Prognostic validity of a clinical trunk control test for independence and walking in individuals with spinal cord injury

Relationship of serial muscle ultrasound of rectus femoris and ambulatory recovery in patients with acute incomplete spinal cord injury: A prospective observational study

CONTEXT/OBJECTIVE

To investigate the change in serial muscle ultrasound of rectus femoris of patients with incomplete spinal cord injury (SCI) performed within 2 months after SCI during acute rehabilitation, and the relationship with functional outcomes at 1 year post-injury.

DESIGN

Prospective observational study.

SETTING

Inpatient multi-speciality tertiary rehabilitation center in Singapore.

PARTICIPANTS

Fifty-four patients with incomplete SCI, defined as American Spinal Injury Association Impairment Scale B-D, with SCI above L2, were recruited from March 2020 to June 2021. Serial muscle ultrasound of the rectus femoris thickness and echo intensity were obtained at 1 week post-injury and after 2 months via standardized protocols.

OUTCOME MEASURES

Functional Independence Measure (FIM) motor score, Lower Extremity Motor Score (LEMS), Spinal Cord Independence Measure III (SCIM III) indoor mobility component and Walking Index for Spinal Cord Injury II (WISCI II) were assessed in the first week post-admission and at 1 year.

RESULTS

There was a significant positive correlation between change in rectus femoris muscle thickness over 2 months and FIM motor score (P < 0.001), LEMS (P < 0.001), SCIM III indoor mobility component (P < 0.001) and WISCI II (P < 0.001) at 1 year. For the change in echo intensity over 2 months, there was a significantly negative correlation with FIM motor score (P = 0.002), LEMS (P = 0.002), SCIM III indoor mobility component (P = 0.001) and WISCI II (P = 0.001) at 1 year.

CONCLUSION

The findings suggest that ultrasonographic serial assessment of rectus femoris muscle thickness and echo intensity during rehabilitation may be useful for determining the long-term functional outcomes in patients with incomplete SCI.

Recovery of Volitional Motor Control and Overground Walking in Participants With Chronic Clinically Motor Complete Spinal Cord Injury: Restoration of Rehabilitative Function With Epidural Spinal Stimulation (RESTORES) Trial-A Preliminary Study

Spinal cord injury (SCI) is damage to any part of the spinal cord resulting in paralysis, bowel and/or bladder incontinence, and loss of sensation and other bodily functions. Current treatments for chronic SCI are focused on managing symptoms and preventing further damage to the spinal cord with limited neuro-restorative interventions. Recent research and independent clinical trials of spinal cord stimulation (SCS) or intensive neuro-rehabilitation including neuro-robotics in participants with SCI have suggested potential malleability of the neuronal networks for neurological recovery. We hypothesize that epidural electrical stimulation (EES) delivered via SCS in conjunction with mental imagery practice and robotic neuro-rehabilitation can synergistically improve volitional motor function below the level of injury in participants with chronic clinically motor-complete SCI. In our pilot clinical RESTORES trial (RESToration Of Rehabilitative function with Epidural spinal Stimulation), we investigate the feasibility of this combined multi-modal approach in restoring volitional motor control and achieving independent overground locomotion in participants with chronic motor complete thoracic SCI. Secondary aims are to assess the safety of this combination therapy including the off-label SCS usage as well as improving functional outcome measures. To our knowledge, this is the first clinical trial that investigates the combined impact of this multi-modal EES and rehabilitation strategy in participants with chronic motor complete SCI. Two participants with chronic motor-complete thoracic SCI were recruited for this pilot trial. Both participants have successfully regained volitional motor control below their level of SCI injury and achieved independent overground walking within a month of post-operative stimulation and rehabilitation. There were no adverse events noted in our trial and there was an improvement in post-operative truncal stability score. Results from this pilot study demonstrates the feasibility of combining EES, mental imagery practice and robotic rehabilitation in improving volitional motor control below level of SCI injury and restoring independent overground walking for participants with chronic motor-complete SCI. Our team believes that this provides very exciting promise in a field currently devoid of disease-modifying therapies.

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.

Determination of cut-off points in the Trunk control test for spinal cord injury to assess the ability to perform different activities of daily living

STUDY DESIGN

Observational, comparative, and transversal study.

OBJECTIVE

To identify the cut-off points in the Trunk Control Test (TCT) for individuals with Spinal Cord Injury (SCI) to determine the ability to perform independently the different activities of daily living (ADL) according to the Spinal Cord Independence Measure-III (SCIM-III).

SETTING

National Institute of Rehabilitation, Mexico City.

METHODS

Individuals with SCI of any neurologic level and severity according to ISNCSCI, in sub-acute and chronic phases were included. Receiver Operating Characteristic (ROC) curves were made to identify the cut-off points on the TCT that discriminate the individuals that can independently perform each of the ADL described in the SCIM-III.

RESULTS

A total of 604 participants were evaluated, 70.7% male; mean age of 34 (± 14) years; time since injury was 134 ± 360 days; predominating motor complete injury (50.1%). It was demonstrated through ROC curves, that there are different cut-off points in the TCT that are sensitive and specific to discriminate individuals that can independently perform the majority of the items of the SCIM-III of those who perform it with assistance. Domains that do not depend on an adequate trunk control (respiration and sphincter management) had poor areas under the curve, with low sensitivity and specificity.

CONCLUSIONS

The application of the TCT in individuals with SCI allows to discriminate between individuals who perform the different ADL independently of those who do not, at this subject institute. These results can guide the management of individuals with SCI, helping to establish short term goals.

Prognostic validity of trunk control scales for mobility in individuals with motor complete thoracic SCI: a prospective cohort study

STUDY DESIGN

Prospective cohort study.

OBJECTIVES

To investigate the sensitivity to change and prognostic validity of Trunk Control Test (TCT) and Thoracic-Lumbar Control Scale (TLC) in terms of mobility in persons with motor complete thoracic spinal cord injury (SCI).

SETTING

Participants were recruited at an Italian SCI rehabilitation facility from October 2015 to January 2020.

METHODS

Inclusion criteria were acute traumatic or non-traumatic event and T1-L1 neurological level. Trunk control and mobility were assessed at baseline, discharge, and at 6 and 18-month follow-ups. Mobility was measured using Spinal Cord Independence Measure III mobility subscale. Linear regression models were used to analyze changes in trunk control and mobility over time, and the relationship between these measures.

RESULTS

The 39 participants were predominantly male, with a mean age of 38 years. Trunk control improved during rehabilitation, at 6-month follow-up, and remained stable thereafter, according to TCT and TLC scales. A higher baseline TCT score was associated with improvements in mobility at discharge and at follow-ups. Baseline TLC score and its change during rehabilitation were unrelated with changes in mobility.

CONCLUSIONS

Results suggest that the TCT and TLC scales are useful to capture changes in trunk control during the acute and subacute phases. Improvements in functional mobility are however associated with TCT score only, suggesting the potential of this test as a useful prognostic indicator. Further research with larger sample sizes is warranted to determine whether these findings are consistent across neurological level strata.

Validity of the trunk assessment scale for spinal cord injury (TASS) and the trunk control test in individuals with spinal cord injury

BACKGROUND

The Trunk Assessment Scale for Spinal Cord Injury (TASS) and the Trunk Control Test for individuals with a Spinal Cord Injury (TCT-SCI) are highly reliable assessment tools for evaluating the trunk function of individuals with SCIs. However, the potential differences in the validity of these two scales are unclear.

OBJECTIVES

To evaluate the criterion validity of the TASS and the construct validity of the TASS and TCT-SCI.

PARTICIPANTS AND METHODS

We evaluated 30 individuals with SCIs (age 63.8 ± 10.7 yrs, 17 with tetraplegia). To evaluate criterion validity, we calculated Spearman's rho between the TASS and the gold standard (the TCT-SCI). To determine construct validity, we used the following hypothesis testing approaches: (i) calculating Spearman's rho between each scale and the upper and lower extremity motor scores (UEMS, LEMS), the Walking Index for SCI-II (WISCI-II), and the motor score of the Functional Independence Measure (mFIM); and (ii) determining the cut-off point for identifying ambulators with SCIs (≥ 3 points on item 12 of Spinal Cord Independent Measure III) by a receiver operating characteristics analysis.

RESULTS

A moderate correlation was confirmed between the TASS and the TCT-SCI (r = 0.68). Construct validity was supported by six of the eight prior hypotheses. The cut-off points for identifying ambulators with SCIs were 26 points (TASS) and 18 points (TCT-SCI).

CONCLUSION

Our results indicate that the contents of the TASS and the TCT-SCI might reflect the epidemiological characteristics of the populations in which they were developed.

Italian translation and reliability of Fist-Sci Scale for chronic paraplegic patients: an observational study

BACKGROUND AND AIM

Lack of trunk control following spinal cord injury implicates a worse quality of life and a higher dependence on caregivers; literature proposes several evaluation scales, but studies show poor methodological quality. This study aimed to translate and explore the significance of the Italian version of the FIST-SCI scale for chronic spinal cord injury patients.

METHODS

A longitudinal cohort study was conducted at Fiorenzuola D'Arda Hospital. After a forward/backward translation of the FIST-SCI scale in Italian content and face translational validity, intervalutator reliability was assessed. Patients were recruited by historical tracking of patients who received acute rehabilitation care at the Villanova D'Arda Spinal Unit. Two researchers administered the FIST-SCI scale to the same patients at the follow-up.

RESULTS

Ten patients took part in the study; results showed that higher inter-rater correlation coefficient (Pearson's R= 0.89, p= 0.01 Intra-class correlation coefficient= 0.94, p=0.000). Content validity was also excellent (Scale Content Validity Index = 0.91); some experts suggested future scale developments.

DISCUSSION

Italian FIST-SCI scale for assessing trunk control in chronic spinal patients appears to be an excellent assessment tool concerning intervalutator reliability. Content validity further confirms the validity of the instrument.

Clustering trunk movements of children and adolescents with neurological gait disorders undergoing robot-assisted gait therapy: the functional ability determines if actuated pelvis movements are clinically useful

INTRODUCTION

Robot-assisted gait therapy is frequently used for gait therapy in children and adolescents but has been shown to limit the physiological excursions of the trunk and pelvis. Actuated pelvis movements might support more physiological trunk patterns during robot-assisted training. However, not every patient is expected to react identically to actuated pelvis movements. Therefore, the aim of the present study was to identify different trunk movement patterns with and without actuated pelvis movements and compare them based on their similarity to the physiological gait pattern.

METHODS AND RESULTS

A clustering algorithm was used to separate pediatric patients into three groups based on different kinematic reactions of the trunk to walking with and without actuated pelvis movements. The three clusters included 9, 11 and 15 patients and showed weak to strong correlations with physiological treadmill gait. The groups also statistically differed in clinical assessment scores, which were consistent with the strength of the correlations. Patients with a higher gait capacity reacted with more physiological trunk movements to actuated pelvis movements.

CONCLUSION

Actuated pelvis movements do not lead to physiological trunk movements in patients with a poor trunk control, while patients with better walking functions can show physiological trunk movements. Therapists should carefully consider for whom and why they decide to include actuated pelvis movements in their therapy plan.

Effects of Compression Stockings on Body Balance in Hemiplegic Patients with Subacute Stroke

(1) Background: Stroke patients with hemiplegia have an increased risk of developing deep vein thrombosis (DVT). DVT increases the risk of life-threatening pulmonary embolism and is associated with poor prognosis. The early wearing of compression stockings can help prevent DVT. This study aimed to assess the impact of compression stockings on body balance in stroke patients with unilateral lower extremity muscle weakness; (2) Methods: Hemiplegic stroke patients in the subacute phase who were able to walk with assistance were recruited. The patients were divided into two groups: one group received rehabilitation treatment with compression stockings, and the other received treatment without compression stockings. The rehabilitation treatment involved hospitalization for 4 weeks, the Trunk Control Test (TCT), the Trunk Impairment Scale (TIS), and the Berg Balance Scale (BBS). The patients were evaluated before and 4 weeks after the start of treatment. The differences in BBS, TCT, and TIS before and after treatment between the two groups were compared; (3) Results: Altogether, 236 hemiplegic stroke patients were recruited. There was an improvement in body balance after treatment in both groups, and BBS, TCT, and TIS scores significantly increased in the group that received rehabilitation treatment with compression stockings; (4) Conclusions: In patients with hemiplegic stroke in the subacute period, rehabilitation while wearing compression stockings appears to improve body balance.

Responsiveness and minimal clinically important differences of the Trunk Assessment Scale for Spinal Cord injury (TASS)

OBJECTIVE

To confirm the responsiveness and minimal clinically important differences (MCIDs) of the Trunk Assessment Scale for Spinal Cord Injury (TASS).

PARTICIPANTS AND METHODS

We evaluated 48 Japanese individuals with spinal cord injury (SCI) (age 64.1 ± 10.4 yrs, 28 with tetraplegia) admitted to two institutions at admission, at 1 month of hospitalization, and at discharge with the TASS, the Trunk Control Test in individuals with an SCI (TCT-SCI) motor score, the Functional Independence Measure motor score (mFIM), and the Global Rating of Change Scale (GRCS). We assessed the TASS responsiveness by determining the correlation coefficients for the changes in the TASS' and other assessments' scores. We calculated the MCIDs by five anchor-based methods.

RESULTS

The changes in the TASS and those in the other assessments were weakly correlated at 1 month and moderately correlated at discharge. The TASS MCIDs were observed at 1 month and at discharge.

CONCLUSION

Our findings confirmed that the change in TASS scores had weak-to-moderate correlations with the changes in the participants' upper- and lower-limb function and activities of daily living. Using the MCID for the TASS determined by anchor-based methods may lead to a better interpretation of changes in the trunk function of individuals with SCIs.

Reliability and minimal detectable change of the Trunk Assessment Scale for Spinal Cord Injury (TASS) and the trunk control test for individuals with spinal cord injury

STUDY DESIGN

Cross-sectional study.

OBJECTIVES

To evaluate the reliability and calculate the measurement error of the Trunk Assessment Scale for Spinal Cord Injury (TASS) and trunk control test (TCT-SCI) in individuals with spinal cord injury (SCI).

SETTING

Rehabilitation Hospital in Japan.

METHODS

The evaluations of TASS and TCT-SCI for individuals with SCI were video-recorded. The inter-rater reliability (two physiotherapists) was confirmed using the videos. ICC (2,1), kappa coefficient (κ) were used to determine the reliability of the total score and each item. Each minimal detectable change (MDC) was calculated.

RESULTS

The TASS and TCT-SCI total scores showed excellent inter-rater reliability (ICC = 0.99, and 1.00). The kappa coefficients of TASS were acceptable to excellent for 8 items (κ = 0.76-1.00), below acceptable for 1 item (κ = 0.62). The kappa coefficients of TCT-SCI were excellent for 12 items (κ = 0.83-1.00), below acceptable for 1 item (κ = 0.68). The inter-rater MDC of the TASS total score was 4.07 points, and the MDC of the TCT-SCI total score was 1.13 points. The intra-rater MDC of the TASS total score was 3.86 points.

CONCLUSION

Both TASS and TCT-SCI showed high reliability. Differences of less than four points in TASS and one point in TCT-SCI were interpreted as measurement errors between the two raters.

Measurement of Human Walking Movements by Using a Mobile Health App: Motion Sensor Data Analysis

Background

This study presents a new approach to measure and analyze the walking balance of humans by collecting motion sensor data in a smartphone.

Objective

We aimed to develop a mobile health (mHealth) app that can measure the walking movements of human individuals and analyze the differences in the walking movements of different individuals based on their health conditions. A smartphone’s motion sensors were used to measure the walking movements and analyze the rotation matrix data by calculating the variation of each xyz rotation, which shows the variables in walking-related movement data over time.

Methods

Data were collected from 3 participants, that is, 2 healthy individuals (1 female and 1 male) and 1 male with back pain. The participant with back pain injured his back during strenuous exercise but he did not have any issues in walking. The participants wore the smartphone in the middle of their waistline (as the center of gravity) while walking. They were instructed to walk straight at their own pace in an indoor hallway of a building. The walked a distance of approximately 400 feet. They walked for 2-3 minutes in a straight line and then returned to the starting location. A rotation vector in the smartphone, calculated by the rotation matrix, was used to measure the pitch, roll, and yaw angles of the human body while walking. Each xyz-rotation vector datum was recalculated to find the variation in each participant’s walking movement.

Results

The male participant with back pain showed a diminished level of walking balance with a wider range of xyz-axis variations in the rotations compared to those of the healthy participants. The standard deviation in the xyz-axis of the male participant with back pain was larger than that of the healthy male participant. Moreover, the participant with back pain had the widest combined range of right-to-left and forward-to-backward motions. The healthy male participant showed smaller standard deviation while walking than the male participant with back pain and the female healthy participant, indicating that the healthy male participant had a well-balanced walking movement. The walking movement of the female healthy participant showed symmetry in the left-to-right (x-axis) and up-to-down (y-axis) motions in the x-y variations of rotation vectors, indicating that she had lesser bias in gait than the others.

Conclusions

This study shows that our mHealth app based on smartphone sensors and rotation vectors can measure the variations in the walking movements of different individuals. Further studies are needed to measure and compare walking movements by age, gender, as well as types of health problems or disease. This app can help in finding differences in gait in people with diseases that affect gait.

Effects of Virtual Reality Therapy on Gait and Balance Among Individuals With Spinal Cord Injury: A Systematic Review and Meta-analysis

Background and Purpose. The use of virtual reality (VR) therapy among individuals with spinal cord injury (SCI) is a relatively new rehabilitation approach replicating real-life scenarios. The aim of this study was to evaluate the effectiveness of VR therapy for improving gait and balance in individuals with SCI. Methods. Databases of PubMed, Web of Science, Scopus, SportDiscuss, and CINHAL were searched from inception until September 2019. Two independent reviewers screened articles for inclusion, extracted data, and evaluated methodological quality of the trials. Results. Ten trials, including 3 randomized clinical trials (RCTs) and 7 pre-post trials, with a total of 149 participants were analyzed. Meta-analysis of RCTs demonstrated significant improvement in sitting balance (standardized mean difference [SMD] = 1.65; 95% CI 1.21-2.09; P < .01) after VR therapy with conventional rehabilitation compared with only conventional rehabilitation. Also, pre-post studies using VR therapy without a control group showed improvement in standing balance (Berg Balance Scale, MD = 4.22; 95% CI 1.78-6.66; P < .01 and Activities-specific Balance Confidence scale, MD = 8.53; 95% CI 2.52-14.53; P = .01) and a trend for improvement in gait (SMD = 0.34; 95% CI 0.02-0.66; P = .04). Conclusion. This study demonstrated the beneficial effects of VR therapy to enhance sitting and standing balance and showed a trend of gait improvement in individuals with SCI. This conclusion is based on mainly preliminary data and therefore, more RCTs are needed to confirm the effects of the use of VR in individuals with SCI.

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

Study design

This work is a case series.

Objectives

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

Setting

Tertiary Rehabilitation Hospital, Ontario, Canada.

Methods

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

Results

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

Conclusions

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