Effects of body weight-support treadmill training on postural sway and gait independence in patients with chronic spinal cord injury

Balance Interventions to Improve Upright Balance Control and Balance Confidence in People With Motor-Incomplete Spinal Cord Injury or Disease: A Systematic Review and Meta-analysis

OBJECTIVES

To assist with clinical decision making, evidence syntheses are needed to demonstrate the efficacy of available interventions and examine the intervention components and dosage parameters. This systematic review and meta-analysis described the efficacy, components and dosage of interventions targeting upright balance control, balance confidence, and/or falls in adults with motor-incomplete spinal cord injury/disease (SCI/D).

DATA SOURCES

A search strategy following the population, intervention, control, outcome framework was developed. Six databases were searched: APA PsychInfo, Cumulative Index to Nursing and Allied Health Literature, Embase, Emcare Nursing, Web of Science CC, and Medline.

STUDY SELECTION

Title, abstract, and full-text screening were conducted by 2 researchers independently. Inclusion criteria included the following: (1) adults with chronic, motor-incomplete SCI/D; (2) physical intervention targeting upright postural control; and (3) clinical and/or biomechanical measures of upright balance control and/or balance confidence and/or documentation of falls.

DATA EXTRACTION

Participant characteristics, balance intervention details, adverse events, and study results were extracted. The Downs and Black Checklist was used to assess methodological quality. Meta-analyses on pre-post intervention outcomes and a meta-regression of dosage were completed. Grading of Recommendations, Assessment, Development, and Evaluations approach was used to evaluate the quality of the evidence.

DATA SYNTHESIS

The search returned 1664 unique studies; 26 were included. Methodological quality was moderate to good. Participants were 500 individuals with SCI/D, aged 18-74 years (males: females = 2.4:1). Minor adverse events were reported in 8 studies (eg, muscle soreness and fatigue). Walking interventions and upright balance training with visual feedback had clinically meaningful and significant pooled effects on improving standing balance control. Only walking interventions had a significant pooled effect on improving balance confidence. There were no significant findings on dosage response. Few studies evaluated the effects of balance interventions on the occurrence of falls.

CONCLUSIONS

Walking interventions and upright balance training with visual feedback had greater effects on upright balance control than conventional physiotherapy; however, the quality of the evidence was very low.

Effects of the walking independence on lower extremity and trunk muscle activity during straight-leg raising following incomplete cervical cord injury

The purpose of this study was to compare the acceleration and surface electromyography (EMG) of the lower extremity and trunk muscles during straight-leg raising (SLR) in patients with incomplete cervical cord injury according to their levels of walking independence. Twenty-four patients were measured acceleration and EMG during SLR held for 10 s. Data were analyzed separately for the dominant and nondominant sides and compared between the nonindependent (NI) and independent (ID) groups based on their levels of walking independence. Frequency analysis of the EMG showed that the high-frequency (HF) band of the contralateral biceps femoris (BF) in the ID group and bands below the medium-frequency (MF) of the BF and the HF and MF bands of the rectus abdominis in the NI group were significantly higher during dominant and nondominant SLR. During the nondominant SLR, the low-frequency band of the internal oblique and the MF band of the external oblique were significantly higher in the NI group. The ID group mobilized muscle fiber type 2 of the BF, whereas the NI group mobilized type 1 of the BF and types 2 and 1 of the trunk muscles to stabilize the pelvis. This result was more pronounced during the nondominant SLR.

Long-term body-weight-supported treadmill training for incomplete cervical spinal cord injury: a case report

[Purpose] To investigate the effects of long-term body-weight-supported treadmill training on walking ability and physical function in an elderly individual with incomplete cervical spinal cord injury. [Participant and Methods] The patient was a 68 year-old male with an incomplete spinal cord injury at the C3/C4 level, incurred when he was 56 years old. He initiated home-based body-weight-supported treadmill training using a body-weight-supported treadmill installed at his home. His walking ability was measured as the percentage of body weight load reduction, and his physical function was evaluated using manual muscle testing and measuement of the range of motion of his lower limbs. [Results] The physical function of the lower limbs was improved, maintained, or showed delayed decline until 9.5 years post-injury. [Conclusion] Long-term body-weight-supported treadmill training may improve, maintain, or at least delay the decline of the physical function of participants for several years, without causing any remarkable complications.

Validation of inertial measurement units for the assessment of trunk control in subjects with spinal cord injury

BACKGROUND

Trunk control (TC) constitutes one of the main objectives in the rehabilitation of people with a spinal cord injury (SCI), but there are few clinically validated tests to assess it. Accelerometers have been proposed as sensitive and suitable procedures to assess TC.

OBJECTIVE

To evaluate test-retest reliability, construct and criterion validity of accelerometer parameters to assess TC in people with SCI.

METHODS

A cross-sectional study of simultaneous application of Clinical Trunk Control Test (CTCT) and accelerometer evaluation was conducted. Accelerometers were placed on the trunks of 27 people with SCI and 15 people without SCI. Reliability was assessed by three repeated measures in random order of selected static and dynamic TC tasks. Acceleration on three axes was analyzed using five metrics. Criterion validity was assessed by analyzing correlation of acceleration to CTCT scores. Construct validity was assessed by analyzing capacity of inertial measurement units (IMU) to differentiate individual's characteristics, ASIA Impairment scale, gait capacity, level of TC, and neurological level of injury.

RESULTS

Reliable IMU data were obtained in people with SCI and without SCI, of all accelerometer axes, metrics, and tested items of the CTCT. Reliability of acceleration decreases with the increasing demand for TC tasks. Ten acceleration parameters showed construct and criterion validity.

CONCLUSION

Accelerometer parameters are reliable, valid, and sensitive to evaluate TC in people with SCI.

SIGNIFICANCE

A set of IMU parameters were validated as reliable and valid measures to evaluate TC, which could be useful for the assessment of progression of people with SCI and clinical interventions.

Effect of virtual reality training on standing balance in individuals with incomplete spinal cord injury

Recovery of balance ability during standing is one of the primary and essential aims of rehabilitative programs in individuals with incomplete spinal cord injury (iSCI). A sample of ten participants (mean age: 35.7 years, range: 25-63 years) with traumatic or non-traumatic iSCI (AIS grade C or D) and were able to stand with or without the support of an assistive device for a minimum of 2 min were recruited from the rehabilitation department of the Indian Spinal Injuries Centre, New Delhi, India. The participants received Virtual Reality (VR) based balance training for one hour, three times a week for four weeks on the Nintendo Wii gaming console. Participants were assessed three times: pre-intervention, post-intervention and follow-up assessment for the total ellipse area (TEA), total sway perimeter (TSP), sway range (anterior-posterior/medio-lateral (AP/ML)) and limits of stability (LOS). At post-intervention assessment, significant increases in comparison with pre-intervention scores was found in LOS (P=0.00), TEA with eyes open (EO) (P=0.00) and eyes closed (EC) (P=0.00), TSP with EO (P=0.00) and EC (P=0.00), sway range in AP direction (SD-AP) with EO (P=0.01) and EC (P=0.02) and sway range in ML direction (SD-ML) with EO (P=0.02) and EC (P=0.01). At follow-up assessment, a significant improvement in comparison to post intervention scores was found in TEA measured both in EO (P=0.01) and EC conditions (P=0.02), TSP measured with EO (P=0.01) and SD-ML both with EO (P=0.04) and EC (P=0.01). No significant changes were found in LOS (P=0.89), TSP measured with EC (P=0.38) and SD-AP both with EO (P=0.50) and EC (P=1). However, significant improvement was seen on comparing follow-up assessment scores with pre-intervention scores for all variables, such as LOS (P=0.00), TEA in EO (P=0.00) and EC (P=0.00), TSP with EO (P=0.00) and EC (P=0.00), SD-AP with EO (P=0.01) and EC (P=0.02) and SD-ML with EO (P=0.01) and EC (P=0.00). VR-based balance training intervention was able to elicit improvements in balance ability and maintain it during follow-up despite a small training dosage suggesting that it is a promising intervention for standing balance rehabilitation among individuals with iSCI. The VR-based balance training challenges elements of balance, which physical therapists may want to consider when designing a comprehensive rehabilitation program.

Clinical Trials Registry-India: CTRI/2018/12/016814.

Technology-assisted balance assessment and rehabilitation in individuals with spinal cord injury: A systematic review

BACKGROUND: Balance is a crucial function of basic Activities of Daily Living (ADL) and is often considered the priority in Spinal Cord Injury (SCI) patients’ rehabilitation. Technological devices have been developed to support balance assessment and training, ensuring an earlier, intensive, and goal-oriented motor therapy. OBJECTIVE: The aim of this systematic review is to explore the technology-assisted strategies to assess and rehabilitate balance function in persons with SCI. METHODS: A systematic review was conducted in the databases PubMed, Scopus, IEEE Xplore, Cochrane Library, and Embase. Full reports on Randomized Clinical Trials (RCTs) of parallel-group or cross-over design and non-RCTs were included according to the following criteria: i) publication year from 1990 to 2021; ii) balance considered as a primary or secondary outcome; iii) population of individuals with SCI with age over 18 years old, regardless of traumatic or non-traumatic lesions, Time Since Injury, lesion level, Asia Impairment Scale score and gender. The methodological quality was determined for each included study according to the recognized Downs and Black (D&B) tool. RESULTS: Nineteen articles met the inclusion criteria and were included in the analysis. Four articles focused on balance assessment while 15 targeted rehabilitation interventions to improve balance by using Treadmill-Based Devices (TBD), OverGround Devices (OGD) and Tilt Table Devices (TTD). Statistically significant effects on balance can be found in TBD subcategory, in the hip-knee guidance subcategory of OGD and in the study of TTD category. CONCLUSION: Although different studies reported positive effects, improvements due to technology-assisted rehabilitation were not greater than those obtained by means of other rehabilitation therapies. The heterogeneity, low methodological quality, and the small number of the studies included do not allow general conclusions about the usefulness of technology-assisted balance assessment and training in individuals with SCI, even if significant improvements have been reported in some studies.

Lower limb joint-specific contributions to standing postural sway in persons with unilateral lower limb loss

BACKGROUND

Individuals with lower limb loss are at an increased risk for falls, likely due to impaired balance control. Standing balance is typically explained by double- or single-inverted pendulum models of the hip and/or ankle, neglecting the knee joint. However, recent work suggests knee joint motion contributes toward stabilizing center-of-mass kinematics during standing balance.

RESEARCH QUESTION

To what extent do hip, knee, and ankle joint motions contribute to postural sway in standing among individuals with lower limb loss?

METHODS

Forty-two individuals (25 m/17f) with unilateral lower limb loss (30 transtibial, 12 transfemoral) stood quietly with eyes open and eyes closed, for 30 s each, while wearing accelerometers on the pelvis, thigh, shank, and foot. Triaxial inertial measurement units were transformed to inertial anterior-posterior components and sway parameters were computed: ellipse area, root-mean-square, and jerk. A state-space model with a Kalman filter calculated hip, knee, and ankle joint flexion-extension angles and ranges of motion. Multiple linear regression predicted postural sway parameters from intact limb joint ranges of motion, with BMI as a covariate (p < 0.05).

RESULTS

With eyes open, intact limb hip flexion predicted larger sway ellipse area, whereas hip flexion and knee extension predicted larger sway root-mean-square, and hip flexion, knee extension, and ankle plantarflexion predicted larger sway jerk. With eyes closed, intact limb hip flexion remained the predictor of sway ellipse area; no other joint motions influenced sway parameters in this condition.

SIGNIFICANCE

Hip, knee, and ankle motions influence postural sway during standing balance among individuals with lower limb loss. Specifically, increasing intact-side hip flexion, knee extension, and ankle plantarflexion motion increased postural sway. With vision removed, a re-weighting of lower limb joint sensory mechanisms may control postural sway, such that increasing sway may be regulated by proximal coordination strategies and vestibular responses, with implications for fall risk.

Independent community walking after a short protocol of repetitive transcranial magnetic stimulation associated with body weight-support treadmill training in a patient with chronic spinal cord injury: a case report

PURPOSE

Our report describes the effect of repetitive transcranial magnetic stimulation (rTMS) combined with body weight-supported treadmill training (BWSTT) on independent gait recovery in a patient with incomplete spinal cord injury (iSCI).

CASE DESCRIPTION

The patient was a 31-year-old male, household ambulator (aid walker) and community wheelchair user who was 8.5 year post traumatic iSCI (T8 vertebra injury, AIS D).

INTERVENTION

The patient participated in 12 sessions (three times/week for four weeks) of rTMS (1800 pulses, 10 Hz, intensity of 90% resting motor threshold) followed by BWSTT (15-20 min, moderate intensity).

OUTCOMES

After treatment, the patient's score increased 3 points on the Walking Index for Spinal Cord Injury II (walking independence) and he became a community ambulator with crutches. His American Spinal Injury Association (ASIA) lower extremities motor score (motor function) increased from 33 to 45 points and the Spinal Cord Independence Measure III (functional independence) score increased from 23 to 29 for the mobility indoors/outdoors subscale. The patient's lower limb spasticity was reduced (Modified Ashworth Scale), and quality of life improved based on the Short-Form Health Survey - 36, and the Patient Global Impression of Change Scale showed considerable perception of improvement.

CONCLUSION

Our report suggests that a short protocol of rTMS combined with BWSTT improved walking independence, motor function, spasticity, functional mobility and quality of life in this patient with iSCI.

Acute intermittent hypoxia as a potential adjuvant to improve walking following spinal cord injury: evidence, challenges, and future directions

Purpose of Review

The reacquisition and preservation of walking ability are highly valued goals in spinal cord injury (SCI) rehabilitation. Recurrent episodes of breathing low oxygen (i.e., acute intermittent hypoxia, AIH) is a potential therapy to promote walking recovery after incomplete SCI via endogenous mechanisms of neuroplasticity. Here, we report on the progress of AIH, alone or paired with other treatments, on walking recovery in persons with incomplete SCI. We evaluate the evidence of AIH as a therapy ready for clinical and home use and the real and perceived challenges that may interfere with this possibility.

Recent Findings

Repetitive AIH is a safe and an efficacious treatment to enhance strength, walking speed and endurance, as well as, dynamic balance in persons with chronic, incomplete SCI.

Summary

The potential for AIH as a treatment for SCI remains high, but further research is necessary to understand treatment targets and effectiveness in a large cohort of persons with SCI.

Impact of Visual Biofeedback of Trunk Sway Smoothness on Motor Learning during Unipedal Stance

The assessment of trunk sway smoothness using an accelerometer sensor embedded in a smartphone could be a biomarker for tracking motor learning. This study aimed to determine the reliability of trunk sway smoothness and the effect of visual biofeedback of sway smoothness on motor learning in healthy people during unipedal stance training using an iPhone 5 measurement system. In the first experiment, trunk sway smoothness in the reliability group (n = 11) was assessed on two days, separated by one week. In the second, the biofeedback group (n = 12) and no-biofeedback group (n = 12) were compared during 7 days of unipedal stance test training and one more day of retention (without biofeedback). The intraclass correlation coefficient score 0.98 (0.93–0.99) showed that this method has excellent test–retest reliability. Based on the power law of practice, the biofeedback group showed greater improvement during training days (p = 0.003). Two-way mixed analysis of variance indicates a significant difference between groups (p < 0.001) and between days (p < 0.001), as well as significant interaction (p < 0.001). Post hoc analysis shows better performance in the biofeedback group from training days 2 and 7, as well as on the retention day (p < 0.001). Motor learning objectification through visual biofeedback of trunk sway smoothness enhances postural control learning and is useful and reliable for assessing motor learning.