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A prospective trial to demonstrate the efficacy of intrathecal baclofen therapy by implanted pump for adults with spasticity due to spinal cord injury or multiple sclerosis was initiated in our hospital. Of the 140 patients assessed, 7 met the following criteria for inclusion in the study: a modified Ashworth score > 3, a spasm frequency score > 2, and an inadequate response to oral anti-spasticity drugs, (i.e., baclofen, clonidine and cyproheptadine). All patients responded to intrathecal bolus injection of baclofen in the double blind, placebo-controlled screening phase (mean bolus dose = 42.8 micrograms). Programmable Medtronic pumps were implanted in 4 patients while 3 patients received non-programmable Infusaid pumps. Post-implantation, a marked decrease in spasticity occurred with a significant reduction of the Ashworth score (mean = 1.8, p < .005), a reduced spasm score (mean = 0.8, p < .005), and an improved leg swing in the pendulum test. These effects were maintained during a follow-up of 24-41 months (average infusion dose = 218.7 micrograms/day). The gross cost-savings due to reduced hospitalizations related to spasticity was calculated by comparing the cost for the two year period before pump implantation to the same period after treatment for 6 of the 7 patients. The cost of in-hospital implantation as well as the cost of the pumps were deducted from the gross savings. There was a net cost-saving of $153,120. Our findings agree with the reported efficacy and safety of intrathecal baclofen treatment, and illustrate the cost-effectiveness of this treatment.

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Patients with quadriplegia have a limited capacity to recruit expiratory muscles and are deprived of respiratory-related feedback from the rib cage and abdominal wall. We wished to evaluate the compensatory strategies available to such patients during expiratory resistive loading (ERL) and to compare their responses with those of normal healthy individuals. In addition, to determine whether the quadriplegic subjects have a blunted sensory appreciation of added ERL, we also compared sensory detection thresholds (delta R50). Steady-state ventilatory responses to ERL (delta R = 12 cm H2O/L/s) were compared in seven quadriplegic patients (level of injury, C6, C7) and six age-matched normal subjects. Highly significant intergroup differences were evident in the extent of prolongation of expiratory time (TE) and total cycle duration (Ttot) during ERL; values of delta TE and delta Ttot in quadriplegics were, on average, 46% of those of normals (p < 0.001). Minute ventilation (VE) was defended to an equal or better extent in quadriplegics. ERL-induced changes in tidal volume, inspiratory duration, mean inspiratory and expiratory flows, and end-expiratory lung volume (EELV) were not significantly different. Average delta R50 in quadriplegics and normals were (mean +/- SD), 1.73 +/- 0.039 cm H2O/L/s and 1.62 +/- 0.4 cm H2O/L/s, respectively (p = ns). Quadriplegics, therefore, despite substantial sensory and motor deficits, defend ventilation and EELV as effectively as normal individuals and show no attenuation in the ability to detect an added expiratory resistance.

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Central nervous system (CNS) trauma can produce a multitude of physical and psychological sequelae, depending on the neurological level of injury. Clinicians have long recognized the adjustment difficulties posed in marriages of CNS trauma victims, yet there is little research documentation for this observation. The marital relationships of moderate (n = 31) and severe (n = 17) head injury (HI) groups and a spinal cord injury (SCI) group (n = 24) were assessed through spouses' self-reports in interview and through standardized questionnaires. Analyses indicated that the three groups were not statistically different in age, number of months post-injury, pre- and post-injury occupational status, and level of income. In the post-injury marital relationship, the severe HI group was significantly lower than the moderate HI and SCI groups on standardized and validated scales assessing affectional expression (p less than 0.002), dyadic satisfaction (p less than 0.001), dyadic cohesion (p less than 0.01), and total dyadic adjustment (p less than 0.001). On a scale of social role functioning, the severe HI group's performance was significantly lower than the moderate HI and SCI groups (p less than 0.005). These results empirically substantiate the clinical observation that adjustment difficulties may be more intense for wives of the severely head injured than the moderately injured or the SCI, as they must deal with neuropsychological as well as physical fall-out from the injury.

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The alterations in lung function and breathing pattern were examined in 6 quadriplegics at 3, 6 and greater than 12 months post injury, and were compared to 6 able bodied controls. Subjects were studied in both the seated and supine positions. Functional residual capacity (FRC), forced vital capacity (FVC), inspiratory capacity (IC), and maximum mouth pressure (Pimax) at FRC were measured. Total lung capacity (TLC) and residual volume (RV) were calculated. Resting breathing pattern was assessed for 20 minutes from a spirogram derived from summed rib cage and abdominal strain gauge signals. At 3 months in quadriplegics, TLC was reduced (p less than 0.05), RV increased (p less than 0.01) and FRC was normal in sitting; in supine, only TLC was reduced (p less than 0.05); Pimax was decreased (p less than 0.01) in both positions in quadriplegics at 3 months, but increased over the first year in the seated position (p less than 0.01). There were no alterations in breathing pattern at any time interval in quadriplegics in supine. In contrast, at 3 months post injury in sitting, expiratory time (Te) was shortened (p less than 0.05), tidal volume (Vt) was decreased, and heart rate elevated as compared to controls (p less than 0.05). Inspiratory time (Ti) was not significantly shortened at 3 months in quadriplegics, but a lengthening of Ti occurred between 3 and 6 months (p less than 0.025) resulting in increased Vt, and heart rate decreased to normal. Vt/Ti was reduced, and did not alter with time. The lengthening of Ti/Ttot observed in supine in control subjects (p less than 0.025), was not observed in quadriplegics. Quadriplegics sighed as frequently in supine as did controls at all stages post injury, whereas they decreased sighing frequency in sitting at 3 and 6 months post injury (p less than 0.05). The improvement in resting breathing pattern observed in quadriplegics in sitting with time, may be due to increased accessory muscle function, improved chest wall stability and thoracoabdominal coupling, or a combination of these factors. It is also possible that the alterations in breathing pattern were a response to cardiovascular adjustments occurring in the same time frame. Quadriplegics retain the sigh reflex, but do not take as many big breaths in sitting as they do in supine, probably due to the increased work of breathing in the seated posture.

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The resting breathing pattern in 14 chronic C6 and C7 traumatic quadriplegics was compared with six age-matched healthy controls. All quadriplegics had complete motor loss below the lesion level and were at least two years postinjury. Tests were performed with subjects seated. Forced vital capacity (FVC), forced expiratory volume in one second (FEV1.0), inspiratory capacity (IC), and maximum inspiratory mouth pressure (Pimax) were measured. Resting breathing pattern was assessed for 20 minutes using mercury in rubber strain gauges and a computer-assisted data acquisition and analysis program. Inspiratory time (Ti), expiratory time (Te), and tidal volume (Vt) were measured, and the remaining timing components were calculated from these values. The variability of breathing was assessed by comparing the coefficients of variation of each variable. The FVC, IC, and Pimax were significantly reduced; Vt was significantly lower (p less than 0.01) and frequency significantly elevated (p less than 0.05) in quadriplegics. The decreased Vt in quadriplegics was due entirely to a significantly decreased mean inspiratory flow (p less than 0.01); Ti was the same in quadriplegics as in controls. The ratio of mean Ti to total cycle time (Ti/Ttot) was significantly longer in quadriplegics (p less than 0.005). There was no difference in variability of breathing between the two groups for any timing component of ventilation. There was no significant difference in sighing frequency between groups for either breaths greater than 2x mean Vt or breaths greater than 3x mean Vt. Chronic quadriplegics demonstrated a rapid, shallow breathing pattern, probably due to the mechanical restrictions resulting from paralysis of the thorax musculature. They retained the ability to sigh, suggesting that chest wall afferents may not be required in this process.

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We examined the effects of ventilatory muscle endurance training on resting breathing pattern in 12 C6-C7 traumatic quadriplegics at least 1 year post-injury. All subjects had complete motor loss below the lesion level. Subjects were randomly assigned to a training (N = 6), or a control group (N = 6). Baseline tests included measurement of resting ventilation and breathing pattern using mercury in rubber strain gauges for 20 minutes in a seated position; maximum inspiratory mouth pressure (MIP) at FRC, and sustainable inspiratory mouth pressure for 10 minutes (SIP); lung volumes, and arterial blood gases (ABG's). The training protocol consisted of breathing through an inspiratory resistor equivalent to 85% SIP for 15 minutes twice daily, 5 days a week for 8 weeks. Both trainers and controls attended the lab every 2 weeks for reassessment of MIP and SIP and the inspiratory resistance was increased in the training group as SIP increased. At the end of 8 weeks, baseline tests were repeated. All subjects had normal ABG's. There was a significant increase in mean MIP and SIP in both the control group (30% +/- 19% and 31% +/- 18% respectively), and in the training group (42% +/- 24% and 78% +/- 49% respectively). Although the absolute values for both MIP and SIP were greater in the training group than in the control group, the differences were not significant. The alterations in resting breathing pattern were also the same in both groups. Mean frequency decreased significantly in the control group (20.2/minute to 16.9/minute) and, while insignificant, the change in frequency in the training group was the same, 19.4/minute to 16.4/minute. Mean tidal volume (Vt) increased 18.2% of baseline Vt in the control group and 17.0% baseline in the trainers, resulting in no change in minute ventilation. As MIP and SIP increased similarly in both groups, the data from the control and trainers was pooled and timing changes re-evaluated pre- and post-study. A significant decrease in mean Ti/Ttot was observed, while no change in Vt/Ti was found. We concluded that the testing procedure itself provided the stimulus resulting in a significant increase in MIP and SIP. The addition of training did not increase MIP and SIP further. The increased MIP and SIP resulted in a slower and deeper breathing pattern and a significantly shorter Ti/Ttot in both trainers and control subjects.

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Normal subjects preserve tidal volume (VT) in the face of added inspiratory resistance by increasing maximal amplitude and duration of the rising phase of respiratory driving pressure (DP) and by changing the shape of this phase to one that is more concave to the time axis. To explore the possible role of chest wall afferents in mediating these responses, we determined averaged DP in eight quadriplegic subjects during steady-state unloaded breathing and while breathing through an inspiratory resistance (8.5 cmH2O X 1(-1) X s). As with normal subjects, quadriplegics preserved VT (loaded VT = 106% control) by utilizing all three mechanisms. However, prolongation of the inspiratory duration derived from the DP waveform (+22% vs. +42%) and shape response were significantly less in the quadriplegic subjects. Shape response was completely absent in subjects with C4 lesions. The results provide strong evidence that respiratory muscle spindles are responsible for shape response and that changes in afferent feedback from the chest wall play an important role in mediating inspiratory prolongation.

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Twenty-two spinal fractures in 20 patients with chronic ankylosing spondylitis are reported. Nineteen fractures occurred in the cervical region. Fourteen of the fractures were caused by minor falls, 3 by falls down steps, 4 by motor vehicle accidents, and 1 by cardiopulmonary resuscitation. Long-term followup (mean 3.2 years) of 9 fractures diagnosed early and managed conservatively showed bony union of all fractures. No patient deteriorated neurologically and 3 patients made major recovery. Long-term followup is also reported on 6 patients in whom the diagnosis was delayed. The difficulties in diagnosis and management are discussed.

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HLA typing for the A and B loci and radiographic examination of the sacroiliac joints were performed in 54 randomly selected patients with paraplegia or quadriplegia of more than 3 years' duration. The sacroiliac joints were abnormal in 24 patients. No association was found between any of the HLA antigens of the A and B loci and the sacroiliac joint changes. There was, however, an increased incidnece of sacroiliac joint changes in quadriplegic as compared to paraplegic patients.

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The ankylosed osteoporotic spines of patients with long-standing ankylosing spondylitis are prone to fracture. The spinal trauma is of a trivial nature in many patients and the diagnosis may be overlooked, unless neurologic damage occurs. The fractures most commonly occur in the cervical region and may be multiple. Because of spinal osteoporosis and deformity, radiographic visualization of the fracture site may be difficult. Tomography may be helpful in some patients. Management may be conservative or surgical and is complicated by increased instability of the fracture site, spinal osteoporosis, and deformity. Conservative management of cervical fractures is probably best accomplished by halo traction and body cast. Progression of the neurologic deficit is an indication for surgical intervention.

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The telemetered electromyographic (EMG) activity of pretibial muscles (tibialis anterior), triceps surae (lateral gastrocnemius), medial hamstring group and quadriceps (vastus lateralis) of 20 normal subjects was examined during locomotion. The ages of the subjects ranged from 8 to 72 years (mean, 37 years). A microswitch shoe was used to correlate the EMG activity with eight specific components of the gait cycle. Tibialis anterior showed two peaks of activity, the first at the swing-stance transition, the second at the stance-swing transition. Gastrocnemius showed a single peak of activity recorded during push-off. The medial hamstring showed its greatest activity during deceleration in the swing phase. Vastus lateralis demonstrated peak activity at the transition from swing to stance. The mean cadence was 106 steps per minute. Swing phase occupied 39.6% and stance phase 60.4% of the gait cycle.

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The telemetered electromyographic (EMG) activity of quadriceps, hamstrings, triceps surae and pretibial muscles on the affected side of 20 adult hemiplegic subjects was examined during locomotion. The subjects ranged in age from 29 to 68 years (mean, 52.1). Duration of the lesions ranged from 1 month to 8 years: in 11 subjects the duration of the lesions ranged from 1 to 9 months (mean, 4.9 months), and in the remaining 9 subjects from 1 to 8 years (mean, 4 years 2 months). Shoes with five microswitches, two in the heel and three in the sole, were used to correlate the EMG activity with eight specific components of the gait cycle. The results of the study showed a loss of the phasic pattern associated with normal locomotion. The hemiplegic subjects showed the greatest activity in the period of midstance. Expressed as a percentage of the total cycle, the mean stance time of the paretic lower limb was 67% and the mean swing time was 33%. The unaffected lower limb showed a stance phase of 80% and a swing phase of 20%.

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