Aquatic-Based Therapy in Spinal Cord Injury Rehabilitation: Effective Yet Underutilized

Neuromechanical Adaptation to Walking With Electromechanical Ankle Exoskeletons Under Proportional Myoelectric Control

OBJECTIVE

To determine if robotic ankle exoskeleton users decrease triceps surae muscle activity when using proportional myoelectric control, we studied healthy young participants walking with commercially available electromechanical ankle exoskeletons (Dephy Exoboot) with a novel controller. The vast majority of robotic lower limb exoskeletons do not have direct neural input from the user which makes adaptation of exoskeleton dynamics based on user intent difficult. Proportional myoelectric control has proven to allow considerable adaptation in muscle activation and gait kinematics in pneumatic, tethered ankle exoskeletons. In this study we quantified the changes in muscle activity and joint biomechanics of twelve participants walking for 30 minutes on a treadmill.

RESULTS

The exoskeletons provided 29% of the peak total ankle power and 18% of the peak total ankle moment by the end of the practice session. There was a decrease of 12% in soleus, 17% in lateral gastrocnemius and 5% in medial gastrocnemius electromyography (EMG) root mean square (root mean squared) after walking with the exoskeleton for 30 minutes compared to not wearing the exoskeleton, but this difference was not statistically significant. There were no differences in joint biomechanics of the ankle, hip, or knee between the end of training compared to walking without the exoskeletons.

CONCLUSIONS

Contrary to expectations, triceps surae muscle activity showed only small non-significant decreases in 30 minutes of walking with portable, electromechanical ankle exoskeletons under proportional myoelectric control. The commercially available ankle exoskeletons were likely too weak to produce a statistically meaningful decline in triceps surae recruitment. Future research should include a wider variety of tasks, including measurements of metabolic energy expenditure, and provide a longer period of adaptation to evaluate the ankle exoskeletons.

Wearable technologies for monitoring aquatic exercises: A systematic review

Objective

To review methods for aquatic exercise monitoring using wearables.

Data sources

Database search of PubMed, IEEEXplore, Scopus and Web of Science based on keywords, considering articles from the year 2000. The last search was performed on 26 October 2022.

Review methods

Following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) protocol, eligible articles on water exercises were selected and summarized. Further screening process concentrated on studies exploiting wearable devices, organized according to demographics, purpose, protocols, outcomes and methods. A custom critical appraisal questionnaire was applied.

Results

Out of the 1062 articles identified, 572 were considered eligible and subjected to preliminary synthesis. The final review focused on 27 articles featuring wearable devices applied to aquatic exercises. Four studies were disregarded as they applied wearable devices to determine daily physical activity or for sleep monitoring after training. Summary tables of 23 studies exploiting wearable devices for underwater motion analysis are provided, specifying the investigated parameters, major outcomes and study quality. This review identified four research gaps: (a) the absence of clinical protocols for underwater motion studies, (b) a deficit of whole-body studies, (c) the lack of longitudinal studies monitored via wearable devices and (d) the reliance of underwater studies on measurement and assessment methods developed for land-based investigations.

Conclusions

This review emphasizes the need for both technological and methodological improvements for underwater motion analysis studies using wearables. We advocate for longitudinal clinical investigations with wearables to substantiate water exercise as an addition or replacement for land-based physical activity.

Factors influencing the use of aquatic therapy: perspectives from occupational therapists

Background/Aims

Aquatic therapy has been identified as more conducive than land-based treatment options to improve health and quality of life in some patient populations. However, the prevalence of occupational therapists who implement aquatic therapy in practice is low. The aim of this study was to understand the perceptions of barriers and facilitators to aquatic therapy use by occupational therapists in the USA.

Methods

Individual semi-structured interviews were completed (via Skype) with four occupational therapists who held an ‘aquatic therapeutic exercise certificate’ from the Aquatic Therapy and Rehab Institute. Interviews were audio recorded and manually transcribed verbatim. Inductive thematic analysis was employed to identify themes and sub-themes in the data.

Results

The following three overarching themes were identified: institutional constraints and resources impact aquatic therapy implementation; the perceived lack of unity within the occupational and aquatic therapy communities; and implications of aquatic therapy's low prevalence within the occupational therapy profession.

Conclusions

Institutional factors including pool accessibility, insurance coverage, and employer support are determinants of practitioners' abilities to use aquatic therapy. The research identified a desire for support through networking and the need to build the authority of occupational therapists in aquatic therapy to offset the barriers implicated with being a minority profession.

Supporting front crawl swimming in paraplegics using electrical stimulation: a feasibility study

Background

Participation in physical and therapeutic activities is usually severely restricted after a spinal cord injury (SCI). Reasons for this are the associated loss of voluntary motor function, inefficient temperature regulation of the affected extremities, and early muscle fatigue. Hydrotherapy or swim training offer an inherent weight relief, reduce spasticity and improve coordination, muscle strength and fitness.

Methods

We present a new hybrid exercise modality that combines functional electrical stimulation (FES) of the knee extensors and transcutaneous spinal cord stimulation (tSCS) with paraplegic front crawl swimming. tSCS is used to stimulate the afferent fibers of the L2–S2 posterior roots for spasticity reduction. By activating the tSCS, the trunk musculature is recruited at a motor level. This shall improve trunk stability and straighten the upper body. Within this feasibility study, two complete SCI subjects (both ASIA scale A, lesion level Th5/6), who have been proficient front crawl swimmers, conducted a 10-week swim training with stimulation support. In an additional assessment swim session nine months after the training, the knee extension, hip extension, and trunk roll angles where measured using waterproof inertial measurement units (IMUs) and compared for different swimming conditions (no stimulation, tSCS, FES, FES plus tSCS).

Results

For both subjects, a training effect over the 10-week swim training was observed in terms of measured lap times (16 m pool) for all swimming conditions. Swimming supported by FES reduced lap times by 15.4% and 8.7% on average for Subject A and Subject B, respectively. Adding tSCS support yielded even greater mean decreases of 19.3% and 20.9% for Subjects A and B, respectively. Additionally, both subjects individually reported that swimming with tSCS for 30–45 minutes eliminated spasticity in the lower extremities for up to 4 hours beyond the duration of the session. Comparing the median as well as the interquartile range of all different settings, the IMU-based motion analysis revealed that FES as well as FES+tSCS improve knee extension in both subjects, while hip extension was only increased in one subject. Trunk roll angles were similar for all swimming conditions. tSCS had no influence on the knee and hip joint angles. Both subjects reported that stimulation-assisted swimming is comfortable, enjoyable, and they would like to use such a device for recreational training and rehabilitation in the future.

Conclusions

Stimulation-assisted swimming seems to be a promising new form of hybrid exercise for SCI people. It is safe to use with reusable silicone electrodes and can be performed independently by experienced paraplegic swimmers except for transfer to water. The study results indicate that swimming speed can be increased by the proposed methods and spasticity can be reduced by prolonged swim sessions with tSCS and FES. The combination of stimulation with hydrotherapy might be a promising therapy for neurologic rehabilitation in incomplete SCI, stroke or multiples sclerosis patients. Therefore, further studies shall incorporate other neurologic disorders and investigate the potential benefits of FES and tSCS therapy in the water for gait and balance.

The use of aquatic therapy among rehabilitation professionals for individuals with spinal cord injury or disorder

Context/Objective: Aquatic therapy (AT) has been used to enhance balance and mobility in people with disabilities; however, AT is reported to be underused among people with spinal cord injury or disorder (SCI/D). We aimed to understand the perceptions of AT use by physical therapists (PT), PT assistants (PTA) and kinesiologists (KIN) across Canada for clients with SCI/D. Design/Methods: Individual semi-structured interviews were completed with PT, PTA and KIN (phone or in-person). PT, PTA and KIN who had used AT with at least one client with SCI/D in the past year were eligible. Interview questions queried each participant's AT setting, AT approaches, and perceived facilitators and barriers to AT implementation for clients with SCI/D. Interviews were audio recorded and transcribed verbatim. Thematic analysis was used to identify themes and subthemes. Results: Six PT (2 male, 4 female), three PTA (female) and 1 KIN (female) participated. The following four themes were identified: (1) multi-system benefits from AT (e.g. from impairment to function, confidence and enjoyment); (2) application of AT (e.g. based on principles of the water); (3) perceived barriers to implementing AT (e.g. pool accessibility, client comorbidities); and (4) water as an enabler to function on land. Conclusions: The participants reported AT was a unique and versatile approach that benefits the multi-dimensional aspects of the health of individuals with SCI/D. They successfully integrated AT into their clinical practice despite the barriers faced by professionals and clients.

Exercise in the Aquatic Environment for Patients With Chronic Spinal Cord Injury and Invasive Appliances: Successful Integration and Therapeutic Interventions

OBJECTIVE

Our primary objectives of this initial "proof-of-principle" trial were to evaluate the interventions used in skilled aquatic therapy and to identify any clinical benefits for individuals with spinal cord injuries who use invasive appliances including pressure injury dressings, suprapubic catheters, indwelling catheters, colostomy bags, and tracheostomy tubes.

DESIGN

This is a retrospective chart review of patients with chronic spinal cord injuries using invasive appliances who had also undergone skilled aquatic therapy.

RESULTS

Forty-nine patients with traumatic spinal cord injuries demonstrated scores showing statistically significant improvement using their total mobility and self-care of the Spinal Cord Independence Measure III (P ≤ 0.021, 0.039, 0.021) scores. Forty-five patients with traumatic spinal cord injuries demonstrated significant improvement of ASIA Impairment Scale motor scores (P ≤ 0.002) and nine patients with traumatic spinal cord injuries walked longer distances in 6-min walk test (P ≤ 0.011). The Spinal Cord Independence Measure III efficiency was 0.26 per hour (95% confidence interval = 0.037-0.475). There was one reported unplanned bowel evacuation that occurred but did not prevent future therapy. All patients successfully completed a sequence of aquatic therapy.

CONCLUSIONS

Spinal cord injury patients with various invasive appliances can safely participate in specialized aquatic therapy without complications and seem to achieve clinically significant benefits. We recommend that spinal cord injury rehabilitation centers seek out and connect with opportunities for aquatic therapy within their institutions and communities.

Effects of water immersion on quasi-static standing exploring center of pressure sway and trunk acceleration: a case series after incomplete spinal cord injury

Study design

This work is a case series.

Objectives

We assessed the influence of the aquatic environment on quasi-static posture by measuring center of pressure (COP) sway and trunk acceleration parameters after incomplete spinal cord injury (iSCI) in water and on land.

Setting

Tertiary Rehabilitation Hospital, Ontario, Canada.

Methods

Six adult participants with iSCI (4 cervical/2 thoracic injuries, AIS D) were enrolled. Baseline balance was assessed by the Berg Balance Scale and Mini-Balance Evaluation System Test. Participants stood on a waterproof force plate for one minute per trial on land and in water; participants completed testing with their eyes open or closed in random order over 10 trials. Individuals' perceptions of their standing balance were obtained. COP and trunk acceleration parameters were analyzed in the time-domain.

Results

COP sway and upper to lower trunk acceleration ratios in the AP direction increased in water, which was in contrast to standing on land in both visual conditions for 5/6 participants. Three participants (P1, P3 & P4) with greater sensorimotor deficits had larger COP sway in water with the eyes closed. Two (P1 & P4) of six participants reported more discomfort standing in water than standing on land.

Conclusions

Increased COP sway seemed to reflect the balance and sensorimotor impairments of the participants, especially when standing with eyes closed in water. Although most participants (4/6) perceived that they swayed more in water in contrast to on land, 5 out of 6 participants reported that water felt like a safer environment in which to stand.

The benefits of hydrotherapy to patients with spinal cord injuries

Background

Many patients with spinal cord injury (PWSCI) lead sedentary lifestyles, experiencing poor quality of life and medical challenges. PWSCI don’t like to participate in land-based-exercises because it’s tedious to perform the same exercises, decreasing their rehabilitative compliance and negatively impacting their well-being. An alternative exercise environment and exercises may alleviate boredom, enhancing compliance.

Objectives

Discuss the benefits of hydrotherapy to PWSCI concerning underwater gait-kinematics, thermoregulatory and cardiovascular responses and spasticity.

Methodology

A literature surveillance was conducted between 1998 and 2017, through the Crossref meta-database and Google Scholar, according to the PRISMA procedures. Key search words were water-therapy, aquatic-therapy, hydrotherapy, spinal cord injury, rehabilitation, human, kinematics, underwater gait, cardiorespiratory, thermoregulation and spasticity. The quality of each paper was evaluated using a modified Downs and Black Appraisal Scale. The participants were records pertaining to PWSCI and hydrotherapy. The outcomes of interest were: hydrotherapy interventions, the impact of hydrotherapy on gait-kinematics, thermoregulation during water submersion and cardiorespiratory function of PWSCI. Omitted records included: non-English publications from before 1998 or unrelated to hydrotherapy and PWSCI. The record screening admissibility was performed as follows: the title screen, the abstract screen and the full text screen.

Results

Literature search identified 1080 records. Upon application of the exclusion criteria, 92 titles, 29 abstracts and 17 full text records were eligible. Only 15 records were selected to be included in this clinical commentary. Evidence shows a paucity of randomised control trials (RCT) conducted in this field.

Conclusion

Hydrotherapy improves PWSCI underwater gait-kinematics, cardiorespiratory and thermoregulatory responses and reduces spasticity.