Effects of Activity-Based Therapy Interventions on Mobility, Independence, and Quality of Life for People with Spinal Cord Injuries: A Systematic Review and Meta-Analysis

Exploring knowledge and implementation gaps of activity-based therapy in centers lacking specialized spinal cord injury services: understanding therapists' perspectives

STUDY DESIGN

Qualitative exploratory OBJECTIVES: Rehabilitation following spinal cord injury (SCI) is a life-long process involving healthcare in a variety of settings, including facilities lacking SCI-specific services (i.e., non-SCI-specialized centers). Activity-based therapy (ABT) is a neurorestorative approach involving intensive, task-specific movement practice below the injury level. This study explored the existing knowledge, perceptions, and implementation of ABT among physical and occupational therapists working in non-SCI-specialized centers.

SETTING

Canadian hospitals and community clinics DESIGN/METHODS: Semi-structured interviews were conducted with Canadian therapists who worked at non-SCI-specialized centers and treated at least one patient with SCI within the last 18 months. The Theoretical Domains Framework was used to develop interview questions that queried therapists' experiences in delivering SCI rehabilitation, their understanding of ABT and experience with its implementation. Interviews were audio-recorded, transcribed verbatim and analyzed using interpretive description.

RESULTS

Four physical therapists and three occupational therapists, from diverse settings (i.e., acute care, inpatient rehabilitation, long-term care, outpatient rehabilitation, rural outpatient clinic) participated. Three themes were identified: (1) Available knowledge, resources and therapy time in non-SCI-specialized centers challenge ABT implementation, (2) How current therapy practices in non-SCI-specialized centers align with ABT and (3) Desire for ABT knowledge. Although participants were not familiar with the term ABT, it was identified that they were unknowingly incorporating some components of ABT into their practice. Participants expressed a keenness to learn more about ABT.

CONCLUSION

Current knowledge and implementation of ABT in non-SCI-specialized centers is limited. Tailoring ABT education to therapists at non-SCI-specialized centers may increase ABT implementation.

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.

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.

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.

Exploring sport participation in individuals with spinal cord injury: A qualitative thematic synthesis

CONTEXT

Individuals with spinal cord injury (SCI) are susceptible to various physical, psychological, and social challenges. Sport is an activity that may holistically address these concerns. No existing research provides an overview of the current landscape of SCI-specific sport participation.

OBJECTIVE

To synthesize the findings of qualitative studies exploring the perceptions of people with SCI participating in sport, in relation to physical, psychological, and social health.

METHODS

This thematic synthesis included studies published in APA PsycInfo, CINAHL, Embase, Emcare, Medline, and PubMed. Eligible articles studied adults who had a SCI for ≥12 months and explored experiences following ≥3 months of sport participation using qualitative or mixed-methods. Articles were excluded if participants with SCI composed less than one-third of the study sample. From 8473 unique titles and abstracts screened, 47 articles underwent full-text review and 14 articles were included. The Mixed Methods Appraisal Tool was used to critically appraise the 13 qualitative studies and one mixed-methods study.

RESULTS

The overarching theme was that sport facilitates the progression to living an enriching life with SCI. Four sub-themes were identified within this theme: adjusting to SCI, factors influencing sport initiation, outcomes resulting from sport participation, and reshaping views of SCI. Participants detailed many benefits of sport, including improved fitness, independence, confidence, and sense of community. Beyond the participants themselves, sport helped reshape views of SCI by breaking stereotypes and inspiring others.

CONCLUSION

Sport can play a crucial role in facilitating the progression to living an enriching life following SCI.

Mechanism of skeletal muscle atrophy after spinal cord injury: A narrative review

Spinal cord injury leads to loss of innervation of skeletal muscle, decreased motor function, and significantly reduced load on skeletal muscle, resulting in atrophy. Factors such as braking, hormone level fluctuation, inflammation, and oxidative stress damage accelerate skeletal muscle atrophy. The atrophy process can result in skeletal muscle cell apoptosis, protein degradation, fat deposition, and other pathophysiological changes. Skeletal muscle atrophy not only hinders the recovery of motor function but is also closely related to many systemic dysfunctions, affecting the prognosis of patients with spinal cord injury. Extensive research on the mechanism of skeletal muscle atrophy and intervention at the molecular level has shown that inflammation and oxidative stress injury are the main mechanisms of skeletal muscle atrophy after spinal cord injury and that multiple pathways are involved. These may become targets of future clinical intervention. However, most of the experimental studies are still at the basic research stage and still have some limitations in clinical application, and most of the clinical treatments are focused on rehabilitation training, so how to develop more efficient interventions in clinical treatment still needs to be further explored. Therefore, this review focuses mainly on the mechanisms of skeletal muscle atrophy after spinal cord injury and summarizes the cytokines and signaling pathways associated with skeletal muscle atrophy in recent studies, hoping to provide new therapeutic ideas for future clinical work.

Aquatic Therapy after Incomplete Spinal Cord Injury: Gait Initiation Analysis Using Inertial Sensors

Populations with potential damage to somatosensory, vestibular, and visual systems or poor motor control are often studied during gait initiation. Aquatic activity has shown to benefit the functional capacity of incomplete spinal cord injury (iSCI) patients. The present study aimed to evaluate gait initiation in iSCI patients using an easy-to-use protocol employing four wearable inertial sensors. Temporal and acceleration-based anticipatory postural adjustment measures were computed and compared between dry-land and water immersion conditions in 10 iSCI patients. In the aquatic condition, an increased first step duration (median value of 1.44 s vs. 0.70 s in dry-land conditions) and decreased root mean squared accelerations for the upper trunk (0.39 m/s² vs. 0.72 m/s² in dry-land conditions) and lower trunk (0.41 m/s² vs. 0.85 m/s² in dry-land conditions) were found in the medio-lateral and antero-posterior direction, respectively. The estimation of these parameters, routinely during a therapy session, can provide important information regarding different control strategies adopted in different environments.

Multi-center, single-blind randomized controlled trial comparing functional electrical stimulation therapy to conventional therapy in incomplete tetraplegia

Background

Loss of upper extremity function after tetraplegia results in significant disability. Emerging evidence from pilot studies suggests that functional electrical stimulation (FES) therapy may enhance recovery of upper extremity function after tetraplegia. The aim of this trial was to determine the effectiveness of FES therapy delivered by the Myndmove stimulator in people with tetraplegia.

Methods

A multi-center, single-blind, parallel-group, two-arm, randomized controlled trial was conducted comparing FES to conventional therapy in adults (≥18 years) with C4–C7 traumatic incomplete tetraplegia between 4 and 96 months post-injury, and with a baseline spinal cord injury independence measure III -self-care (SCIM III-SC) score of ≤10. Participants were enrolled at four SCI-specialized neurorehabilitation centers in the U.S. and Canada. Participants were stratified by center and randomized in a 1:1 ratio to receive either 40 sessions of FES or conventional therapy targeting upper extremities over a 14-week period. Blinded assessors measured SCIM III, Toronto Rehabilitation Institute Hand Function Test, and Graded Redefined Assessment of Strength, Sensibility, and Prehension at baseline, after 20th session, after 40th session or 14 weeks after 1st session, and at 24 weeks after 1st session. The primary outcome measure was change in SCIM III-SC from baseline to end of the treatment. Based on the primary outcome measure, a sample size of 60 was calculated. Seventeen participants' progress in the study was interrupted due to the COVID-19 lockdown. The protocol was modified for these participants to allow them to complete the study.

Results

Between June 2019 to August 2021, 51 participants were randomized to FES (n = 27) and conventional therapy (n = 24). Both groups gained a mean of 2 points in SCIM-SC scores at the end of treatment, which was a clinically meaningful change. However, there was no statistically significant difference between the groups on any outcomes.

Conclusion

Forty sessions of FES therapy delivered by the MyndMove stimulator are as effective as conventional therapy in producing meaningful functional improvements that persist after therapy is completed. Limitations of this study include the impact of COVID-19 limiting the ability to recruit the target sample size and per-protocol execution of the study in one-third of the participants.

Registration

This trial is registered at www.ClinicalTrials.gov, NCT03439319.

A Scoping Review of the Characteristics of Activity-based Therapy Interventions Across the Continuum of Care for People Living With Spinal Cord Injury or Disease

Objective

To identify the characteristics of activity-based therapy (ABT) that individuals with spinal cord injury and disease (SCI/D) participate in across the continuum of care.

Data Sources

A search of 8 databases was conducted from inception to 4 March 2020: Medline, CINAHL, Embase, Emcare, PEDro, APA PsycINFO, Cochrane Database of Systematic Reviews, and the CENTRAL. The search strategy used terms identifying the population (SCI/D) and concept (ABT).

Study Selection

Original studies involving individuals with SCI/D ≥16 years of age participating in ABT interventions for >1 session were included in the review. The Joanna Briggs Institute guidelines for scoping reviews were followed. The initial search produced 2306 records. Title, abstract, and full-text screening by 2 independent reviewers yielded 140 articles.

Data Extraction

Data extraction was conducted by 3 independent reviewers and charted according to key themes. Data fields included participant demographics, ABT interventions, exercises, parameters, technology, and setting. Data synthesis included frequency counts and descriptive analysis of key themes.

Data Synthesis

Eighty percent of participants were male. Eighty-seven percent of studies included individuals with tetraplegia (26% exclusive). Fifty-six percent of studies occurred in a research lab. Fifty-four percent of studies were single modality interventions encompassing the whole body (71%). Sixteen main types of ABT exercises were identified. The most common were treadmill training (59%), muscle strengthening (36%), and overground walking (33%). Electrical stimulation (50%) and virtual reality (6%) were used in combination with an ABT exercise. Eighty-four types of parameters were identified. Six were general intervention parameters and 78 were specific to the type of ABT exercise. Sixteen main categories of technology were reported. The most common were motorized treadmills (47%) and transcutaneous electrical stimulation (44%).

Conclusions

The characteristics of ABT are diverse in scope. The results will inform the content to include in tools that track ABT participation and performance.

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.

Gabapentin add-on therapy for patients with spinal cord injury associated neurogenic overactive detrusors that are unresponsive to combined anticholinergic and beta-3 adrenergic therapy

Introduction

Spinal cord injury is a major cause of lifelong morbidity and functional micturition problems. Some patients are refractory to the available therapeutics, even when used in combination. In this paper we report our results of using gabapentin as an add-on treatment in refractory overactive detrusor cases secondary to spinal cord injury.

Material and methods

A total of 27 patients who had a spinal cord injury between the levels of the second thoracic and fourth lumbar vertebrae and had an overactive detrusor in urodynamic studies were included in this retrospective study. The patients were selected due to the fact that they also had not responded to a combination of an anticholinergic and mirabegron and had neuropathic pain. Gabapentin treatment was added to the previous therapy. Demographics, previous treatments, chronic conditions, urodynamic findings, clinical and urodynamic responses are reported in this paper.

Results

We observed a response to treatment in the urodynamic studies of 11 patients (40.17%), in terms of decreased detrusor contractions, maximal detrusor pressure, and the number of incontinence episodes. Sixteen patients did not respond to the gabapentin add-on therapy and were referred for Botulinum toxin injections to the bladder.

Conclusions

Gabapentin add-on therapy can be considered as a third or further option, before Botulinum toxin injection, for patients with neurogenic overactive detrusor who did not respond to the combination of anticholinergics and mirabegron. The approved usage of gabapentin for neurogenic pain justifies its usage in this area. In our selected patient group, who had not responded to the combination therapy, we observed a clinical benefit in one-third of the patients.

Application and progress of three-dimensional bioprinting in spinal cord injury

Spinal cord injury (SCI) is a central nervous system disorder that can lead to sensory and motor dysfunction, which can seriously increase pressure and economic burden on families and societies. The current SCI treatment is mainly to stabilize the spine, prevent secondary damage, and control inflammation. Drug treatment is limited to early, large-scale use of steroids to reduce the effects of edema after SCI. In short, there is no direct treatment for SCI. Recent 3D bioprinting development provides a new solution for SCI treatment: a series of spinal cord bionic scaffolds are being developed to improve spinal cord function after injury. This paper reviews the pathophysiological characteristics of SCI, current treatment methods, and the progress of 3D bioprinting in SCI. Finally, its challenges and prospects in SCI treatment are summarized.

Functional electrical stimulation cycling exercise after spinal cord injury: a systematic review of health and fitness-related outcomes

OBJECTIVES

The objective of this review was to summarize and appraise evidence on functional electrical stimulation (FES) cycling exercise after spinal cord injury (SCI), in order to inform the development of evidence-based clinical practice guidelines.

METHODS

PubMed, the Cochrane Central Register of Controlled Trials, EMBASE, SPORTDiscus, and CINAHL were searched up to April 2021 to identify FES cycling exercise intervention studies including adults with SCI. In order to capture the widest array of evidence available, any outcome measure employed in such studies was considered eligible. Two independent reviewers conducted study eligibility screening, data extraction, and quality appraisal using Cochranes' Risk of Bias or Downs and Black tools. Each study was designated as a Level 1, 2, 3 or 4 study, dependent on study design and quality appraisal scores. The certainty of the evidence for each outcome was assessed using GRADE ratings ('High', 'Moderate', 'Low', or 'Very low').

RESULTS

Ninety-two studies met the eligibility criteria, comprising 999 adults with SCI representing all age, sex, time since injury, lesion level and lesion completeness strata. For muscle health (e.g., muscle mass, fiber type composition), significant improvements were found in 3 out of 4 Level 1-2 studies, and 27 out of 32 Level 3-4 studies (GRADE rating: 'High'). Although lacking Level 1-2 studies, significant improvements were also found in nearly all of 35 Level 3-4 studies on power output and aerobic fitness (e.g., peak power and oxygen uptake during an FES cycling test) (GRADE ratings: 'Low').

CONCLUSION

Current evidence indicates that FES cycling exercise improves lower-body muscle health of adults with SCI, and may increase power output and aerobic fitness. The evidence summarized and appraised in this review can inform the development of the first international, evidence-based clinical practice guidelines for the use of FES cycling exercise in clinical and community settings of adults with SCI. Registration review protocol: CRD42018108940 (PROSPERO).

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.

Effect of a semi-immersive virtual reality navigation therapy on quality of life in persons with spinal cord injury

PURPOSE

This study aims to develop a sailing simulation-based therapeutic rehabilitation program for individuals with Spinal Cord Injuries (SCI) during the subacute phase of the injury.

METHODS

Participants were 11 patients, aged between 20-56 years (Mage = 42.36, SDage=12.90), who were randomly assigned into experimental group and control group, within a pre-test/post-test quasi-experimental design. While both groups followed the rehabilitation programmed by the hospital, experimental group participants were enrolled in an interactive rehabilitation exercise (The vSail-Access®, Virtual Sailing Pty Ltd). For this intervention, each subject underwent a semi-immersive Virtual Reality (VR) navigation therapy for 30-40 min per day, three times per week for six weeks. Quality of life (QoL), functionality and balance variables were measured for both groups one week before and after the intervention. Data was generated based on patients' responses using validated questionnaires and tests. A 2 (groups) × 2 (test-time) MANOVA was performed to detect between-group and within-group differences.

RESULTS

Significant improvements were obtained in the experimental group in the mobility and balance variables, and in the global result of QoL.

CONCLUSIONS

The sailing simulation program, included as a therapy within the rehabilitation process after a SCI, provides participants with an overall increase in QoL and functionality.IMPLICATIONS FOR REHABILIATIONVirtual reality is a therapy that can be part of the rehabilitation process of spinal cord injuries in the acute phase, improving functional capacity.The initiation to recreational sailing in a virtual way is a safe tool for the initiation to the practice of sports.The practice of a dynamic sport, such as sailing, helps to improve the quality of life in spinal cord injuries.

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.

Effects of App-Based Transitional Care on the Self-Efficacy and Quality of Life of Patients With Spinal Cord Injury in China: Randomized Controlled Trial

BACKGROUND

Spinal cord injury (SCI) severely impairs the physical and mental health of patients, decreasing their self-efficacy in coping with daily life and quality of life (QOL). In China, a large gap remains between the complex long-term health needs of SCI patients and the current community care system. With the prevalence of mobile terminals, the usage of mobile health apps has the potential to fill this gap by extending qualified medical resources to the families of SCI patients. Our team developed the app Together for the transitional care of home-dwelling SCI patients in China.

OBJECTIVE

This study aimed to evaluate the effects of app-based transitional care on the self-efficacy and QOL of SCI patients.

METHODS

Through a three-round Delphi process, an Android app was designed. Both medical staff and patients could access the app. Medical staff used it for providing remote transitional care to SCI patients. Patients used it to view transitional care time and send messages to medical staff. Thereafter, a multicenter and assessor-blinded randomized controlled trial was conducted. Participants (n=98) who had SCI and lived at home following discharge were recruited and randomly assigned to a study group (n=49) and control group (n=49) using a randomized number list in four research centers. Patients in both groups received systematic discharge education before discharge. The study group received five follow-ups conducted by trained nurses through the app, which had four core functions, namely remote assessment, health education, interdisciplinary referral, and patient interaction, at weeks 2, 4, 6, 8, and 12 following discharge. The control group received a routine telephone follow-up conducted by nurses at week 12 following discharge. The outcome measures were the Moorong Self-Efficacy Scale (MSES) and 36-item Short-Form Health Survey (SF-36) scores. Data were collected before discharge (T0) and at weeks 12 (T1) and 24 following discharge (T2). Differences between the groups were tested by repeated measures analysis of variance and simple effect analysis.

RESULTS

After the follow-up, the total MSES scores in the study group improved over time (T0=67.80, T1=71.90, and T2=76.29) and were higher than those in the control group (T2=64.49) at 24 weeks following discharge (simple effect analysis: F1=8.506, P=.004). Regarding the total SF-36 score, although it was higher in patients from the study group (T2=65.36) than those from the control group (T2=58.77) at 24 weeks following discharge, only time effects were significant (F2,95=6.671, P=.002) and neither the group effects nor the interaction effects influenced the change in QOL (group effects: F1,96=0.082, P=.78; interaction effects: F2,95=3.059, P=.052).

CONCLUSIONS

This study confirmed that app-based transitional care improves the self-efficacy of SCI patients. Nevertheless, QOL improvement is not yet evident. Future investigations with larger sample sizes and longer observation periods are warranted to further verify the effects.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR-IPR-17012317; http://www.chictr.org.cn/showproj.aspx?proj=19828.

Perspectives of people living with a spinal cord injury on activity-based therapy

PURPOSE

Activity-Based Therapy (ABT) targets recovery of function below the injury level in individuals with spinal cord injury (SCI). This qualitative study is the first to capture the perspectives of individuals with SCI on community ABT programs in Canada.

METHODS

Ten participants (6 males, aged 23.0-65.0 years, 2.5-23.0 years post-SCI) were recruited using purposive sampling, and completed semi-structured interviews. Interview questions explored benefits and challenges, facilitators and barriers to access, and motivations for participating in ABT. Themes were identified using conventional content analysis and collaboratively analyzed using the DEPICT model.

RESULTS

An overarching theme of ABT as a key part of participants' evolving and lifelong recovery process emerged. Motivations for initiating ABT included dissatisfaction with early rehabilitation, and a desire to improve function and stay active. Participants perceived that ABT contributed to neurological recovery, physical and mental health benefits, independence, and hope. Factors contributing to recovery and factors limiting accessibility and participation in ABT were identified. Participants discussed advocating for ABT, and how ABT empowered self-management.

CONCLUSIONS

ABT was perceived to play a significant role in promoting ongoing recovery and well-being in individuals with SCI. Addressing limitations in awareness and availability of ABT may improve participation in ABT programs.Implications for rehabilitationActivity-Based Therapy (ABT) targets recovery of function and sensation below the level of injury in individuals with spinal cord injury (SCI).ABT plays a key role in the evolving and lifelong recovery process of individuals with SCI.Participants reported that ABT has a positive impact on physical, functional, and psychosocial domains, leading to improved independence and quality of life.Awareness and availability of ABT remain limited, highlighting a need to further explore and address factors limiting access to this therapy.

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.

Reaching and Grasping Training Improves Functional Recovery After Chronic Cervical Spinal Cord Injury

Previous studies suggest locomotion training could be an effective non-invasive therapy after spinal cord injury (SCI) using primarily acute thoracic injuries. However, the majority of SCI patients have chronic cervical injuries. Regaining hand function could significantly increase their quality of life. In this study, we used a clinically relevant chronic cervical contusion to study the therapeutic efficacy of rehabilitation in forelimb functional recovery. Nude rats received a moderate C5 unilateral contusive injury and were then divided into two groups with or without Modified Montoya Staircase (MMS) rehabilitation. For the rehabilitation group, rats were trained 5 days a week starting at 8 weeks post-injury (PI) for 6 weeks. All rats were assessed for skilled forelimb functions with MMS test weekly and for untrained gross forelimb locomotion with grooming and horizontal ladder (HL) tests biweekly. Our results showed that MMS rehabilitation significantly increased the number of pellets taken at 13 and 14 weeks PI and the accuracy rates at 12 to 14 weeks PI. However, there were no significant differences in the grooming scores or the percentage of HL missteps at any time point. Histological analyses revealed that MMS rehabilitation significantly increased the number of serotonergic fibers and the amount of presynaptic terminals around motor neurons in the cervical ventral horns caudal to the injury and reduced glial fibrillary acidic protein (GFAP)-immunoreactive astrogliosis in spinal cords caudal to the lesion. This study shows that MMS rehabilitation can modify the injury environment, promote axonal sprouting and synaptic plasticity, and importantly, improve reaching and grasping functions in the forelimb, supporting the therapeutic potential of task-specific rehabilitation for functional recovery after chronic SCI.

Rehabilitative Training in Animal Models of Spinal Cord Injury

Rehabilitative motor training is currently one of the most widely used approaches to promote moderate recovery following injuries of the central nervous system. Such training is generally applied in the clinical setting, whereas it is not standard in preclinical research. This is a concern as it is becoming increasingly apparent that neuroplasticity enhancing treatments require training or some form of activity as a co-therapy to promote functional recovery. Despite the importance of training and the many open questions regarding its mechanistic consequences, its use in preclinical animal models is rather limited. Here we review approaches, findings and challenges when training is applied in animal models of spinal cord injury, and we suggest recommendations to facilitate the integration of training using an appropriate study design, into pre-clinical studies.

Effects of Combined Upper Limb Robotic Therapy in Patients With Tetraplegic Spinal Cord Injury

OBJECTIVE

To confirm the effects of combined upper limb robotic therapy (RT) as compared to conventional occupational therapy (OT) in tetraplegic spinal cord injury (SCI) patients and to suggest the optimized treatment guidelines of combined upper limb RT.

METHODS

After subject recruitment and screening for eligibility, the baseline evaluation for outcome measures were performed. We evaluated the Graded and Redefined Assessment of Strength, Sensibility, and Prehension (GRASSP), the American Spinal Injury Association upper extremity motor score, grip and pinch strength, and the Spinal Cord Independence Measurement III (SCIM-III). In this study, the pre-tested participants were divided randomly into the RT and OT group. The utilized interventions included combined upper limb RT using ArmeoPower and Amadeo (RT group), or conventional OT (OT group) in addition to daily inpatient rehabilitation program. The participants underwent 40 minutes×3 sessions×5 weeks of interventions.

RESULTS

A total of 30 tetraplegic SCI patients completed entire study program. After 5 weeks of intervention, both groups demonstrated increases in GRASSP-strength and SCIM-III. The manual muscle test scores of elbow flexion, elbow extension, 2-5th metacarpophalangeal extension, and SCIM-III subscores of bathing-upper, dressing-upper, and grooming as well as the GRASSP-qualitative prehension score were noted to have been significantly increased in the RT group as evaluated. The OT group showed improvements in the GRASSP-quantitative prehension score and some items in grip and pinch strength. There was no significant difference between the two groups in almost all measurements except for the SCIM-III bathing-upper subscore.

CONCLUSION

Combined upper limb RT demonstrated beneficial effects on the upper limb motor function in patients with tetraplegic SCI, which were comparable with conventional OT.

Comparison of the Effect of 8-Week Rebound Therapy-Based Exercise Program and Weight-Supported Exercises on the Range of Motion, Proprioception, and the Quality of Life in Patients with Parkinson's Disease

Introduction

Parkinson's disease (PD) is a chronic, progressive disorder that mainly affects the central nervous system and, consequently, the patient's functional status. This study aimed to compare the effect of 8-week rebound therapy-based exercise program and weight-supported exercises on the range of motion, proprioception, and the quality of life in patients with PD.

Methods

Twenty patients were randomly divided into two equal groups of weight-bearing exercises and rebound exercise with no significant differences in age, weight, and height. The variables of the range of motion, proprioception, and the quality of life were assessed in pre- and posttest. Data were analyzed using repeated measure ANOVA and t-test at a significant level of P < 0.05.

Results

All of the variables in the two groups were significantly improved after 8 weeks of exercise, whereas the improvement rate in the rebound therapy group was more than the weight-bearing exercises group in range of motion (134.60 ± 13.22 vs. 118.38 ± 12.48), proprioception (7.60 ± 3.22 vs. 10.38 ± 2.48), and the quality of life (147.60 ± 13.22 vs. 118.38 ± 12.48) of the patients (P < 0.001 for all variables).

Conclusions

Given that both rebound and weight-supported exercises are effective on improving the range of motion, proprioception, and the quality of life of people with PD, it is recommended that the benefits of these exercises to be used in physical rehabilitation programs. However, rebound therapy exercises have had a greater effect on people with PD, and it seems better to use these exercises more than others.

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.

Clinical Trials in Traumatic Spinal Cord Injury

Traumatic spinal cord injury (SCI) results in impaired neurologic function that for many individuals is permanent and significantly impacts health, function, quality of life, and life expectancy. Many efforts have been taken to develop effective treatments for SCI; nevertheless, proven therapies targeting neurologic regeneration and functional recovery have been limited. Existing therapeutic approaches, including early surgery, strict blood pressure control, and consideration of treatment with steroids, remain debated and largely focus on mitigating secondary injury after the primary trauma has occurred. Today, there is more research being performed in SCI than ever before. Current clinical trials are exploring pharmacologic, cell-based, physiologic, and rehabilitation approaches to reduce secondary injury and also overcome barriers to neurorecovery. In the future, it is likely that tailored treatments combining many of these strategies will offer significant benefits for persons with SCI. This article aims to review key past, current and emerging neurologic and rehabilitation therapeutic approaches for adults with traumatic SCI.

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.

Body System Effects of a Multi-Modal Training Program Targeting Chronic, Motor Complete Thoracic Spinal Cord Injury

The safety and efficacy of pharmacological and cellular transplantation strategies are currently being evaluated in people with spinal cord injury (SCI). In studies of people with chronic SCIs, it is thought that functional recovery will be best achieved when drug or cell therapies are combined with rehabilitation protocols. However, any functional recovery attributed to the therapy may be confounded by the conditioned state of the body and by training-induced effects on neuroplasticity. For this reason, we sought to investigate the effects of a multi-modal training program on several body systems. The training program included body-weight-supported treadmill training for locomotion, circuit resistance training for upper body conditioning, functional electrical stimulation for activation of sublesional muscles, and wheelchair skills training for overall mobility. Eight participants with chronic, thoracic-level, motor-complete SCI completed the 12-week training program. After 12 weeks, upper extremity muscular strength improved significantly for all participants, and some participants experienced improvements in function, which may be explained by increased strength. Neurological function did not change. Changes in pain and spasticity were highly variable between participants. This is the first demonstration of the effect of this combination of four training modalities. However, balancing participant and study-site burden with capturing meaningful outcome measures is also an important consideration.