Activity-based therapy for recovery of walking in individuals with chronic spinal cord injury: results from a randomized clinical trial

Non-invasive Transcutaneous Spinal Cord Stimulation Programming Recommendations for the Treatment of Upper Extremity Impairment in Tetraplegia

OBJECTIVES

This study analyzes the stimulation parameters implemented during two successful trials that used non-invasive transcutaneous spinal cord stimulation (tSCS) to effectively improve upper extremity function after chronic spinal cord injury (SCI). It proposes a framework to guide stimulation programming decisions for the successful translation of these techniques into the clinic.

MATERIALS AND METHODS

Programming data from 60 participants who completed the Up-LIFT trial and from 17 participants who subsequently completed the LIFT Home trial were analyzed. All observations of stimulation amplitudes, frequencies, waveforms, and electrode configurations were examined. The incidence of adverse events and relatedness to stimulation parameters is reported. A comparison of parameter usage across the American Spinal Injury Association Impairment Scale (AIS) subgroups was conducted to evaluate stimulation strategies across participants with varying degrees of sensorimotor preservation.

RESULTS

Active (cathodal) electrodes were typically placed between the C3/C4 and C6/C7 spinous processes. Most sessions featured return (anodal) electrodes positioned bilaterally over the anterior superior iliac spine, although clavicular placement was frequently used by 12 participants. Stimulation was delivered with a 10-kHz carrier frequency and typically a 30-Hz burst frequency. Biphasic waveforms were used in 83% of sessions. Average stimulation amplitudes were higher for biphasic waveforms. The AIS B subgroup required significantly higher amplitudes than did the AIS C and D subgroups. Device-related adverse events were infrequent, and not correlated with specific waveforms or amplitudes. Within the home setting, participants maintained their current amplitudes within 1% of the preset values. The suggested stimulation programming framework dictates the following hierarchical order of parameter adjustments: current amplitude, waveform type, active/return electrode positioning, and burst frequency, guided by clinical observations as required.

CONCLUSIONS

This analysis summarizes effective stimulation parameters from the trials and provides a decision-making framework for clinical implementation of tSCS for upper extremity functional restoration after SCI. The parameters are aligned with existing literature and proved safe and well tolerated by participants.

Brief High-Velocity Motor Skill Training Increases Step Frequency and Improves Length/Frequency Coordination in Slow Walkers With Chronic Motor-Incomplete Spinal Cord Injury

OBJECTIVE

To quantify spatiotemporal coordination during overground walking among persons with motor-incomplete spinal cord injury (PwMISCI) by calculating the step length (SL)/step frequency (SF) ratio (ie, the Walk Ratio [WR]) and to examine the effects of motor skill training (MST) on the relationship between changes in these parameters and walking speed (WS).

DESIGN

Between-day exploratory analysis.

SETTING

Research laboratory in a rehabilitation hospital PARTICIPANTS: PwMISCI (N=26).

INTERVENTIONS

3-day high-velocity MST.

MAIN OUTCOME MEASURES

Overground WS, SL, SF, and WR measured during the 10-Meter Walk Test.

RESULTS

Among the full sample, MST was associated with increases in WS, SL, SF, and a decrease in the WR. Relative change in WS and SF was higher among slow (ΔWS=↑46%, ΔSF=↑28%) vs fast (ΔWS=↑16%, ΔSF=↑8%) walkers. Change in the WR differed between groups (slow: ΔWR=↓10%; fast: ΔWR=0%). Twenty-six percent of the variability observed in ΔWR among slow walkers could be explained by ΔSF, while ΔSL did not contribute to ΔWR. Among fast walkers, ΔSL accounted for more than twice the observed ΔWR (43%) compared to ΔSF (15%).

CONCLUSIONS

On the whole, WR values among PwMISCI are higher than previous reports in other neurologic populations; however, values among fast walkers were comparable to noninjured adults. Slow walkers demonstrated greater variability in the WR, with higher values associated with slower WS. Following MST, increases in WS coincided with a decrease in the WR among slow walkers, mediated primarily through an effect on SF. This finding may point to a specific mechanism by which MST facilitates improvements in WS among PwMISCI with greater mobility deficits.

A systematic review of the effects of robotic exoskeleton training on energy expenditure and body composition in adults with spinal cord injury

Metabolic diseases disproportionately affect people with spinal cord injury (SCI). Increasing energy expenditure and remodeling body composition may offset deleterious consequences of SCI to improve cardiometabolic health. Evidence is emerging that robotic exoskeleton use increases physical activity in SCI, but little is known about its effects on energy expenditure and body composition. This study therefore aimed to evaluate the impact of robotic exoskeleton training on body composition and energy expenditure in adults with SCI. A systematic literature review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Five databases were searched to retrieve studies meeting pre-set eligibility criteria: adults with SCI, interventions evaluating the effects of robotic exoskeleton devices on body composition or energy expenditure. The PEDro scale guided quality assessments with findings described narratively. Of 2163 records, 10 studies were included. Robotic exoskeleton training does not significantly improve energy expenditure compared to other exercise interventions. Significant changes ( P  < 0.05) in body composition, particularly reduced fat mass, however, were reported. High variability seen with the interventions was coupled with poor quality of the studies. While robotic exoskeleton interventions may propose modest cardiometabolic benefits in adults with SCI, further robust trials in larger samples are needed to strengthen these findings.

Interventions to improve outdoor mobility among people living with disabilities: A systematic review

Background

Around 15% of the global population live with some form of disabilities and experience worse health outcomes, less participation in the community and are part of fewer activities outside the home. Outdoor mobility interventions aim to improve the ability to move, travel and orient outside the home and could influence the number of activities outside the home, participation and quality of life. However, outdoor mobility interventions may also lead to harm like falls or injuries or have unforeseen effects which could lead to mortality or hospitalization.

Objectives

To assess the efficacy of interventions aiming to improve outdoor mobility for adults living with disabilities and to explore if the efficacy varies between different conditions and different intervention components.

Search Methods

Standard, extensive Campbell search methods were used, including a total of 12 databases searched during January 2023, including trial registries.

Selection Criteria

Only randomized controlled trials were included, focusing on people living with disabilities, comparing interventions to improve outdoor mobility to control interventions as well as comparing different types of interventions to improve outdoor mobility.

Data Collection and Analysis

Standard methodological procedures expected by Campbell were used. The following important outcomes were 1. Activity outside the home; 2. Engagement in everyday life activities; 3. Participation; 4. Health-related Quality of Life; 5. Major harms; 6. Minor harms. The impact of the interventions was evaluated in the shorter (≤6 months) and longer term (≥7 months) after starting the intervention. Results are presented using risk ratios (RR), risk difference (RD), and standardized mean differences (SMD), with the associated confidence intervals (CI). The risk of bias 2-tool and the GRADE-framework were used to assess the certainty of the evidence.

Main Results

The screening comprised of 12.894 studies and included 22 studies involving 2.675 people living with disabilities and identified 12 ongoing studies. All reported outcomes except one (reported in one study, some concerns of bias) had overall high risk of bias. Thirteen studies were conducted in participants with disabilities due to stroke, five studies with older adults living with disabilities, two studies with wheelchair users, one study in participants with disabilities after a hip fracture, and one study in participants with cognitive impairments. Skill training interventions versus control interventions (16 studies) The evidence is very uncertain about the benefits and harms of skill training interventions versus control interventions not aimed to improve outdoor mobility among all people living with disabilities both in the shorter term (≤6 months) and longer term (≥7 months) for Activity outside the home; Participation; Health-related Quality of Life; Major harms; and Minor harms, based on very low certainty evidence. Skill training interventions may improve engagement in everyday life activities among people with disabilities in the shorter term (RR: 1.46; 95% CI: 1.16 to 1.84; I 2 = 7%; RD: 0.15; 95% CI: -0.02 to 0.32; I 2 = 71%; 692 participants; three studies; low certainty evidence), but the evidence is very uncertain in the longer term, based on very low certainty evidence. Subgroup analysis of skill training interventions among people living with disabilities due to cognitive impairments suggests that such interventions may improve activity outside the home in the shorter term (SMD: 0.44; 95% CI: 0.07 to 0.81; I 2 = NA; 118 participants; one study; low certainty evidence). Subgroup analysis of skill training interventions among people living with cognitive impairments suggests that such interventions may improve health-related quality of life in the shorter term (SMD: 0.49; 95% CI: 0.12 to 0.88; I 2 = NA; 118 participants; one study; low certainty evidence). Physical training interventions versus control interventions (five studies) The evidence is very uncertain about the benefits and harms of physical training interventions versus control interventions not aimed to improve outdoor mobility in the shorter term (≤6 months) and longer term (≥7 months) for: Engagement in everyday life activities; Participation; Health-related Quality of Life; Major harms; and Minor harms, based on very low certainty evidence. Physical training interventions may improve activity outside the home in the shorter (SMD: 0.35; 95% CI: 0.08 to 0.61; I 2 = NA; 228 participants; one study; low certainty evidence) and longer term (≥7 months) (SMD: 0.27; 95% CI: 0.00 to 0.54; I 2 = NA; 216 participants; one study; low certainty evidence). Comparison of different outdoor mobility interventions (one study) The evidence is very uncertain about the benefits and harms of outdoor mobility interventions of different lengths in the shorter term (≤6 months) and longer term (≥7 months) for Activity outside the home; Engagement in everyday life activities; Participation; Health-related Quality of Life; Major harms; and Minor harms, based on very low certainty evidence. No studies explored the efficacy of other types of interventions.

Authors’ Conclusions

Twenty-two studies of interventions to improve outdoor mobility for people living with disabilities were identified, but the evidence still remains uncertain about most benefits and harms of these interventions, both in the short- and long term. This is primarily related to risk of bias, small underpowered studies and limited reporting of important outcomes for people living with disabilities. For people with disabilities, skill training interventions may improve engagement in everyday life in the short term, and improve activity outside the home and health-related quality of life for people with cognitive impairments in the short term. Still, this is based on low certainty evidence from few studies and should be interpreted with caution. One study with low certainty evidence suggests that physical training interventions may improve activity outside the home in the short term. In addition, the effect sizes across all outcomes were considered small or trivial, and could be of limited relevance to people living with disabilities. The evidence is currently uncertain if there are interventions that can improve outdoor mobility for people with disabilities, and can improve other important outcomes, while avoiding harms. To guide decisions about the use of interventions to improve outdoor mobility, future studies should use more rigorous design and report important outcomes for people with disabilities to reduce the current uncertainty.

Physiotherapy Strategies for Redefining Recovery in a Patient With Grade II Ependymoma: A Case Report

Neuroepithelial tumors known as ependymomas can develop from cortical rests, the central canal of the spinal cord, or the ependymal cells of the cerebral ventricles. Ependymomas may arise anywhere along the neuraxis. Here, we present a 40-year-old male, a known case of grade II ependymomas, with a chief complaint of bilateral lower limb weakness and loss of sensation in the bilateral lower limb for 20 days. He started facing difficulties in performing activities such as walking, toileting activities, and squatting activities. The physiotherapy (PT) rehabilitation of the patient was tailored to achieve functional independence of the patient. The treatment session lasted for six weeks. Several outcome indicators were employed to evaluate our patient's progress toward functional recovery. Outcomes are measured using the Tone Grading Scale (TGS), the American Spinal Injury Association (ASIA) Impairment Scale, the World Health Organization Quality of Life (WHOQOL), manual muscle test, and the Barthel Index. Outcome measures were assessed on day one of treatment and the last day of the PT treatment. The patient's preliminary involvement in PT supported him to prevent serious complications like joint contractures and bed sores. Physical therapy is one of the most important parts of the rehabilitation practice for spinal cord injury (SCI) patients.

Tracking activity-based therapy for people living with spinal cord injury or disease: insights gained through focus group interviews with key stakeholders

PURPOSE

The development of a tool to track participation in activity-based therapy (ABT) for people with spinal cord injury or disease (SCI/D) was identified as a priority of the Canadian ABT Community of Practice. The objective of this study was to understand multi-stakeholder perspectives on tracking ABT participation across the continuum of care.

MATERIALS AND METHODS

Forty-eight individuals from six stakeholder groups (persons living with SCI/D; hospital therapists; community trainers; administrators; researchers; and funders, advocates and policy experts) were recruited to participate in focus group interviews. Participants were asked open-ended questions concerning the importance of and parameters around tracking ABT. Transcripts were analyzed using conventional content analysis.

RESULTS

Themes reflected the Who, What, Where, When, Why and How of tracking ABT. Participants described the importance of involving hospital therapists, community trainers and individuals with SCI/D in tracking ABT to capture both subjective and objective parameters across the continuum of care and injury trajectory. Digital tracking tools were favoured, although paper-based versions were regarded as a necessity in some circumstances.

CONCLUSIONS

Findings highlighted the importance of tracking ABT participation for individuals with SCI/D. The information may guide the development of ABT practice guidelines and support the implementation of ABT in Canada.

Effect of Exercise on Mental Health and Health-related Quality of Life in Adults With Spinal Cord Injury: A Systematic Review and Meta-Analysis

OBJECTIVES

To determine the effect of exercise interventions on mental health and health-related quality of life (HRQoL) in individuals with SCI.

DATA SOURCES

We searched Embase, CINAHL, Medline, PsychINFO, and SPORTDiscus from inception to September 2023.

STUDY SELECTION

We included randomized controlled trials that (1) involved participants ≥18 years old with a SCI; (2) administered an exercise intervention; and (3) measured subjective well-being, psychological well-being, social well-being, and/or HRQoL as outcomes. We reported standardized means differences (d) with a 95% confidence interval (CI), assessed the risk of bias by using the Revised Cochrane Risk-of-bias Tool for Randomized Trials (RoB 2), and the certainty of the evidence using GRADE.

DATA SYNTHESIS

Nineteen studies (797 participants, mean age <65 years in every study) were included. Exercise improved overall well-being (d=0.494; 95% CI 0.268, 0.720; low certainty evidence), subjective well-being (d=0.543; 95% CI 0.270, 0.816; low certainty evidence), psychological well-being (d=0.499; 95% CI 0.193, 0.805; low certainty evidence), social well-being (d=0.452; 95% CI 0.151, 0.752; low certainty evidence), and HRQoL (d=0.323; 95% CI 0.072, 0.574; low certainty evidence). Four serious adverse events probably attributable to the interventions were reported in 3 studies.

CONCLUSIONS

Exercise interventions can improve well-being and HRQoL in adults with SCI <65 years of age. Additional research is needed to determine effectiveness in adults ≥65 years of age.

DADLE promotes motor function recovery by inhibiting cytosolic phospholipase A2 mediated lysosomal membrane permeabilization after spinal cord injury

BACKGROUND AND PURPOSE

Autophagy is a protective factor for controlling neuronal damage, while necroptosis promotes neuroinflammation after spinal cord injury (SCI). DADLE (D-Ala2 , D-Leu5 ]-enkephalin) is a selective agonist for delta (δ) opioid receptor and has been identified as a promising drug for neuroprotection. The aim of this study was to investigate the mechanism/s by which DADLE causes locomotor recovery following SCI.

EXPERIMENTAL APPROACH

Spinal cord contusion model was used and DADLE was given by i.p. (16 mg·kg-1 ) in mice for following experiments. Motor function was assessed by footprint and Basso mouse scale (BMS) score analysis. Western blotting used to evaluate related protein expression. Immunofluorescence showed the protein expression in each cell and its distribution. Network pharmacology analysis was used to find the related signalling pathways.

KEY RESULTS

DADLE promoted functional recovery after SCI. In SCI model of mice, DADLE significantly increased autophagic flux and inhibited necroptosis. Concurrently, DADLE restored autophagic flux by decreasing lysosomal membrane permeabilization (LMP). Additionally, chloroquine administration reversed the protective effect of DADLE to inhibit necroptosis. Further analysis showed that DADLE decreased phosphorylated cPLA2 , overexpression of cPLA2 partially reversed DADLE inhibitory effect on LMP and necroptosis, as well as the promotion autophagy. Finally, AMPK/SIRT1/p38 pathway regulating cPLA2 is involved in the action DADLE on SCI and naltrindole inhibited DADLE action on δ receptor and on AMPK signalling pathway.

CONCLUSION AND IMPLICATION

DADLE causes its neuroprotective effects on SCI by promoting autophagic flux and inhibiting necroptosis by decreasing LMP via activating δ receptor/AMPK/SIRT1/p38/cPLA2 pathway.

Development of a rocking chair for use by children with spinal cord injuries

PURPOSE

Activity-based locomotor training improves intrinsic trunk control in children with spinal cord injury (SCI). To reinforce these improvements, there is a need to develop community integration activities to allow a patient to apply the retrained nervous system at home. One activity that has been explored is rocking in a rocking chair. This paper describes the design, fabrication, and evaluation of a rocking chair for children with SCI.

MATERIALS AND METHODS

The Quality Function Deployment (QFD) design process was used. Fundamental needs and features for the rocking chair were defined in a focus group with experienced therapists, and needs were then rated for importance. A House of Quality (HOQ) matrix was developed to correlate needs with design features, and a prototype design was generated. Virtual motion studies and finite element analysis (FEA) were utilized to assess the design. The chair was fabricated and physical testing was performed, including tipping and static and dynamic load assessments.

RESULTS AND CONCLUSIONS

The needs identified through the QFD process were categorized into (1) safety, (2) therapeutic, (3) practical and aesthetic, and (4) data to track chair use. Features selected to meet these needs include safety stops, padding, straps, a stable base, armrests, adjustable footrest, and sensors to capture rocking data. FEA showed a factor of safety (FOS) > 5. Physical testing confirmed physical integrity, load-bearing capacity, and stability of the prototype glider rocking chair. The prototype provides a safe tool for further investigation of rocking for promotion of trunk muscle activation in children with SCI.

Activity-Based Therapy for Mobility, Function and Quality of Life after Spinal Cord Injuries-A Mixed-Methods Case Series

(1) Background: Despite inconclusive evidence on the benefits of activity-based therapies (ABTs) in people with spinal cord injuries, implementation has occurred in clinics worldwide in response to consumers' requests. We explored the clinical changes and participants' perceptions from engaging in an ABT program in the community. (2) Methods: This mixed-methods study involved a pragmatic observational multiple-baseline design and an evaluation of participants' perceptions. Fifteen participants were included. Outcome measures were balance in sitting using the Seated Reach Distance test, mobility using the Modified Rivermead Mobility Index and quality of life using the Quality of Life Index SCI version pre- and post-participation in an ABT community-based program. Linear mixed models and logistic regressions were used to analyse the effects of intervention. Semi-structured interviews explored participants' perceptions using inductive thematic analysis. (3) Results: There was an increase of 9% in the standardised reach distance (95% CI 2-16) for sitting balance, 1.33 points (95% CI: 0.81-1.85) in mobility and 1.9 points (0.17-2.1) in quality of life. Two themes emerged from the interviews: (1) reduced impact of disability and an increased sense of life as before, and (2) the program was superior to usual rehabilitation. No adverse events related to the intervention were observed. (4) Conclusion: ABT delivered in the community improved clinical outcomes in people with a chronic SCI. High levels of satisfaction with the program were reported.

Challenges in Translating Regenerative Therapies for Spinal Cord Injury

Regenerating the injured spinal cord is a substantial challenge with many obstacles that need to be overcome to achieve robust functional benefits. This abundance of hurdles can partly explain the limited success when applying regenerative intervention treatments in animal models and/or people. In this article, we elaborate on a few of these obstacles, starting with the applicability of animal models and how they compare to the clinical setting. We then discuss the requirement for combinatorial interventions and the associated problems in experimental design, including the addition of rehabilitative training. The article expands on differences in lesion sizes and locations between humans and common animal models, and how this difference can determine the success or failure of an intervention. An additional and frequently overlooked problem in the translation of interventions that applies beyond the field of neuroregeneration is the reporting bias and the lack of transparency in reporting findings. New data mandates are tackling this problem and will eventually result in a more balanced view of the field. Finally, we will discuss strategies to negotiate the challenging course of successful translation to facilitate successful translation of regeneration promoting interventions.

Providing Insights into the Challenges of Implementing Activity-Based Therapy in Canada: A Comparative Analysis Using Focus Group Interviews with Key Interest Groups

Background

Activity-based therapy (ABT) has emerged as a therapeutic approach that may promote neurorecovery and reduce secondary complications in people living with spinal cord injury or disease (SCI/D). In spite of the numerous health benefits, adoption of ABT into practice has been limited across the Canadian care continuum.

Objectives

This study aimed to understand the challenges of implementing ABT in Canada for people living with SCI/D through the perspectives of key interest groups.

Methods

Researchers, hospital therapists, community trainers, administrators, persons living with SCI/D, and advocates, funders, and policy experts who had knowledge of and/or experience with ABT participated in focus group interviews to share their perspectives on the barriers to ABT practice. Interviews were analyzed using conventional content analysis followed by a comparative analysis across groups.

Results

The 48 participants identified six key challenges: (1) challenge of gaps in knowledge/training, (2) challenge of standardizing ABT, (3) challenge of determining the optimal timing of ABT, (4) challenge of defining, characterizing, and achieving high dosage and intensity, (5) challenge of funding ABT, and (6) challenge of measuring participation and performance in ABT. A comparative analysis found some challenges were emphasized by certain groups, such as the cost of ABT for persons with SCI/D, lack of education and training in ABT for therapists and trainers, minimal evidence to develop guidelines for researchers and advocates, and funding ABT programs for administrators.

Conclusion

Participants highlighted several challenges that limit ABT practice. Strategies to address these challenges will support successful implementation of ABT in Canada.

Early and intensive Motor Training for people with spinal cord injuries (the SCI-MT Trial): description of the intervention

STUDY DESIGN

Descriptive.

OBJECTIVES

The primary objective is to describe the intervention that will be provided in a large multi-centre randomised controlled trial titled: Early and Intensive Motor Training for people with Spinal Cord Injuries (the SCI-MT Trial). The secondary objective is to describe the strategies that will be used to operationalise and standardise the Motor Training provided to participants while keeping the intervention person-centred.

METHODS

The paper focuses on the rationale and principles of Motor Training for people with spinal cord injuries (SCI). The description of the intervention is based on the Template for Intervention Description and Replication (TIDieR) checklist. Specifically, it addresses the following 6 criteria of the TIDieR checklist: why the effectiveness of Motor Training is being examined; what, how, where and when the Motor Training will be administered; and how much Motor Training will be provided.

RESULTS

A detailed intervention manual has been developed to help standardise the delivery of the intervention.

CONCLUSIONS

This paper describes the details of a complex intervention administered as part of a large randomised controlled trial. It will facilitate the subsequent interpretation of the trial results and enable the intervention to be reproduced in clinical practice and future trials.

Motor and autonomic concomitant health improvements with neuromodulation and exercise (MACHINE) training: a randomised controlled trial in individuals with spinal cord injury

INTRODUCTION

Motor and autonomic dysfunctions are widespread among people with spinal cord injury (SCI), leading to poor health and reduced quality of life. Exercise interventions, such as locomotor training (LT), can promote sensorimotor and autonomic recovery post SCI. Recently, breakthroughs in SCI research have reported beneficial effects of electrical spinal cord stimulation (SCS) on motor and autonomic functions. Despite literature supporting the independent benefits of transcutaneous SCS (TSCS) and LT, the effect of pairing TSCS with LT is unknown. These therapies are non-invasive, customisable and have the potential to simultaneously benefit both sensorimotor and autonomic functions. The aim of this study is to assess the effects of LT paired with TSCS in people with chronic SCI on outcomes of sensorimotor and autonomic function.

METHODS AND ANALYSIS

Twelve eligible participants with chronic (>1 year) motor-complete SCI, at or above the sixth thoracic segment, will be enrolled in this single-blinded, randomised sham-controlled trial. Participants will undergo mapping for optimisation of stimulation parameters and baseline assessments of motor and autonomic functions. Participants will then be randomly assigned to either LT+TSCS or LT+Sham stimulation for 12 weeks, after which postintervention assessments will be performed to determine the effect of TSCS on motor and autonomic functions. The primary outcome of interest is attempted voluntary muscle activation using surface electromyography. The secondary outcomes relate to sensorimotor function, cardiovascular function, pelvic organ function and health-related quality of life. Statistical analysis will be performed using two-way repeated measures Analysis of variance (ANOVAs) or Kruskal-Wallis and Cohen's effect sizes.

ETHICS AND DISSEMINATION

This study has been approved after full ethical review by the University of British Columbia's Research Ethics Board. The stimulator used in this trial has received Investigation Testing Authorisation from Health Canada. Trial results will be disseminated through peer-reviewed publications, conference presentations and seminars.

TRIAL REGISTRATION NUMBER

NCT04726059.

Epidural stimulation restores muscle synergies by modulating neural drives in participants with sensorimotor complete spinal cord injuries

Multiple studies have corroborated the restoration of volitional motor control after motor-complete spinal cord injury (SCI) through the use of epidural spinal cord stimulation (eSCS), but rigorous quantitative descriptions of muscle coordination have been lacking. Six participants with chronic, motor and sensory complete SCI underwent a brain motor control assessment (BMCA) consisting of a set of structured motor tasks with and without eSCS. We investigated how muscle activity complexity and muscle synergies changed with and without stimulation. We performed this analysis to better characterize the impact of stimulation on neuromuscular control. We also recorded data from nine healthy participants as controls. Competition exists between the task origin and neural origin hypotheses underlying muscle synergies. The ability to restore motor control with eSCS in participants with motor and sensory complete SCI allows us to test whether changes in muscle synergies reflect a neural basis in the same task. Muscle activity complexity was computed with Higuchi Fractal Dimensional (HFD) analysis, and muscle synergies were estimated using non-negative matrix factorization (NNMF) in six participants with American Spinal Injury Association (ASIA) Impairment Score (AIS) A. We found that the complexity of muscle activity was immediately reduced by eSCS in the SCI participants. We also found that over the follow-up sessions, the muscle synergy structure of the SCI participants became more defined, and the number of synergies decreased over time, indicating improved coordination between muscle groups. Lastly, we found that the muscle synergies were restored with eSCS, supporting the neural hypothesis of muscle synergies. We conclude that eSCS restores muscle movements and muscle synergies that are distinct from those of healthy, able-bodied controls.

Robotic locomotor training for spasticity, pain, and quality of life in individuals with chronic SCI: A pilot randomized controlled trial

Objective

The prevention and treatment of secondary complications is a key priority for people with spinal cord injury and a fundamental goal of rehabilitation. Activity-based Training (ABT) and Robotic Locomotor Training (RLT) demonstrate promising results for reducing secondary complications associated with SCI. However, there is a need for increased evidence through randomized controlled trials. Therefore, we aimed to investigate the effect of RLT and ABT interventions on pain, spasticity, and quality of life in individuals with spinal cord injuries.

Methods

Participants with chronic motor incomplete tetraplegia (n = 16) were recruited. Each intervention involved 60-minute sessions, 3× per week, over 24-weeks. RLT involved walking in an Ekso GT exoskeleton. ABT involved a combination of resistance, cardiovascular and weight-bearing exercise. Outcomes of interest included the Modified Ashworth Scale, the International SCI Pain Basic Data Set Version 2, and the International SCI Quality of Life Basic Data Set.

Results

Neither intervention altered symptoms of spasticity. Pain intensity increased from pre-post intervention for both groups, with a mean increase of 1.55 [-0.82, 3.92] (p = 0.03) and 1.56 [-0.43, 3.55] (p = 0.02) points for the RLT and ABT group, respectively. The ABT group had an increase in pain interference scores of 100%, 50%, and 109% for the daily activity, mood, and sleep domain, respectively. The RLT group had an increase in pain interference scores of 86% and 69% for the daily activity and mood domain respectively, but no change in the sleep domain. The RLT group had increased perceptions of quality of life with changes of 2.37 [0.32, 4.41], 2.00 [0.43, 3.56] and 0.25 [-1.63, 2.13] points, p = 0.03, for the general, physical, and psychological domains, respectively. The ABT group had increased perceptions of general, physical and psychological quality of life with changes of 0.75 [-1.38, 2.88], 0.62 [-1.83, 3.07] and 0.63 [-1.87, 3.13] points, respectively.

Conclusions

Despite increased pain ratings and no change in symptoms of spasticity, there was an increase in perceived quality of life for both groups over 24-weeks. This dichotomy warrants additional investigation in future large-scale randomized controlled trials.

Robotic Walking to Mitigate Bone Mineral Density Decline and Adverse Body Composition in Individuals With Incomplete Spinal Cord Injury: A Pilot Randomized Clinical Trial

OBJECTIVE

The aim of the study was to determine whether 24 wks of robotic locomotor training or activity-based training was sufficient time to induce bone mineral density and body composition changes in individuals with spinal cord injury. This study reports the secondary analysis of a randomized pilot trial.

DESIGN

Participants with chronic motor incomplete tetraplegia ( N = 16) were recruited. Interventions involved 60-min sessions, 3× per week, over 24 wks. Robotic locomotor training involved walking in the Ekso GT suit. Activity-based training involved a combination of resistance, cardiovascular, and weight-bearing exercise.

RESULTS

Hip bone mineral density was maintained during robotic locomotor training; however, it was significantly reduced ( P = 0.04, effect size = 0.86) during activity-based training by 0.03 (-0.29 to 0.23) g/cm 2 after intervention. Both interventions improved arm fat-free soft tissue mass, but neither group experienced changes in leg fat-free soft tissue mass. The activity-based training group had a significant decrease in visceral adipose tissue ( P = 0.04, effect size = 0.72) and gynoid fat mass ( P = 0.01, effect size = 0.62).

CONCLUSIONS

Twenty-four weeks of robotic locomotor training is possibly a sufficient duration to prevent the progressive decline of bone mineral density usually occurring in this population. A longitudinal period of activity-based training serves as an effective rehabilitation strategy to reduce indices of fat mass in individuals with spinal cord injury.

A Pilot Study of Intensive Locomotor-Related Skill Training and Transcranial Direct Current Stimulation in Chronic Spinal Cord Injury

BACKGROUND AND PURPOSE

Improved walking function is a priority among persons with motor-incomplete spinal cord injury (PwMISCI). Accessibility and cost limit long-term participation in locomotor training offered in specialized centers. Intensive motor training that facilitates neuroplastic mechanisms that support skill learning and can be implemented in the home/community may be advantageous for promoting long-term restoration of walking function. Additionally, increasing corticospinal drive via transcranial direct current stimulation (tDCS) may enhance training effects. In this pilot study, we investigated whether a moderate-intensity motor skill training (MST) circuit improved walking function in PwMISCI and whether augmenting training with tDCS influenced outcomes.

METHODS

Twenty-five adults (chronic, motor-incomplete spinal cord injury) were randomized to a 3-day intervention of a locomotor-related MST circuit and concurrent application of sham tDCS (MST+tDCS sham ) or active tDCS (MST+tDCS). The primary outcome was overground walking speed. Secondary outcomes included walking distance, cadence, stride length, and step symmetry index (SI).

RESULTS

Analyses revealed significant effects of the MST circuit on walking speed, walking distance, cadence, and bilateral stride length but no effect on interlimb SI. No significant between-groups differences were observed. Post hoc analyses revealed within-groups change in walking speed (ΔM = 0.13 m/s, SD = 0.13) that app-roached the minimally clinically important difference of 0.15 m/s.

DISCUSSION AND CONCLUSIONS

Brief, intensive MST involving locomotor-related activities significantly increased walking speed, walking distance, and spatiotemporal measures in PwMISCI. Significant additive effects of tDCS were not observed; however, participation in only 3 days of MST was associated with changes in walking speed that were comparable to longer locomotor training studies.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A386 ).

Wide bandgap semiconductor nanomembranes as a long-term biointerface for flexible, implanted neuromodulator

Electrical neuron stimulation holds promise for treating chronic neurological disorders, including spinal cord injury, epilepsy, and Parkinson's disease. The implementation of ultrathin, flexible electrodes that can offer noninvasive attachment to soft neural tissues is a breakthrough for timely, continuous, programable, and spatial stimulations. With strict flexibility requirements in neural implanted stimulations, the use of conventional thick and bulky packages is no longer applicable, posing major technical issues such as short device lifetime and long-term stability. We introduce herein a concept of long-lived flexible neural electrodes using silicon carbide (SiC) nanomembranes as a faradic interface and thermal oxide thin films as an electrical barrier layer. The SiC nanomembranes were developed using a chemical vapor deposition (CVD) process at the wafer level, and thermal oxide was grown using a high-quality wet oxidation technique. The proposed material developments are highly scalable and compatible with MEMS technologies, facilitating the mass production of long-lived implanted bioelectrodes. Our experimental results showed excellent stability of the SiC/silicon dioxide (SiO₂) bioelectronic system that can potentially last for several decades with well-maintained electronic properties in biofluid environments. We demonstrated the capability of the proposed material system for peripheral nerve stimulation in an animal model, showing muscle contraction responses comparable to those of a standard non-implanted nerve stimulation device. The design concept, scalable fabrication approach, and multimodal functionalities of SiC/SiO₂ flexible electronics offer an exciting possibility for fundamental neuroscience studies, as well as for neural stimulation-based therapies.

Effectiveness of Activity-Based Therapy for Individuals With Spinal Cord Injury in Promoting Static and Dynamic Sitting Balance: Is Olfactory Mucosa Autograft a Factor?

Background

Activity-based therapy (ABT) appears to improve outcomes for individuals with spinal cord injury (SCI); however, few studies have examined sitting static and dynamic balance. It was unknown whether individuals after SCI who elected to undergo an olfactory mucosa autograft (OMA) would respond differently to ABT.

Objectives

The first objective was to assess changes in sitting strength (static) and dynamic balance in a group of individuals with SCI undergoing intensive ABT. The second objective was to determine whether sitting balance changes would be different for those who had participated in ABT after the OMA versus those who had ABT alone.

Methods

A handheld dynamometer measured peak force (sitting strength) and the multi-directional reach test measured dynamic balance (n = 16).

Results

ABT (average dose: 7 hours per week over 4.6 months) appeared to promote improvements in sitting strength in four directions (0.6-0.8 kg per month) and dynamic balance in four of five directions (0.7-1.3 cm per month). Individuals who had undergone an OMA had similar, but not greater, improvements in static and dynamic balance when compared with those who had ABT alone. It is unknown whether balance improvements resulted from natural or other factors.

Conclusion

ABT may have contributed to balance changes in individuals with SCI. Although small improvements in sitting static and dynamic balance did occur, future research documenting therapy intervention details and ABT dose-response in larger groups of individuals with SCI must be performed to provide guidance as to the optimal, effective ABT dose required to generate clinically meaningful functional improvements.

Novel Noninvasive Spinal Neuromodulation Strategy Facilitates Recovery of Stepping after Motor Complete Paraplegia

It has been suggested that neuroplasticity-promoting neuromodulation can restore sensory-motor pathways after spinal cord injury (SCI), reactivating the dormant locomotor neuronal circuitry. We introduce a neuro-rehabilitative approach that leverages locomotor training with multi-segmental spinal cord transcutaneous electrical stimulation (scTS). We hypothesized that scTS neuromodulates spinal networks, complementing the neuroplastic effects of locomotor training, result in a functional progression toward recovery of locomotion. We conducted a case-study to test this approach on a 27-year-old male classified as AIS A with chronic SCI. The training regimen included task-driven non-weight-bearing training (1 month) followed by weight-bearing training (2 months). Training was paired with multi-level continuous and phase-dependent scTS targeting function-specific motor pools. Results suggest a convergence of cross-lesional networks, improving kinematics during voluntary non-weight-bearing locomotor-like stepping. After weight-bearing training, coordination during stepping improved, suggesting an important role of afferent feedback in further improvement of voluntary control and reorganization of the sensory-motor brain-spinal connectome.

Walking and Balance Outcomes Are Improved Following Brief Intensive Locomotor Skill Training but Are Not Augmented by Transcranial Direct Current Stimulation in Persons With Chronic Spinal Cord Injury

Motor training to improve walking and balance function is a common aspect of rehabilitation following motor-incomplete spinal cord injury (MISCI). Evidence suggests that moderate- to high-intensity exercise facilitates neuroplastic mechanisms that support motor skill acquisition and learning. Furthermore, enhancing corticospinal drive via transcranial direct current stimulation (tDCS) may augment the effects of motor training. In this pilot study, we investigated whether a brief moderate-intensity locomotor-related motor skill training (MST) circuit, with and without tDCS, improved walking and balance outcomes in persons with MISCI. In addition, we examined potential differences between within-day (online) and between-day (offline) effects of MST. Twenty-six adults with chronic MISCI, who had some walking ability, were enrolled in a 5-day double-blind, randomized study with a 3-day intervention period. Participants were assigned to an intensive locomotor MST circuit and concurrent application of either sham tDCS (MST+tDCS_sham) or active tDCS (MST+tDCS). The primary outcome was overground walking speed measured during the 10-meter walk test. Secondary outcomes included spatiotemporal gait characteristics (cadence and stride length), peak trailing limb angle (TLA), intralimb coordination (ACC), the Berg Balance Scale (BBS), and the Falls Efficacy Scale-International (FES-I) questionnaire. Analyses revealed a significant effect of the MST circuit, with improvements in walking speed, cadence, bilateral stride length, stronger limb TLA, weaker limb ACC, BBS, and FES-I observed in both the MST+tDCS_sham and MST+tDCS groups. No differences in outcomes were observed between groups. Between-day change accounted for a greater percentage of the overall change in walking outcomes. In persons with MISCI, brief intensive MST involving a circuit of ballistic, cyclic locomotor-related skill activities improved walking outcomes, and selected strength and balance outcomes; however, concurrent application of tDCS did not further enhance the effects of MST.

Walking endurance, muscle oxygen extraction, and perceived fatigability after overground locomotor training in incomplete spinal cord injury: A pilot study

Objective: The purpose of this study was to examine the effects of overground locomotor training (OLT) on walking endurance and gastrocnemius oxygen extraction in people with chronic cervical motor-incomplete spinal cord injury (SCI).Design: Prospective single-arm pre-post pilot study.Setting: Human Performance Research Laboratory.Participants: Adult men with traumatic chronic cervical SCI (n = 6; age = 30.8 ± 12.5).Intervention: Twenty-four sessions of structured OLT.Outcome measures: Walking endurance was determined during a constant work-rate time-to-exhaustion treadmill test. Normalized perceived fatigability was calculated by dividing subjective ratings of tiredness by walking time. Cardiorespiratory outcomes and muscle oxygen extraction were analyzed using breath-by-breath gas-exchange and near-infrared spectroscopy.Results: OLT resulted in large effects on walking endurance (1232 ± 446 s vs 1645 ± 255 s; d = 1.1; P = 0.045) and normalized perceived fatigability (5.3 ± 1.5 a.u. vs 3.6 ± 0.9 a.u.; d = 1.3; P = 0.033). Small-to-medium effects on absolute (2.8 ± 2.5 a.u. vs 4.2 ± 3.5 a.u.; d = 0.42; P = 0.035) and isotime (2.8 ± 2.5 a.u. vs 3.8 ± 3.0 a.u.; d = 0.33; P = 0.023) muscle oxygen extraction were also observed after OLT.Conclusion: These findings provide preliminary data supporting the potential for improved walking endurance, enhanced muscle O2 extraction, and reduced perceived fatigability in people with chronic cervical motor-incomplete SCI following the OLT program described in this study.

Análise da independência funcional em indivíduos com lesão da medula espinal

Resumo Introdução A lesão da medula espinal (LME) muda radicalmente a vida da pessoa devido às alterações na dinâmica corporal, levando à incapacidades e redução da funcionalidade. Objetivo Analisar a independência funcional de indivíduos com LME e comparar os grupos. Métodos Indivíduos com LME foram entrevistados sobre sua independência funcional por meio da versão brasileira do Spinal Cord Independence Measure - Self-Reported Version (brSCIM-SR) e posteriormente seus respectivos domínios e subdomínios foram comparados entre os grupos diagnósticos, tempo de lesão e gênero. Resultados A amostra foi composta por 50 indivíduos com idade de 40,92 ± 13,93 anos, prevalecendo homens e diagnóstico de paraplegia. Na maioria dos domínios do brSCIM-SR todos os entrevistados atingiram boa independência no autocuidado, na respiração e controle esfincteriano e no total do brSCIM-SR, exceto na mobilidade. Na paraplegia, as LMEs crônicas e ambos os sexos alcançaram excelente independência na maioria dos subdomínios e no total do instrumento. Valores significantemente baixos foram encontrados na tetraplegia e nas LMEs recentes no subdomínio autocuidado. Na maioria dos subdomínios, a tetraplegia atingiu valores significativamente inferiores. Nos subdomínios da respiração e controle esfincteriano, os participantes eram independentes na função respiração, mas nas tetraplegias apresentaram significativa depen-dência nas transferências para o vaso sanitário. Na mobilidade houve grande dependência nos itens subir e descer escadas e transferir-se do chão para a cadeira de rodas. Conclusão Os indivíduos com LME demonstra-ram boa independência funcional, com pior desempenho na tetraplegia e lesões recentes, mas a mobilidade apresentou parcial dependência nos participantes.

Functional independence analysis in persons with spinal cord injury

Abstract Introduction Spinal cord injury (SCI) radically changes a person’s life because of alterations in body dynamics, leading to disabilities and reduced functionality. Objective To analyze the functional independence of individuals with spinal cord injury and compare the groups. Methods Individuals with SCI were interviewed about their functional independence using the Brazilian version of the Spinal Cord Independence Measure - Self-Reported Version (brSCIM-SR) and later their respective domains and subdomains were compared between diagnostic groups, time since injury and sex. Results The sample consisted of fifty individuals aged 40.92 ± 13.93 years, predominantly men and diagnosed with paraplegia. In most brSCIM-SR domains, all respondents achieved good independence in self-care, respiration and sphincter management, and in the total brSCIM-SR, except for mobility. In paraplegia, chronic SCIs and both sexes achieved excellent independence in most subdomains and in the total. Significantly low values were found for tetraplegia and recent SCI in the self-care subdomain. In most subdomains, tetraplegia reached significantly lower values. In the subdomains of respiration and sphincter management, the participants were independent in the breathing function, but in tetraplegia, they showed significant dependence on transfer to the toilet. In terms of mobility, there was great dependence on the items going up and down stairs and transfer from the floor to the wheelchair. Conclusion The brSCIM-SR measures the degree of functionality, allowing health professionals and the patient to quantify and locate the items that indicate their deficits or gains during the rehabilitation process. Here, individuals with SCI showed good functional independence, with worse performance in the tetraplegia and recent injury groups: however, mobility showed partial dependence in the participants.

Physical Activity and the Health of Wheelchair Users: A Systematic Review in Multiple Sclerosis, Cerebral Palsy, and Spinal Cord Injury

OBJECTIVE

To understand the benefits and harms of physical activity in people who may require a wheelchair with a focus on people with multiple sclerosis (MS), cerebral palsy (CP), and spinal cord injury (SCI).

DATA SOURCES

Searches were conducted in MEDLINE, Cumulative Index to Nursing and Allied Health, PsycINFO, Cochrane CENTRAL, and Embase (January 2008 through November 2020).

STUDY SELECTION

Randomized controlled trials, nonrandomized trials, and cohort studies of observed physical activity (at least 10 sessions on 10 days) in participants with MS, CP, and SCI.

DATA EXTRACTION

We conducted dual data abstraction, quality assessment, and strength of evidence. Measures of physical functioning are reported individually where sufficient data exist and grouped as "function" where data are scant.

DATA SYNTHESIS

No studies provided evidence for prevention of cardiovascular conditions, development of diabetes, or obesity. Among 168 included studies, 44% enrolled participants with MS (38% CP, 18% SCI). Studies in MS found walking ability may be improved with treadmill training and multimodal exercises; function may be improved with treadmill, balance exercises, and motion gaming; balance is likely improved with balance exercises and may be improved with aquatic exercises, robot-assisted gait training (RAGT), motion gaming, and multimodal exercises; activities of daily living (ADL), female sexual function, and spasticity may be improved with aquatic therapy; sleep may be improved with aerobic exercises and aerobic fitness with multimodal exercises. In CP, balance may be improved with hippotherapy and motion gaming; function may be improved with cycling, treadmill, and hippotherapy. In SCI, ADL may be improved with RAGT.

CONCLUSIONS

Depending on population and type of exercise, physical activity was associated with improvements in walking, function, balance, depression, sleep, ADL, spasticity, female sexual function, and aerobic capacity. Few harms of physical activity were reported in studies. Future studies are needed to address evidence gaps and to confirm findings.

Epidural spinal cord stimulation as an intervention for motor recovery after motor complete spinal cord injury

Spinal cord injury (SCI) commonly results in permanent loss of motor, sensory, and autonomic function. Recent clinical studies have shown that epidural spinal cord stimulation may provide a beneficial adjunct for restoring lower extremity and other neurological functions. Herein, we review the recent clinical advances of lumbosacral epidural stimulation for restoration of sensorimotor function in individuals with motor complete SCI and we discuss the putative neural pathways involved in this promising neurorehabilitative approach. We focus on three main sections: review recent clinical results for locomotor restoration in complete SCI; discuss the contemporary understanding of electrical neuromodulation and signal transduction pathways involved in spinal locomotor networks; and review current challenges of motor system modulation and future directions toward integrative neurorestoration. The current understanding is that initial depolarization occurs at the level of large diameter dorsal root proprioceptive afferents that when integrated with interneuronal and latent residual supraspinal translesional connections can recruit locomotor centers and augment downstream motor units. Spinal epidural stimulation can initiate excitability changes in spinal networks and supraspinal networks. Different stimulation parameters can facilitate standing or stepping, and it may also have potential for augmenting myriad other sensorimotor and autonomic functions. More comprehensive investigation of the mechanisms that mediate the transformation of dysfunctional spinal networks to higher functional states with a greater focus on integrated systems-based control system may reveal the key mechanisms underlying neurological augmentation and motor restoration after severe paralysis.

Utility and Feasibility of Transcutaneous Spinal Cord Stimulation for Patients With Incomplete SCI in Therapeutic Settings: A Review of Topic

Transcutaneous Spinal Cord Stimulation (TSCS) has been shown to enhance the excitability of spinal neural circuits. This excitation is associated with enhanced voluntary performance in patients with incomplete SCI (iSCI). Though there is much we do not know, combining this altered state of exciability with therapy has the potential to enhance the outcomes associated with activity-based interventions. It is a promising tool to augment the work being done in therapeutic settings with the potential to expedite recovery. There is, however, a lag in assimilating the science for clinical practice. This article will examine current literature related to the application of TSCS in combination with therapeutic interventions for motor recovery and aims to elucidate trends in waveform selection, duration and frequency, and combinatorial therapies that may inform clinical practice. With specific consideration for therapeutic settings, potential benefits, applications, and pitfalls for clinical use are considered. Finally, the next steps in research to move toward wider clinical utility are discussed.

An Adaptive Assistance Controller to Optimize the Exoskeleton Contribution in Rehabilitation

In this paper, we present a novel adaptation rule to optimize the exoskeleton assistance in rehabilitation tasks. The proposed method adapts the exoskeleton contribution to user impairment severity without any prior knowledge about the user motor capacity. The proposed controller is a combination of an adaptive feedforward controller and a low gain adaptive PD controller. The PD controller guarantees the stability of the human-exoskeleton system during feedforward torque adaptation by utilizing only the human-exoskeleton joint positions as the sensory feedback for assistive torque optimization. In addition to providing a convergence proof, in order to study the performance of our method we applied it to a simplified 2-DOF model of human-arm and a generic 9-DOF model of lower limb to perform walking. In each simulated task, we implemented the impaired human torque to be insufficient for the task completion. Moreover, the scenarios that violate our convergence proof assumptions are considered. The simulation results show a converging behavior for the proposed controller; the maximum convergence time of 20 s is observed. In addition, a stable control performance that optimally supplements the remaining user motor contribution is observed; the joint angle tracking error in steady condition and its improvement compared to the start of adaptation are as follows: shoulder 0.96±2.53° (76%); elbow −0.35±0.81° (33%); hip 0.10±0.86° (38%); knee −0.19±0.67° (25%); and ankle −0.05±0.20° (60%). The presented simulation results verify the robustness of proposed adaptive method in cases that differ from our mathematical assumptions and indicate its potentials to be used in practice.

Do any physiotherapy interventions increase spinal cord independence measure or functional independence measure scores in people with spinal cord injuries? A systematic review

STUDY DESIGN

Systematic review.

OBJECTIVE

To determine whether any physiotherapy interventions increase Spinal Cord Independence Measure or Functional Independence Measure scores (SCIM/FIM) in people with spinal cord injury (SCI), with the overall aim of determining whether any physiotherapy interventions need to be controlled for in studies examining the effects of novel experimental interventions on SCIM/FIM.

METHODS

A systematic review was conducted to identify all randomised controlled trials examining the effect of any physiotherapy intervention on SCIM/FIM in people with SCI. PEDro scores were used to rate risk of bias. The results of similar trials and comparisons were pooled using meta-analyses.

RESULTS

Thirty-three trials met the inclusion criteria but only 27 provided useable data. The median (IQR) PEDro score was 6.0 (4.0-7.0). A meta-analysis of four trials comparing robotic gait training with overground gait training that used a combination of FIM/SCIM indicated a pooled mean (95% CI) between-group difference of 0.38 standardised mean difference (SMD; 95% CI, 0.08-0.67). A second meta-analysis of two trials comparing upper limb training with and without functional electrical stimulation using FIM indicated a pooled (95% CI) between-group difference of 1.31 SMD (0.62-1.99). Another six trials examining a range of different physiotherapy interventions reported a statistically significant mean between-group difference on SCIM/FIM.

CONCLUSION

There is low-quality evidence to indicate that a small number of physiotherapy interventions increase SCIM/FIM. The importance of controlling for all physiotherapy interventions in studies examining the effects of novel experimental interventions on SCIM/FIM is as yet unclear.

Development of priorities for a Canadian strategy to advance activity-based therapies after spinal cord injury

Study Design

Participatory design.

Objectives

Activity-based therapies (ABT) have physical and psychosocial benefits for individuals with spinal cord injury (SCI). A Canadian ABT summit was held to: (1) identify methods used in stroke rehabilitation that may be appropriate for SCI; (2) understand the current state of ABT activities in Canada; and (3) identify priorities for ABT research and care for the next five years.

Setting

Stakeholder-engaged meeting at a tertiary rehabilitation hospital.

Methods

Thirty-nine stakeholders, including individuals with SCI, frontline clinicians, healthcare administrators, researchers, funders and health policy experts, attended. Two participants were note-takers. Priority identification occurred through input from stakeholder groups, followed by individual voting. Conventional content analysis was used to synthesize the information in the meeting notes.

Results

The strengths of ABT in stroke rehabilitation included clear and clinically feasible definitions, measurements and interventions, and recognized requirements for implementation (e.g. behavior change, partnerships). Knowledge gaps concerning ABT activities in Canada were identified for acute and community settings, non-traumatic populations, and the interventions, equipment and standardized measures (i.e. upper limb, activity levels) used. Five priorities for ABT across the continuum of care were identified: (1) Identify current ABT activities; (2) Create a network to facilitate dialog; (3) Track engagement in ABT activities; (4) Develop and implement best practice recommendations; and (5) Study optimal timing, methods, and dose of ABT. Working groups were formed to address priorities 1–3.

Conclusions

The priorities will guide SCI research and care activities in Canada over the next five years.

Sponsorship

Praxis Spinal Cord Institute.

FES Cycling and Closed-Loop Feedback Control for Rehabilitative Human–Robot Interaction

For individuals with movement impairments due to neurological injuries, rehabilitative therapies such as functional electrical stimulation (FES) and rehabilitation robots hold vast potential to improve their mobility and activities of daily living. Combining FES with rehabilitation robots results in intimately coordinated human–robot interaction. An example of such interaction is FES cycling, where motorized assistance can provide high-intensity and repetitive practice of coordinated limb motion, resulting in physiological and functional benefits. In this paper, the development of multiple FES cycling testbeds and safeguards is described, along with the switched nonlinear dynamics of the cycle–rider system. Closed-loop FES cycling control designs are described for cadence and torque tracking. For each tracking objective, the authors’ past work on robust and adaptive controllers used to compute muscle stimulation and motor current inputs is presented and discussed. Experimental results involving both able-bodied individuals and participants with neurological injuries are provided for each combination of controller and tracking objective. Trade-offs for the control algorithms are discussed based on the requirements for implementation, desired rehabilitation outcomes and resulting rider performance. Lastly, future works and the applicability of the developed methods to additional technologies including teleoperated robotics are outlined.

Robotic Locomotor Training Leads to Cardiovascular Changes in Individuals With Incomplete Spinal Cord Injury Over a 24-Week Rehabilitation Period: A Randomized Controlled Pilot Study

OBJECTIVE

To describe the effect of robotic locomotor training (RLT) and activity-based training (ABT) on cardiovascular indices during various physiological positions in individuals with spinal cord injury.

DESIGN

Randomized controlled pilot study.

SETTING

Private practice: Therapy & Beyond Centre - Walking with Brandon Foundation, Sports Science Institute of South Africa, Cape Town, South Africa.

PARTICIPANTS

Participants with chronic traumatic motor incomplete tetraplegia (N=16) who resided in the Western Cape, South Africa.

INTERVENTION

Robotic locomotor training (Ekso GT) and activity-based training over a 24-week intervention.

MAIN OUTCOME MEASURES

Brachial and ankle blood pressure, heart rate, heart rate variability, and cardiovascular efficiency during 4 physiological positions.

RESULTS

No differences between groups or over time were evident in resting systolic and diastolic blood pressure, ankle systolic pressure, ankle brachial pressure index, and heart rate variability. Standing heart rate at 24 weeks was significantly higher in the ABT group (95.58±12.61 beats/min) compared with the RLT group (75.14±14.96 beats/min) (P=.05). In the RLT group, no significant changes in heart rate variability (standard deviation R-R interval and root mean square of successive differences) was found between the standing and 6-minute walk test physiological positions throughout the intervention. Cardiovascular efficiency in the RLT group during the 6-minute walk test improved from 11.1±2.6 at baseline to 7.5±2.8 beats per meter walked at 6 weeks and was maintained from 6 to 24 weeks.

CONCLUSIONS

Large effect sizes and significant differences between groups found in this pilot study support the clinical effectiveness of RLT and ABT for changing cardiovascular indices as early as 6 weeks and up to 24 weeks of rehabilitation. RLT may be more effective than ABT in improving cardiac responses to orthostatic stress. Based on heart rate variability metrics, the stimulus of standing has comparable effects to RLT on the parasympathetic nervous system. Cardiovascular efficiency of exoskeleton walking improved, particularly over the first 6 weeks. Both the RLT and ABT interventions were limited in their effect on brachial and ankle blood pressure. A randomized controlled trial with a larger sample size is warranted to further examine these findings.

Improvements in Bladder Function Following Activity-Based Recovery Training With Epidural Stimulation After Chronic Spinal Cord Injury

Spinal cord injury (SCI) results in profound neurologic impairment with widespread deficits in sensorimotor and autonomic systems. Voluntary and autonomic control of bladder function is disrupted resulting in possible detrusor overactivity, low compliance, and uncoordinated bladder and external urethral sphincter contractions impairing storage and/or voiding. Conservative treatments managing neurogenic bladder post-injury, such as oral pharmacotherapy and catheterization, are important components of urological surveillance and clinical care. However, as urinary complications continue to impact long-term morbidity in this population, additional therapeutic and rehabilitative approaches are needed that aim to improve function by targeting the recovery of underlying impairments. Several human and animal studies, including our previously published reports, have documented gains in bladder function due to activity-based recovery strategies, such as locomotor training. Furthermore, epidural stimulation of the spinal cord (scES) combined with intense activity-based recovery training has been shown to produce volitional lower extremity movement, standing, as well as improve the regulation of cardiovascular function. In our center, several participants anecdotally reported improvements in bladder function as a result of training with epidural stimulation configured for motor systems. Thus, in this study, the effects of activity-based recovery training in combination with scES were tested on bladder function, resulting in improvements in overall bladder storage parameters relative to a control cohort (no intervention). However, elevated blood pressure elicited during bladder distention, characteristic of autonomic dysreflexia, was not attenuated with training. We then examined, in a separate, large cross-sectional cohort, the interaction between detrusor pressure and blood pressure at maximum capacity, and found that the functional relationship between urinary bladder distention and blood pressure regulation is disrupted. Regardless of one’s bladder emptying method (indwelling suprapubic catheter vs. intermittent catheterization), autonomic instability can play a critical role in the ability to improve bladder storage, with SCI enhancing the vesico-vascular reflex. These results support the role of intersystem stimulation, integrating scES for both bladder and cardiovascular function to further improve bladder storage.

International Spinal Cord Injury Physical Therapy-Occupational Therapy Basic Data Set (Version 1.2)

STUDY DESIGN

Expert workgroup consensus, focused literature review, and vetting via feedback from international presentations and spinal cord professional membership groups.

OBJECTIVES

Develop and refine a basic dataset to enable standardized documentation of physical therapy (PT) and occupational therapy (OT) interventions delivered in a controlled clinical trial intended to improve voluntary motor function.

SETTING

International Expert Working Group.

METHODS

An international working group with expertise in spinal cord injury, PT, OT, and measurement developed a draft of the International Spinal Cord Injury (ISCI) Physical Therapy-Occupational Therapy (PT-OT) Basic Data Set (BDS). Emphasis was placed on efficiency and practicality of use. The BDS was iteratively refined based on applicable literature, and feedback collected from presentations at the 2017 and 2019 International Spinal Cord Society meetings.

RESULTS

The ISCI PT-OT BDS contains seven broad categories of interventions: bed/seated mobility, standing activities, walking/stairs, gross motor upper extremity, fine motor upper extremity, strength training, and endurance training. The first five categories are classified as activity-directed and the last two as impairment-directed interventions. Time spent on interventions per category is recorded in 15-min intervals.

CONCLUSIONS

The ISCI PT-OT BDS enables standardized documentation of PT-OT activity-directed or impairment-directed interventions. The ISCI PT-OT BDS is a documentation tool to facilitate evaluation of the influence of rehabilitation therapies on motor function in clinical trials of biologic or pharmacologic agents or rehabilitation technologies that are delivered in the clinical setting.

Characteristics of activity-based therapy interventions for people living with spinal cord injury or disease across the continuum of care: a scoping review protocol

INTRODUCTION

Individuals living with spinal cord injury and disease (SCI/D) experience sensory and motor impairments below their neurological level of injury. Activity-based therapies (ABT) are interventions that provide activation of the neuromuscular system below the level of lesion with the goal of retraining the nervous system to recover a specific motor task. ABT can lead to increased function and improved quality of life; however, research and clinical settings currently lack tools to track participation in ABT. As a first step towards developing such a tool, a scoping review will be conducted with the objective of identifying the characteristics of ABT that individuals with SCI/D participate in across the continuum of care.

METHODS AND ANALYSIS

The review will follow the Joanna Briggs Institute scoping review framework. Studies that involve at least two sessions of ABT for individuals with SCI/D aged ≥16 years will be included. Seven databases were searched from their inception to 4 March 2020: Medline, Embase, Emcare, Cumulative Index to Nursing and Allied Health Literature, APA PsycINFO, Physiotherapy Evidence Database, Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials. The search will be rerun in November 2020 prior to manuscript submission. Screening of titles and abstracts will be followed by a review of full texts to identify articles meeting inclusion criteria. Stakeholders will be consulted for the creation of the data extraction table. The Downs and Black Checklist or the Mixed Methods Appraisal Tool will be used to assess article quality. Results will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews checklist.

ETHICS AND DISSEMINATION

Ethical approval is not required for this scoping review. Study findings will be shared with key stakeholder groups through academic, clinical and public venues.

Locomotor training in people with spinal cord injury: is this exercise?

Locomotor training holds tremendous appeal to people with spinal cord injury who are wheelchair dependent, as the reacquisition of gait remains one of the most coveted goals in this population. For the last few decades this type of training has remained primarily in the clinical environment, as it requires the use of expensive treadmills with bodyweight support or complex overhead suspension tracks to facilitate overground walking. The development of powered exoskeletons has taken locomotor training out of the clinic, both improving accessibility and providing a potential option for community ambulation in people with lower limb paralysis. A question that has yet to be answered, however, is whether or not locomotor training offers a sufficiently intense stimulus to induce improvements in fitness or health. As inactivity-related secondary health complications are a major source of morbidity and mortality in people with SCI, it would be important to characterize the potential of locomotor training to not only improve functional walking ability, but also improve health-related fitness. This narrative review will summarize the key literature in this area to determine whether locomotor training challenges the cardiovascular, muscular or metabolic systems enough to be considered a viable form of exercise.

Task-Specific Versus Impairment-Based Training on Locomotor Performance in Individuals With Chronic Spinal Cord Injury: A Randomized Crossover Study

Background. Many research studies attempting to improve locomotor function following motor incomplete spinal cord injury (iSCI) focus on providing stepping practice. However, observational studies of physical therapy strategies suggest the amount of stepping practice during clinical rehabilitation is limited; rather, many interventions focus on mitigating impairments underlying walking dysfunction. Objective. The purpose of this blinded-assessor randomized trial was to evaluate the effects of task-specific versus impairment-based interventions on walking outcomes in individuals with iSCI. Methods. Using a crossover design, ambulatory participants with iSCI >1-year duration performed either task-specific (upright stepping) or impairment-based training for up to 20 sessions over ≤6 weeks, with interventions alternated after >4 weeks delay. Both strategies focused on achieving higher cardiovascular intensities, with training specificity manipulated by practicing only stepping practice in variable contexts or practicing tasks targeting impairments underlying locomotor dysfunction (strengthening, balance tasks, and recumbent stepping). Results. Significantly greater increases in fastest overground and treadmill walking speeds were observed following task-specific versus impairment-based training, with moderate associations between differences in amount of practice and outcomes. Gains in balance confidence were also observed following task-specific vs impairment-based training, although incidence of falls was also increased with the former protocol. Limited gains were observed with impairment-based training except for peak power during recumbent stepping tests. Conclusion. The present study reinforces work from other patient populations that the specificity of task practice is a critical determinant of locomotor outcomes and suggest impairment-based exercises may not translate to improvements in functional tasks. Clinical Trial Registration URL. https://clinicaltrials.gov/ ; Unique Identifier: NCT02115685.

Task-Specific Versus Impairment-Based Training on Locomotor Performance in Individuals With Chronic Spinal Cord Injury: A Randomized Crossover Study

Background. Many research studies attempting to improve locomotor function following motor incomplete spinal cord injury (iSCI) focus on providing stepping practice. However, observational studies of physical therapy strategies suggest the amount of stepping practice during clinical rehabilitation is limited; rather, many interventions focus on mitigating impairments underlying walking dysfunction. Objective. The purpose of this blinded-assessor randomized trial was to evaluate the effects of task-specific versus impairment-based interventions on walking outcomes in individuals with iSCI. Methods. Using a crossover design, ambulatory participants with iSCI >1-year duration performed either task-specific (upright stepping) or impairment-based training for up to 20 sessions over ≤6 weeks, with interventions alternated after >4 weeks delay. Both strategies focused on achieving higher cardiovascular intensities, with training specificity manipulated by practicing only stepping practice in variable contexts or practicing tasks targeting impairments underlying locomotor dysfunction (strengthening, balance tasks, and recumbent stepping). Results. Significantly greater increases in fastest overground and treadmill walking speeds were observed following task-specific versus impairment-based training, with moderate associations between differences in amount of practice and outcomes. Gains in balance confidence were also observed following task-specific vs impairment-based training, although incidence of falls was also increased with the former protocol. Limited gains were observed with impairment-based training except for peak power during recumbent stepping tests. Conclusion. The present study reinforces work from other patient populations that the specificity of task practice is a critical determinant of locomotor outcomes and suggest impairment-based exercises may not translate to improvements in functional tasks. Clinical Trial Registration URL. https://clinicaltrials.gov/ ; Unique Identifier: NCT02115685.

Effects of Performance-Based Training on Gait and Balance in Individuals With Incomplete Spinal Cord Injury

OBJECTIVE

To determine changes in balance and gait following a task-specific, performance-based training protocol for overground locomotor training (OLT) in individuals with motor-incomplete spinal cord injury (iSCI).

DESIGN

Convenience sample, prepilot and postpilot study.

SETTING

Human performance research laboratory.

PARTICIPANTS

Adults (N=15; 12 men and 3 women; mean age [y] ± SD, 41.5±16.9), American Spinal Injury Association Impairment Scale C or D, >6 months post-spinal cord injury.

INTERVENTIONS

Two 90-minute OLT sessions per week over 12 to 15 weeks. OLT sessions were built on 3 principles of motor learning: practice variability, task specificity, and progressive overload (movement complexity, resistance, velocity, volume). Training used only voluntary movements without body-weight support, robotics, electrical stimulation, or bracing. Subjects used ambulatory assistive devices as necessary.

MAIN OUTCOME MEASURES

Berg Balance Scale (BBS), Spinal Cord Injury Functional Ambulation Inventory (SCI-FAI) gait parameters, spatiotemporal measures of gait (step length, step width, percent stance, stance:swing ratio) from 7 participants who walked across a pressure-sensitive walkway.

RESULTS

Fourteen participants completed the OLT protocol and 1 participant completed 15 sessions due to scheduled surgery. The BBS scores showed a mean improvement of 4.53±4.09 (P<.001). SCI-FAI scores showed a mean increase of 2.47±3.44 (P=.01). Spatiotemporal measures of gait showed no significant changes.

CONCLUSION

This pilot demonstrated improvements in balance and selected gait characteristics using a task-specific, performance-based OLT for chronic iSCI.

Activity-Based Therapy in a Community Setting for Independence, Mobility, and Sitting Balance for People With Spinal Cord Injuries

INTRODUCTION

Activity-based therapy (ABT) aims to activate the neuromuscular system below the level of the spinal cord lesion and promote recovery of motor tasks through spinal reorganisation, motor learning and changes to muscles and sensory system. We investigated the effects of a multimodal ABT program on mobility, independence and sitting balance in individuals with spinal cord injury (SCI).

METHODS

Retrospective clinical data from 91 adults who independently enrolled in four community-based ABT centres in Australia were analysed. The multimodal ABT program was delivered for 3 to 12 months, one to four times per week. Assessments were undertaken every 3 months and included the Modified Rivermead Mobility Index (MRMI), Spinal Cord Independence Measure (SCIM) and seated reach distance (SRD). A linear mixed model analysis was used to determine time-based and other predictors of change.

RESULTS

There was a significant improvement after 12 months for all outcome measures, with a mean change score of 4 points in the SCIM (95% confidence interval [CI]: 2.7-5.3, d = 0.19), 2 points in the MRMI (95% CI: 1-2.3, d = 0.19) and 0.2 in the SRD (95% CI: 0.1-2.2, d = 0.52). Greater improvements occurred in the first 3 months of intervention. There were no interaction effects between time and the neurological level of injury, American Spinal Injury Association Impairment Scale classification, or duration post-injury for most outcomes.

CONCLUSIONS

A community-based ABT exercise program for people with SCI can lead to small improvements in mobility, independence and balance in sitting, with greater improvements occurring early during intervention.

An Exploratory Electrical Stimulation Protocol in the Management of an Infant With Spina Bifida: A Case Report

An infant with myelomeningocele and underdevelopment of the thoracic spinal cord was treated with 2 protocols of electrical stimulation: functional electrical stimulation and transcutaneous spinal cord electrical stimulation. The protocols were incorporated into the infant’s outpatient early intervention home programs. Prior to initiation of electrical stimulation treatment at age 6 months, the infant exhibited complete loss of sensation below the level of T8 and muscular paralysis below the level of T10. The unexpected emergence of somatosensory responses and spontaneous movements in the trunk and lower extremities are described, focusing on the electrical stimulation protocols. Spinal cord electrical stimulation protocols were not previously described in the medical literature regarding the management of children with spina bifida. Both functional and spinal cord electrical stimulation protocols used with this infant proved safe and well tolerated. The experience gained over 12 months of treatment is the subject of this case report.

Activity-Based Physical Rehabilitation with Adjuvant Testosterone to Promote Neuromuscular Recovery after Spinal Cord Injury

Neuromuscular impairment and reduced musculoskeletal integrity are hallmarks of spinal cord injury (SCI) that hinder locomotor recovery. These impairments are precipitated by the neurological insult and resulting disuse, which has stimulated interest in activity-based physical rehabilitation therapies (ABTs) that promote neuromuscular plasticity after SCI. However, ABT efficacy declines as SCI severity increases. Additionally, many men with SCI exhibit low testosterone, which may exacerbate neuromusculoskeletal impairment. Incorporating testosterone adjuvant to ABTs may improve musculoskeletal recovery and neuroplasticity because androgens attenuate muscle loss and the slow-to-fast muscle fiber-type transition after SCI, in a manner independent from mechanical strain, and promote motoneuron survival. These neuromusculoskeletal benefits are promising, although testosterone alone produces only limited functional improvement in rodent SCI models. In this review, we discuss the (1) molecular deficits underlying muscle loss after SCI; (2) independent influences of testosterone and locomotor training on neuromuscular function and musculoskeletal integrity post-SCI; (3) hormonal and molecular mechanisms underlying the therapeutic efficacy of these strategies; and (4) evidence supporting a multimodal strategy involving ABT with adjuvant testosterone, as a potential means to promote more comprehensive neuromusculoskeletal recovery than either strategy alone.

SCIPA Full-On: A Randomized Controlled Trial Comparing Intensive Whole-Body Exercise and Upper Body Exercise After Spinal Cord Injury

Background. While upper body training has been effective for improving aerobic fitness and muscle strength after spinal cord injury (SCI), activity-based therapies intended to activate the paralyzed extremities have been reported to promote neurological improvement. Objective. To compare the effectiveness of intensive whole-body exercise compared with upper body exercise for people with chronic SCI. Methods. A parallel-group randomized controlled trial was conducted. Participants with a range of SCI levels and severity were randomized to either full-body exercise (FBE) or upper body exercise (UBE) groups (3 sessions per week over 12 weeks). FBE participants underwent locomotor training, functional electrical stimulation-assisted leg cycling, and trunk and lower extremity exercises, while UBE participants undertook upper body strength and aerobic fitness training only. The primary outcome measure was the American Spinal Injury Association (ASIA) motor score for upper and lower extremities. Adverse events were systematically recorded. Results. A total of 116 participants were enrolled and included in the primary analysis. The adjusted mean between-group difference was −0.04 (95% CI −1.12 to 1.04) for upper extremity motor scores, and 0.90 (95% CI −0.48 to 2.27) for lower extremity motor scores. There were 15 serious adverse events in UBE and 16 in FBE, but only one of these was definitely related to the experimental intervention (bilateral femoral condyle and tibial plateau subchondral fractures). No significant between-group difference was found for adverse events, or functional or behavioral variables. Conclusions. Full-body training did not lead to improved ASIA motor scores compared with upper body training in people with chronic SCI.

Shoulder Functional Electrical Stimulation During Wheelchair Propulsion in Spinal Cord Injury Subjects

Background: Subjects with spinal cord injury (SCI) propel their wheelchairs by generating a different level of muscle activity given their multiple deficits in muscle strength. Exercise training programs seem to be effective in improving wheelchair propulsion capacity. Functional electrical stimulation (FES) therapy is a complementary tool for rehabilitation programs. Objectives: To determine the accuracy of the synchronization between the FES activation and the push phase of the propulsion cycle by using hand pressure sensors that allow anterior deltoids activation when the hand is in contact with the pushrim. Methods: We analyzed 2 subjects, with injuries at C6 American Spinal Injury Association Impairment Scale (AIS) A and T12 AIS A. The stimulation parameters were set for a 30 Hz frequency symmetrical biphasic wave, 300 μs pulse width. Data were collected as participants propelled the wheelchair over a 10-m section of smooth, level vinyl floor. Subjects were evaluated in a motion analysis laboratory (ELITE; BTS, Milan, Italy). Results: Subject 1 showed synchronization between the FES activation and the push phase of 87.5% in the left hand and of 80% in the right hand. Subject 2 showed synchronization of 95.1% in the left and of hand 94.9% in the right hand. Conclusion: Our study determined a high accuracy of a novel FES therapeutic option, showing the synchronization between the electrical stimulation and the push phase of the propulsion cycle.

Effects of Training Intensity on Locomotor Performance in Individuals With Chronic Spinal Cord Injury: A Randomized Crossover Study

BACKGROUND

Many physical interventions can improve locomotor function in individuals with motor incomplete spinal cord injury (iSCI), although the training parameters that maximize recovery are not clear. Previous studies in individuals with other neurologic injuries suggest the intensity of locomotor training (LT) may positively influence walking outcomes. However, the effects of intensity during training of individuals with iSCI have not been tested.

OBJECTIVE

The purpose of this pilot, blinded-assessor randomized trial was to evaluate the effects of LT intensity on walking outcomes in individuals with iSCI.

METHODS

Using a crossover design, ambulatory participants with iSCI >1 year duration performed either high- or low-intensity LT for ≤20 sessions over 4 to 6 weeks. Four weeks following completion, the training interventions were alternated. Targeted intensities focused on achieving specific ranges of heart rate (HR) or ratings of perceived exertion (RPE), with intensity manipulated by increasing speeds or applying loads.

RESULTS

Significantly greater increases in peak treadmill speeds (0.18 vs 0.02 m/s) and secondary measures of metabolic function and overground speed were observed following high- versus low-intensity training, with no effects of intervention order. Moderate to high correlations were observed between differences in walking speed or distances and differences in HRs or RPEs during high- versus low-intensity training.

CONCLUSION

This pilot study provides the first evidence that the intensity of stepping practice may be an important determinant of LT outcomes in individuals with iSCI. Whether such training is feasible in larger patient populations and contributes to improved locomotor outcomes deserves further consideration.

Longitudinal Recovery and Reduced Costs After 120 Sessions of Locomotor Training for Motor Incomplete Spinal Cord Injury

OBJECTIVE

To determine the impact of long-term, body weight-supported locomotor training after chronic, incomplete spinal cord injury (SCI), and to estimate the health care costs related to lost recovery potential and preventable secondary complications that may have occurred because of visit limits imposed by insurers.

DESIGN

Prospective observational cohort with longitudinal follow-up.

SETTING

Eight outpatient rehabilitation centers that participate in the Christopher & Dana Reeve Foundation NeuroRecovery Network (NRN).

PARTICIPANTS

Individuals with motor incomplete chronic SCI (American Spinal Injury Association Impairment Scale C or D; N=69; 0.1-45y after SCI) who completed at least 120 NRN physical therapy sessions.

INTERVENTIONS

Manually assisted locomotor training (LT) in a body weight-supported treadmill environment, overground standing and stepping activities, and community integration tasks.

MAIN OUTCOME MEASURES

International Standards for Neurological Classification of Spinal Cord Injury motor and sensory scores, orthostatic hypotension, bowel/bladder/sexual function, Spinal Cord Injury Functional Ambulation Inventory (SCI-FAI), Berg Balance Scale, Modified Functional Reach, 10-m walk test, and 6-minute walk test. Longitudinal outcome measure collection occurred every 20 treatments and at 6- to 12-month follow-up after discharge from therapy.

RESULTS

Significant improvement occurred for upper and lower motor strength, functional activities, psychological arousal, sensation of bowel movement, and SCI-FAI community ambulation. Extended training enabled minimal detectable changes at 60, 80, 100, and 120 sessions. After detectable change occurred, it was sustained through 120 sessions and continued 6 to 12 months after treatment.

CONCLUSIONS

Delivering at least 120 sessions of LT improves recovery from incomplete chronic SCI. Because walking reduces rehospitalization, LT delivered beyond the average 20-session insurance limit can reduce rehospitalizations and long-term health costs.