1
          School of Human Kinetics, 2International Collaboration on Repair Discoveries (ICORD), 3Department of
         Orthopaedics, University of British Columbia, Vancouver, BC, Canada. 4Centre for Biomedical Research and School of
         Exercise Science, Physical and Health Education, University of Victoria, Victoria, BC, Canada.
         Introduction: Approximately 155 000 Canadians (Shields, 2004) and 1.5 million Americans (Kaye et al, 2000) depend
         on manual wheelchairs for locomotion. To date there has been very little research into the neural control of manual
         wheeling. One concept is that rhythmic upper limb movement is regulated by a central pattern generator (CPG) and
         follows a similar pattern of sensory processing as described for walking. This study explores this concept by investigating
         the modulation of cutaneous reflexes during manual wheeling. The purposes of this study are to determine if the
         cutaneous reflex response to stimulation of the superficial radial nerve are phase-dependent during manual wheeling
         and to determine if there are differences in cutaneous reflexes during manual wheeling between able-bodied subjects and
         individuals with spinal cord injuries (SCI) at T1 and below.
         Methods: The purposes of this study are to determine if the cutaneous reflex response to stimulation of the superficial
         radial nerve are phase-dependent during manual wheeling and to determine if there are differences in cutaneous reflexes
         during manual wheeling between able-bodied subjects and individuals with spinal cord injuries (SCI) at T1 and below.
         Results: The majority of muscles showed significant reflexes in both groups and several muscles demonstrated
         significant reflex modulation. There were no significant differences in the amount of modulation that occurred, as
         measured by the modulation index, between the able-bodied group and the SCI group.
         Conclusion: Although, there was no significant differences in the amount of reflex modulation between able-bodied
         and SCI subjects during manual wheeling, future research should examine changes in cutaneous reflexes with
         training. Understanding how and when cutaneous reflexes change after SCI could help to identify important time
         periods for rehabilitation.




     8   Metabolic changes following high- and low-thoracic spinal cord injury:
         implications for reduced lifespan
         Plunet, W., Inskip, J., Ramer, L., Tetzlaff, W., Krassioukov, A., Ramer, M.
         International Collaboration on Repairs Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada.
         Introduction: Long-term survival rate after a spinal cord injury - beyond the first 2 years - has not changed over the
         last 25 years. For example a 25 year old SCI individual who has survived the first 2 years after injury has a 13 to 25 year
         reduction in lifespan compared to the able-bodied population. The contributing factors underlying this reduction in
         lifespan are unknown and understudied.
         Methods: We performed glucose and insulin tolerance testing (GTT, ITT) after complete high-thoracic (T3) and low-
         thoracic (T10) SCI in a rat model to determine whether there was an injury-induced shift toward metabolic syndrome/
         diabetes as reported clinically in the SCI population, and is associated with a reduction in lifespan.
         Results: At 1 and 3 months post injury, both T3 and T10 animals exhibited an attenuated increase in blood glucose in
         the GTT compared to sham-injured controls. Additionally, in the ITT, animals with SCI displayed heightened insulin
         sensitivity at 1 month post-injury (T3) and 3 months post-injury (T10), compared to the intact control group.
         Conclusion: These results suggest that the SCI animals have an exaggerated response to a metabolic challenge (increased
         glucose- and insulin-sensitivity), which is the opposite of what we expected. However, the dysregulation observed is
         reminiscent of other systems regulated by the autonomic nervous system when tested after SCI. This is only an initial
         step into exploring the unknown biological mechanisms behind the greatly reduced lifespan observed in people with a
         spinal cord injury.




24
                              Research Poster Competition

9    Hot ’n’ bothered: TRPV1-positive sensory neurons in autonomic dysreflexia
     Leanne M. Ramer,1,2, Adrian P. van Stolk1, Jessica A. Inskip1,2, John D. Steeves, Ph.D.1, Matt S. Ramer, Ph.D.1,2 ,
     Andrei V. Krassioukov, M.D., Ph.D.1,3,4
     1
       ICORD (International Collaboration on Repair Discoveries), University of British Columbia (UBC),Vancouver, BC,
     Canada; 2Department of Zoology, UBC ; 3GF Strong Rehabilitation Centre, Vancouver; 4Department of Medicine,
     UBC
     Introduction: TRPV1 is expressed by a subpopulation of sensory neurons. It is activated by heat (>43ºC), low pH,
     and capsaicin (the pungent ingredient in hot chili peppers), and has emerged as a promising target for the treatment of
     pain. Both pain and autonomic dysreflexia that develop in the wake of SCI have been attributed to maladaptive sensory
     plasticity. We hypothesize that TRPV-1-positive afferents contribute to the development of autonomic dysreflexia (AD).
     Methods: Wistar rats (300g) received a complete transection of the spinal cord at the third (T3) or tenth (T10) thoracic
     segment or sham injury (durotomy without SCI). After 1-12 weeks, dorsal root ganglia (DRGs) and spinal cord were
     harvested and analyzed immunohistochemically to examine soma size of TRPV1-positive afferents and density of their
     central projections.
     Results: TRPV-1-positive nociceptors exhibited hypertrophy after T3 SCI. Nociceptor hypertrophy only occurred in
     DRGs below the level of SCI, and was more pronounced after high thoracic (T3) SCI. Hypertrophy was pronounced
     in DRGs far distal to SCI, and occurred in DRGs that contained both somatic (L4,L5) and visceral (L6,S1) afferents.
     TRPV-1-expressing nociceptors also appeared to sprout within the lumbar dorsal horn: the area occupied by TRPV-1-
     positive axons was increased one month after SCI.
     Conclusion: TRPV-1-expressing nociceptors respond to SCI by undergoing somal hypertrophy and expanding their central
     terminals in the lumbar dorsal horn. Recent data from another laboratory demonstrates that this anatomical plasticity
     is accompanied by spontaneous activity in TRPV-1-positive afferents caudal to SCI. We are currently using capsaicin to
     determine the contribution of TRPV-1-positive afferents to the development of AD following high-thoracic SCI.




10   ECG-Based Predictors For Cardiac Arrhythmias After Spinal Cord Injury
     Ravensbergen, H.J.C, Walsh M.L., Krassioukov A.V. and Claydon V.E.
     Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, Canada
     Introduction: Individuals with spinal cord injury (SCI) have an increased risk for cardiac arrhythmias, particularly
     during autonomic dysreflexia. This may be partly due to impaired autonomic control of the heart after SCI. The interval
     between the peak and end of the T-wave of the electrocardiograph (ECG) provides an index of transmural dispersion of
     repolarisation, a factor underlying the development of ventricular arrhythmias. We hypothesize that variability of P-wave
     duration is correlated with risk for atrial arrhythmias. We aimed to: i) determine whether there are abnormalities in
     Tpeak-Tend and P-wave variability at rest in those with SCI; ii) determine correlations between ECG parameters and
     measures of autonomic impairment after SCI.
     Methods: ECG intervals were determined using customized software from a 15 minute ECG recording (lead II)
     in 28 subjects with SCI and 27 controls. Variability of these parameters was calculated using autoregressive spectral
     analyses. Autonomic severity of SCI was determined from sympathetic skin responses (SSR), and resting and upright
     noradrenaline (NA) levels.
     Results: Tpeak-Tend variability was increased in those with autonomically complete SCI compared to controls
     (103.3±24.6 vs. 49.7±12.7 ms2). P-wave variability was increased in those with SCI compared to controls (104.9±15.8
     vs. 28.6±5.6 ms2), and was negatively correlated to upright NA (r=-0.50, p=0.035).
     Conclusion: Greater Tpeak-Tend and P-wave variability in individuals with injury to cardiac autonomic pathways could
     provide new risk assessment parameters for predisposition to cardiac arrhythmias in this population.




                                                                                                                                 25
                                    Research Poster Competition

     11   The influence of different wheelchair seating positions on cardiovascular control
          Sahota IS1,2, Camp JE1, Mah CS1, Borisoff JF2, McPhail LT2, Claydon VE1,2
          (1) Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC, Canada
          (2) International Collaboration On Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC,
          Canada
          Introduction: Lightweight wheelchairs are available that allow users to adjust their seating position, offering improved
          comfort and increased independence. Our study examined whether cardiovascular control is affected by changes in
          seating position in two wheelchairs: Instinct Mobility’s Elevation and Levo’s LAE.
          Methods: We evaluated beat-to-beat heart rate (HR), blood pressures (BP; finger plethysmography), stroke volume
          (SV), cardiac output, total peripheral resistance (Modelflow), end-tidal oxygen and carbon dioxide (nasal cannula) and
          cerebral blood flow velocity (CBFV; Doppler ultrasound), continuously for 15-minutes in supine, standard and upright
          (Elevation=68º and LAE=85º) seating positions. Evaluations were performed in healthy able-bodied subjects (Elevation:
          n=13; LAE: n=12).
          Results: BP increased (p<0.05) and CBFV decreased (p<0.05) in the standard and upright seating positions relative
          to supine. HR increased in all seating positions compared to supine (p<0.001), and increased further when upright
          compared to standard seating (p<0.05). With the Elevation wheelchair, SV showed a reciprocal pattern to HR, with
          significant decreases (p<0.001) in all positions compared to supine, and further decreases (p<0.05) when upright
          compared to standard seating positions. In the LAE, SV decreased (p<0.05) when upright compared to supine or standard
          seating. The magnitude of HR and SV responses were greater (p<0.05) with the LAE compared to the Elevation.
          Conclusion: These data suggest that transitions between different wheelchair seating positions are not an inconsiderable
          orthostatic stress, even in healthy able-bodied people. Further studies are warranted to elucidate the effect of altered
          seating positions on cardiovascular control in wheelchair users with and without autonomic dysfunction.



     12   Cellular responses to spinal cord injury in the dorsal root ganglion
          Adrian P. van Stolk1, Leanne M. Ramer,1,2, Jessica A. Inskip, 1,2; Matt S. Ramer, Ph.D.1,2; John D. Steeves, Ph.D.1;
          Andrei V. Krassioukov, M.D., Ph.D,1,3,4
          1
           ICORD (International Collaboration on Repair Discoveries), University of British Columbia (UBC),Vancouver, BC,
          Canada; 2Department of Zoology, UBC ; 3GF Strong Rehabilitation Centre, Vancouver; 4Department of Medicine, UBC
          Introduction: Sensory and autonomic dysfunction following spinal cord injury (SCI) have been attributed in part to
          aberrant growth of sensory axons within the central nervous system. Comparatively little is known about injury-induced
          changes in the attached ganglia. These studies characterize neuronal plasticity and glial reactivity in the dorsal root
          ganglion (DRG) following high-thoracic SCI.
          Methods: Adult Wistar rats received a complete transection of the spinal cord at the third thoracic segment (T3), and
          survived for one, four, or twelve weeks following SCI. Dorsal root ganglia (DRGs) rostral (T1), caudal (T5, T10), and
          far distal (L1-S1) to SCI were harvested and analyzed immunohistochemically.
          Results: Tyrosine hydroxylase (TH) –expressing sympathetic ganglionic axons invaded the rat DRG within one month
          of SCI. The density of TH-expressing axons in DRGs rostral (T1) and distal (L4-5) to SCI was significantly increased
          at one month after SCI. Several phenotypic markers were used to characterize the primary afferent response to SCI. Of
          all populations examined, only TRPV1+ nociceptors in distal DRGs exhibited hypertrophy following SCI. Nociceptor
          hypertrophy was accompanied by increases in glial reactivity, indicated by increases in satellite cell-derived glial fibrillary
          acidic protein (GFAP) and RIP, and increased density of ED2-positive macrophages following SCI.
          Conclusion: Injury-induced changes in the DRG have the potential to effect neuronal hyper-responsiveness or ectopic
          activity following SCI. Thus, abnormal sensory activity following SCI may not be due solely to spinal plasticity, but may
          originate in the peripheral nervous system. We are currently determining whether the degree of injury-induced plasticity
          in the DRG is correlated with the severity of autonomic dysreflexia following SCI.



26
                               Research Poster Competition

13   Autonomic Dysfunction: Heart Rate Variability in Wheelchair Rugby Players
     with Tetraplegia
     Wong, S.C., Krassioukov, A.V., Warburton, D.E.R., Mills, P., Mikhaill, D., Krassioukov-Enns, D.
     ICORD, Department of Experimental Medicine, Department of Medicine, University of British Columbia.
     Introduction: Spinal cord injury (SCI) damages both the somatic and the autonomic nervous systems (ANS). The
     current Paralympic classification of wheelchair athletes does not take into account autonomic functions. Heart rate
     variability (HRV) describes the cyclic changes of the heart period (R-R interval) over time. Analysis of HRV in the
     frequency domain delineates parasympathetic from sympathetic components of the ANS. High frequency (HF)
     components (0.15 to 0.4 Hz) are an index of parasympathetic neural activity. Low frequency (LF) components (0.04
     to 0.15 Hz) are an index of sympathetic neural activity. We examined changes in HRV among tetraplegic rugby players
     and able-bodied controls with the goal of working towards developing a validated system for functional autonomic
     assessment of Paralympic athletes.
     Methods: Paralympic wheelchair rugby athletes with cervical motor complete SCI and able-bodied controls between
     the ages of 18 to 45 were studied. A three-lead electrocardiogram (ECG) (lead II;) was used to record heart rate during
     a 10-minute supine rest period. Data were analyzed offline with HRV software. T-tests were used to compare parameters
     of HRV between groups (p<0.05).
     Results: Able-bodied individuals had significantly greater LF (0.09 + 0.02 vs. 0.04 + 0.02 Hz, respectively) and LF to
     HF (LF/HF) ratio (1.63 + 0.43 vs. 1.04 + 2.10, respectively) in comparison to athletes with tetraplegia.
     Conclusion: Our findings illustrate that there are clear differences in autonomic function between persons with
     cervical SCI and able-bodied individuals. Individuals with SCI experience autonomic dysfunction that could alter their
     performance and this warrants further investigation to improve equality and safety in sport for wheelchair athletes.




14 Does primary motor cortex plasticity parallel adaptive modification to human
   walking?
     Zabukovec J.R., Linsdell M.A., Lam T. & Boyd L.A. University of British Columbia, Rehabilitation Science.
     Introduction: Literature on locomotor adaptation indicates that the nervous system employs a combination of
     feedback and feedforward mechanisms to adapt to task demands during walking. The location and mechanisms of these
     physiological and kinematic changes are unknown. Purpose: (1) To determine if corticospinal (CS) excitability is altered
     by adapted walking. (2) To determine whether CS changes are modulated by attention and whether they are muscle
     specific.
     Methods: Locomotor adaptations were induced in healthy participants using a robotic gait-assisted treadmill (Lokomat).
     Velocity-dependent resistance was applied against hip and knee movements during walking. CS excitability was assessed
     by quantifying motor evoked potentials (MEPs) elicited by transcranial magnetic stimulation immediately before
     and after adaptation to both resisted and nonresisted walking. Recruitment curves were collected by stimulating at
     increments of 5% from 105-145%AMT. To determine whether adaptation is muscle specific, MEPs were measured
     through random assignment of either the biceps femoris (BF) or rectus femoris (RF). To evaluate the impact of attention
     on adaptive walking, half the participants were provided with a visual feedback tracking task requiring them to attend to
     their walking pattern. The other half watched a controlled visual stimulus.
     Results: Preliminary data suggest that compared to baseline values, MEPs increased in the BF and RF after walking
     in the Lokomat with resistance, suggesting an increase in CS excitability. However MEPs decreased when participants
     explicitly focused on their walking pattern with resistance. Results also suggest that the RF demonstrates a larger increase
     in MEP amplitude following resisted walking compared to the BF.
     Conclusions: The role of the CS system in adaptations during walking and the impact of attention on CS excitability are
     important when determining how to improve communication in the spinal cord following injury.



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                   Cover art: T. Gack, Design & Layout: M. Pak.

				
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