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Benn NL, Jervis-Rademeyer H, Souza WH, Pakosh M, Inness EL, Musselman KE. 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. Arch Phys Med Rehabil 2024:S0003-9993(24)01162-6. [PMID: 39111646 DOI: 10.1016/j.apmr.2024.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 06/18/2024] [Accepted: 07/02/2024] [Indexed: 08/27/2024]
Abstract
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.
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Affiliation(s)
- Natasha L Benn
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada; KITE Research Institute, Toronto Rehabilitation Institute-University Health Network, Toronto, Canada
| | | | - Wagner H Souza
- KITE Research Institute, Toronto Rehabilitation Institute-University Health Network, Toronto, Canada
| | - Maureen Pakosh
- KITE Research Institute, Toronto Rehabilitation Institute-University Health Network, Toronto, Canada
| | - Elizabeth L Inness
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada; KITE Research Institute, Toronto Rehabilitation Institute-University Health Network, Toronto, Canada; Department of Physical Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Kristin E Musselman
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada; KITE Research Institute, Toronto Rehabilitation Institute-University Health Network, Toronto, Canada; Department of Physical Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada.
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Plawecki A, Henderson CE, Lotter JK, Shoger LH, Inks E, Scofield M, Voigtmann CJ, Katta-Charles S, Hornby TG. Comparative Efficacy of High-Intensity Training Versus Conventional Training in Individuals With Chronic Traumatic Brain Injury: A Pilot Randomized Controlled Study. J Neurotrauma 2024; 41:807-817. [PMID: 38204184 DOI: 10.1089/neu.2023.0494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024] Open
Abstract
Numerous studies have evaluated the efficacy of interventions to improve locomotion after acute-onset brain injury, although most focus on patients with stroke, with less attention toward traumatic brain injury (TBI). For example, a number of studies in patients post-stroke have evaluated the effects of high-intensity training (HIT) attempting to maximize stepping practice, while no studies have attempted this intervention in patients with TBI. The purpose of this blinded-assessor randomized trial was to evaluate the effects of HIT focused on stepping practice versus conventional training on walking and secondary outcomes in individuals with TBI. Using a crossover design, ambulatory participants with TBI >6-months duration performed HIT focused on stepping in variable contexts (overground, treadmill, stairs) or conventional training for up to 15 sessions over five weeks, with interventions alternated >4 weeks later. HIT focused on maximizing stepping practice while trying to achieve higher cardiovascular intensities (>70% heart rate reserve), while conventional training focused on impairment-based and functional exercises with no restrictions on intensities achieved. Greater increases in 6-min walk test and peak treadmill speed during graded exercise testing were observed after HIT versus conventional training, with moderate associations between differences in stepping practice and outcomes. Greater gains were also observed in estimates of aerobic capacity and efficiency after HIT, with additional improvements in selected cognitive assessments. The present study suggests that the amount and intensity of stepping practice may be important determinants of improved locomotor outcomes in patients with chronic TBI, with possible secondary benefits on aerobic capacity/efficiency and cognition. Clinical Trial Registration-URL: https://clinicaltrials.gov/; Unique Identifier: NCT04503473.
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Affiliation(s)
- Abbey Plawecki
- Rehabilitation Hospital of Indiana, Indianapolis, Indiana, USA
| | - Christopher E Henderson
- Rehabilitation Hospital of Indiana, Indianapolis, Indiana, USA
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | | | - Erin Inks
- Rehabilitation Hospital of Indiana, Indianapolis, Indiana, USA
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Molly Scofield
- Rehabilitation Hospital of Indiana, Indianapolis, Indiana, USA
| | | | - Sheryl Katta-Charles
- Rehabilitation Hospital of Indiana, Indianapolis, Indiana, USA
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - T George Hornby
- Rehabilitation Hospital of Indiana, Indianapolis, Indiana, USA
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Halvorsen J, Henderson C, Romney W, Hågå M, Barkenæs Eggen T, Nordvik JE, Rosseland I, Moore J. Feasibility and Safety of Early Post-COVID-19 High-Intensity Gait Training: A Pilot Study. J Clin Med 2023; 13:237. [PMID: 38202245 PMCID: PMC10780026 DOI: 10.3390/jcm13010237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 12/13/2023] [Accepted: 12/28/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND The feasibility and safety of rehabilitation interventions for individuals recovering from COVID-19 after the acute stage is not well understood. This pilot study aims to provide a preliminary investigation of the feasibility and safety of providing high-intensity gait training (HIT) with a targeted cardiovascular intensity of 70-85% of the age-predicted maximum heart rate (HRmax) for individuals undergoing rehabilitation post-COVID-19. METHODS Consecutive patients who were medically cleared for HIT were invited to participate in the study. Participants practiced walking in varied contexts (treadmill, overground, and stairs), aiming to spend as much time as possible within their target cardiovascular intensity zone during scheduled physical therapy (PT) sessions. Training characteristics and adverse events were collected to determine the feasibility and safety of HIT. The severity of adverse events was graded on a 1-5 scale according to the Common Terminology Criteria for Adverse Events. RESULTS The participants (n = 20) took a mean of 2093 (±619) steps per PT session. The average peak heart rate during PT sessions was 81.1% (±9.4) of HRmax, and 30.1% (±21.0) of the session time was spent at heart rates ≥ 70% HRmax. Mild adverse events (grade 1) occurred in <5% of the sessions, and no intervention-requiring or life-threatening adverse events (grade 2-5) occurred. CONCLUSION This pilot study provides preliminary evidence that HIT may be feasible and safe during inpatient rehabilitation for patients post-COVID-19 following medical clearance.
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Affiliation(s)
- Joakim Halvorsen
- Forsterket Rehabilitering Aker, Helseetaten, Oslo kommune, Trondheimsveien 235, 0586 Oslo, Norway; (M.H.); (I.R.)
| | - Christopher Henderson
- Institute for Knowledge Translation, Carmel, IN 46033, USA; (C.H.); (J.M.)
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis, IN 46254, USA
| | - Wendy Romney
- Department of Physical Therapy and Human Movement Science, Sacred Heart University, Fairfield, CT 06825, USA;
| | - Magnus Hågå
- Forsterket Rehabilitering Aker, Helseetaten, Oslo kommune, Trondheimsveien 235, 0586 Oslo, Norway; (M.H.); (I.R.)
| | | | - Jan Egil Nordvik
- Faculty of Health Sciences, Oslo Metropolitan University, 0166 Oslo, Norway;
| | - Ingvild Rosseland
- Forsterket Rehabilitering Aker, Helseetaten, Oslo kommune, Trondheimsveien 235, 0586 Oslo, Norway; (M.H.); (I.R.)
| | - Jennifer Moore
- Institute for Knowledge Translation, Carmel, IN 46033, USA; (C.H.); (J.M.)
- Regional Kompetansetjeneste for Rehabilitering, Sunnaas HF, Trondheimsveien 235, 0586 Oslo, Norway
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van Helden JFL, Alexander E, Cabral HV, Strutton PH, Martinez-Valdes E, Falla D, Chowdhury JR, Chiou SY. Home-based arm cycling exercise improves trunk control in persons with incomplete spinal cord injury: an observational study. Sci Rep 2023; 13:22120. [PMID: 38092831 PMCID: PMC10719287 DOI: 10.1038/s41598-023-49053-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 12/04/2023] [Indexed: 12/17/2023] Open
Abstract
Arm cycling is used for cardiorespiratory rehabilitation but its therapeutic effects on the neural control of the trunk after spinal cord injury (SCI) remain unclear. We investigated the effects of single session of arm cycling on corticospinal excitability, and the feasibility of home-based arm cycling exercise training on volitional control of the erector spinae (ES) in individuals with incomplete SCI. Using transcranial magnetic stimulation, we assessed motor evoked potentials (MEPs) in the ES before and after 30 min of arm cycling in 15 individuals with SCI and 15 able-bodied controls (Experiment 1). Both groups showed increased ES MEP size after the arm cycling. The participants with SCI subsequently underwent a 6-week home-based arm cycling exercise training (Experiment 2). MEP amplitudes and activity of the ES, and movements of the trunk during reaching, self-initiated rapid shoulder flexion, and predicted external perturbation tasks were measured. After the training, individuals with SCI reached further and improved trajectory of the trunk during the rapid shoulder flexion task, accompanied by increased ES activity and MEP amplitudes. Exercise adherence was excellent. We demonstrate preserved corticospinal drive after a single arm cycling session and the effects of home-based arm cycling exercise training on trunk function in individuals with SCI.
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Affiliation(s)
- Joeri F L van Helden
- Centre of Precision Rehabilitation for Spinal Pain (CPR Spine), School of Sport, Exercise and Rehabilitation Sciences, College of Life and Environmental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Emma Alexander
- The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Hélio V Cabral
- Department of Clinical and Experimental Sciences, Università degli Studi di Brescia, Brescia, Italy
| | - Paul H Strutton
- Department of Surgery & Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Eduardo Martinez-Valdes
- Centre of Precision Rehabilitation for Spinal Pain (CPR Spine), School of Sport, Exercise and Rehabilitation Sciences, College of Life and Environmental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Deborah Falla
- Centre of Precision Rehabilitation for Spinal Pain (CPR Spine), School of Sport, Exercise and Rehabilitation Sciences, College of Life and Environmental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Joy Roy Chowdhury
- Midland Centre for Spinal Injuries, The Robert Jones and Agnes Hunt Orthopaedic Hospital NHSFT, Oswestry, UK
| | - Shin-Yi Chiou
- Centre of Precision Rehabilitation for Spinal Pain (CPR Spine), School of Sport, Exercise and Rehabilitation Sciences, College of Life and Environmental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK.
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Wang Y, Su H, Zhong J, Zhan Z, Zhao Q, Liu Y, Li S, Wang H, Yang C, Yu L, Tan B, Yin Y. Osteopontin enhances the effect of treadmill training and promotes functional recovery after spinal cord injury. MOLECULAR BIOMEDICINE 2023; 4:44. [PMID: 38015348 PMCID: PMC10684450 DOI: 10.1186/s43556-023-00154-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 11/05/2023] [Indexed: 11/29/2023] Open
Abstract
In this study, we examined the combined impact of osteopontin (OPN) and treadmill training on mice with spinal cord injury (SCI). OPN was overexpressed by injecting AAV9-SPP1-GFP into the sensorimotor cortex, followed by a left incomplete C5 crush injury two weeks later. Mice (Ex or Ex + OPN group) were trained at 50% maximum running speed for 8 weeks. To analyze the effects, we used biotinylated dextran amine (BDA) for tracing the corticospinal tract (CST) and performed Western blotting and immunohistochemical methods to assess the activation of the mammalian target of rapamycin (mTOR). We also examined axonal regeneration and conducted behavioral tests to measure functional recovery. The results demonstrated that treadmill training promoted the expression of neurotrophic factors such as brain-derived neurotrophic factor (BNDF) and insulin-like growth factor I (IGF-1) and activated mTOR signaling. OPN amplified the effect of treadmill training on activating mTOR signaling indicated by upregulated phosphorylation of ribosomal protein S6 kinase (S6). The combination of OPN and exercise further promoted functional recovery and facilitated limited CST axonal regeneration which did not occur with treadmill training and OPN treatment alone. These findings indicate that OPN enhances the effects of treadmill training in the treatment of SCI and offer new therapeutic insights for spinal cord injury.
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Affiliation(s)
- Yunhang Wang
- Department of Rehabilitation Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
- Department of Rehabilitation, Zhejiang University School of Medicine Second Affiliated Hospital, 88 Jiefang Road, Hangzhou, Zhejiang, 310009, China
| | - Hong Su
- Department of Rehabilitation Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Juan Zhong
- Department of Rehabilitation Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Zuxiong Zhan
- Department of Rehabilitation Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Qin Zhao
- Department of Rehabilitation Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Yuan Liu
- State Key Laboratory of Trauma, Burns and Combined Injury, Department of Special War Wound, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Sen Li
- State Key Laboratory of Trauma, Burns and Combined Injury, Department of Special War Wound, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Haiyan Wang
- State Key Laboratory of Trauma, Burns and Combined Injury, Department of Special War Wound, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Ce Yang
- State Key Laboratory of Trauma, Burns and Combined Injury, Department of Special War Wound, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Lehua Yu
- Department of Rehabilitation Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Botao Tan
- Department of Rehabilitation Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China.
| | - Ying Yin
- Department of Rehabilitation Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China.
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Stewart AN, Gensel JC, Jones L, Fouad K. Challenges in Translating Regenerative Therapies for Spinal Cord Injury. Top Spinal Cord Inj Rehabil 2023; 29:23-43. [PMID: 38174141 PMCID: PMC10759906 DOI: 10.46292/sci23-00044s] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
Regenerating the injured spinal cord is a substantial challenge with many obstacles that need to be overcome to achieve robust functional benefits. This abundance of hurdles can partly explain the limited success when applying regenerative intervention treatments in animal models and/or people. In this article, we elaborate on a few of these obstacles, starting with the applicability of animal models and how they compare to the clinical setting. We then discuss the requirement for combinatorial interventions and the associated problems in experimental design, including the addition of rehabilitative training. The article expands on differences in lesion sizes and locations between humans and common animal models, and how this difference can determine the success or failure of an intervention. An additional and frequently overlooked problem in the translation of interventions that applies beyond the field of neuroregeneration is the reporting bias and the lack of transparency in reporting findings. New data mandates are tackling this problem and will eventually result in a more balanced view of the field. Finally, we will discuss strategies to negotiate the challenging course of successful translation to facilitate successful translation of regeneration promoting interventions.
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Affiliation(s)
- Andrew N. Stewart
- Spinal Cord and Brain Injury Research Center, University of Kentucky, Lexington, Kentucky, USA
| | - John C. Gensel
- Spinal Cord and Brain Injury Research Center, University of Kentucky, Lexington, Kentucky, USA
| | - Linda Jones
- Department of Occupational Therapy, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Karim Fouad
- Department of Physical Therapy, University of Alberta, Edmonton, Canada
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Muter WM, Mansson L, Tuthill C, Aalla S, Barth S, Evans E, McKenzie K, Prokup S, Yang C, Sandhu M, Rymer WZ, Edgerton VR, Gad P, Mitchell GS, Wu SS, Shan G, Jayaraman A, Trumbower RD. A Research Protocol to Study the Priming Effects of Breathing Low Oxygen on Enhancing Training-Related Gains in Walking Function for Persons With Spinal Cord Injury: The BO 2ST Trial. Neurotrauma Rep 2023; 4:736-750. [PMID: 38028272 PMCID: PMC10659019 DOI: 10.1089/neur.2023.0036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023] Open
Abstract
Brief episodes of low oxygen breathing (therapeutic acute intermittent hypoxia; tAIH) may serve as an effective plasticity-promoting primer to enhance the effects of transcutaneous spinal stimulation-enhanced walking therapy (WALKtSTIM) in persons with chronic (>1 year) spinal cord injury (SCI). Pre-clinical studies in rodents with SCI show that tAIH and WALKtSTIM therapies harness complementary mechanisms of plasticity to maximize walking recovery. Here, we present a multi-site clinical trial protocol designed to examine the influence of tAIH + WALKtSTIM on walking recovery in persons with chronic SCI. We hypothesize that daily (eight sessions, 2 weeks) tAIH + WALKtSTIM will elicit faster, more persistent improvements in walking recovery than either treatment alone. To test our hypothesis, we are conducting a placebo-controlled clinical trial on 60 SCI participants who randomly receive one of three interventions: tAIH + WALKtSTIM; Placebo + WALKtSTIM; and tAIH + WALKtSHAM. Participants receive daily tAIH (fifteen 90-sec episodes at 10% O2 with 60-sec intervals at 21% O2) or daily placebo (fifteen 90-sec episodes at 21% O2 with 60-sec intervals at 21% O2) before a 45-min session of WALKtSTIM or WALKtSHAM. Our primary outcome measures assess walking speed (10-Meter Walk Test), endurance (6-Minute Walk Test), and balance (Timed Up and Go Test). For safety, we also measure pain levels, spasticity, sleep behavior, cognition, and rates of systemic hypertension and autonomic dysreflexia. Assessments occur before, during, and after sessions, as well as at 1, 4, and 8 weeks post-intervention. Results from this study extend our understanding of the functional benefits of tAIH priming by investigating its capacity to boost the neuromodulatory effects of transcutaneous spinal stimulation on restoring walking after SCI. Given that there is no known cure for SCI and no single treatment is sufficient to overcome walking deficits, there is a critical need for combinatorial treatments that accelerate and anchor walking gains in persons with lifelong SCI. Trial Registration ClinicalTrials.gov, NCT05563103.
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Affiliation(s)
- William M. Muter
- Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA
| | - Linda Mansson
- Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher Tuthill
- Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts, USA
| | - Shreya Aalla
- Shirley Ryan AbilityLab, Max Nader Center for Rehabilitation Technologies and Outcomes Research, Chicago, Illinois, USA
| | - Stella Barth
- Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA
- UMass Chan Medical School, University of Massachusetts, Worcester, Massachusetts, USA
| | - Emily Evans
- Department of Physical Therapy, Boston University, Boston, Massachusetts, USA
| | - Kelly McKenzie
- Shirley Ryan AbilityLab, Max Nader Center for Rehabilitation Technologies and Outcomes Research, Chicago, Illinois, USA
| | - Sara Prokup
- Shirley Ryan AbilityLab, Max Nader Center for Rehabilitation Technologies and Outcomes Research, Chicago, Illinois, USA
| | - Chen Yang
- Shirley Ryan AbilityLab, Max Nader Center for Rehabilitation Technologies and Outcomes Research, Chicago, Illinois, USA
| | - Milap Sandhu
- Shirley Ryan AbilityLab, Max Nader Center for Rehabilitation Technologies and Outcomes Research, Chicago, Illinois, USA
| | - W. Zev Rymer
- Shirley Ryan AbilityLab, Max Nader Center for Rehabilitation Technologies and Outcomes Research, Chicago, Illinois, USA
| | - Victor R. Edgerton
- Department of Integrative Biology and Physiology, University of California–Los Angeles, Los Angeles, California, USA
- SpineX Inc., Northridge, California, USA
| | - Parag Gad
- Department of Integrative Biology and Physiology, University of California–Los Angeles, Los Angeles, California, USA
- SpineX Inc., Northridge, California, USA
| | - Gordon S. Mitchell
- Department of Physical Therapy, University of Florida, Gainesville, Florida, USA
| | - Samuel S. Wu
- Department of Biostatistics, University of Florida, Gainesville, Florida, USA
| | - Guogen Shan
- Department of Biostatistics, University of Florida, Gainesville, Florida, USA
| | - Arun Jayaraman
- Shirley Ryan AbilityLab, Max Nader Center for Rehabilitation Technologies and Outcomes Research, Chicago, Illinois, USA
| | - Randy D. Trumbower
- Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts, USA
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Hodgkiss DD, Bhangu GS, Lunny C, Jutzeler CR, Chiou SY, Walter M, Lucas SJE, Krassioukov AV, Nightingale TE. Exercise and aerobic capacity in individuals with spinal cord injury: A systematic review with meta-analysis and meta-regression. PLoS Med 2023; 20:e1004082. [PMID: 38011304 PMCID: PMC10712898 DOI: 10.1371/journal.pmed.1004082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 12/11/2023] [Accepted: 10/30/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND A low level of cardiorespiratory fitness [CRF; defined as peak oxygen uptake ([Formula: see text]O2peak) or peak power output (PPO)] is a widely reported consequence of spinal cord injury (SCI) and a major risk factor associated with chronic disease. However, CRF can be modified by exercise. This systematic review with meta-analysis and meta-regression aimed to assess whether certain SCI characteristics and/or specific exercise considerations are moderators of changes in CRF. METHODS AND FINDINGS Databases (MEDLINE, EMBASE, CENTRAL, and Web of Science) were searched from inception to March 2023. A primary meta-analysis was conducted including randomised controlled trials (RCTs; exercise interventions lasting >2 weeks relative to control groups). A secondary meta-analysis pooled independent exercise interventions >2 weeks from longitudinal pre-post and RCT studies to explore whether subgroup differences in injury characteristics and/or exercise intervention parameters explained CRF changes. Further analyses included cohort, cross-sectional, and observational study designs. Outcome measures of interest were absolute (A[Formula: see text]O2peak) or relative [Formula: see text]O2peak (R[Formula: see text]O2peak), and/or PPO. Bias/quality was assessed via The Cochrane Risk of Bias 2 and the National Institute of Health Quality Assessment Tools. Certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Random effects models were used in all meta-analyses and meta-regressions. Of 21,020 identified records, 120 studies comprising 29 RCTs, 67 pre-post studies, 11 cohort, 7 cross-sectional, and 6 observational studies were included. The primary meta-analysis revealed significant improvements in A[Formula: see text]O2peak [0.16 (0.07, 0.25) L/min], R[Formula: see text]O2peak [2.9 (1.8, 3.9) mL/kg/min], and PPO [9 (5, 14) W] with exercise, relative to controls (p < 0.001). Ninety-six studies (117 independent exercise interventions comprising 1,331 adults with SCI) were included in the secondary, pooled meta-analysis which demonstrated significant increases in A[Formula: see text]O2peak [0.22 (0.17, 0.26) L/min], R[Formula: see text]O2peak [2.8 (2.2, 3.3) mL/kg/min], and PPO [11 (9, 13) W] (p < 0.001) following exercise interventions. There were subgroup differences for R[Formula: see text]O2peak based on exercise modality (p = 0.002) and intervention length (p = 0.01), but there were no differences for A[Formula: see text]O2peak. There were subgroup differences (p ≤ 0.018) for PPO based on time since injury, neurological level of injury, exercise modality, and frequency. The meta-regression found that studies with a higher mean age of participants were associated with smaller changes in A[Formula: see text]O2peak and R[Formula: see text]O2peak (p < 0.10). GRADE indicated a moderate level of certainty in the estimated effect for R[Formula: see text]O2peak, but low levels for A[Formula: see text]O2peak and PPO. This review may be limited by the small number of RCTs, which prevented a subgroup analysis within this specific study design. CONCLUSIONS Our primary meta-analysis confirms that performing exercise >2 weeks results in significant improvements to A[Formula: see text]O2peak, R[Formula: see text]O2peak, and PPO in individuals with SCI. The pooled meta-analysis subgroup comparisons identified that exercise interventions lasting up to 12 weeks yield the greatest change in R[Formula: see text]O2peak. Upper-body aerobic exercise and resistance training also appear the most effective at improving R[Formula: see text]O2peak and PPO. Furthermore, acutely injured, individuals with paraplegia, exercising for ≥3 sessions/week will likely experience the greatest change in PPO. Ageing seemingly diminishes the adaptive CRF responses to exercise training in individuals with SCI. REGISTRATION PROSPERO: CRD42018104342.
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Affiliation(s)
- Daniel D. Hodgkiss
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Gurjeet S. Bhangu
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, Canada
- MD Undergraduate Program, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Carole Lunny
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, and University of British Columbia, Vancouver, Canada
| | - Catherine R. Jutzeler
- Department of Health Sciences and Technology, ETH Zurich, Zurich, Switzerland
- Schulthess Clinic, Zurich, Switzerland
| | - Shin-Yi Chiou
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, United Kingdom
- Centre for Human Brain Health, University of Birmingham, Birmingham, United Kingdom
- MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, University of Birmingham, Birmingham, United Kingdom
- Centre for Trauma Science Research, University of Birmingham, Birmingham, United Kingdom
| | - Matthias Walter
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, Canada
- Department of Urology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Samuel J. E. Lucas
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, United Kingdom
- Centre for Human Brain Health, University of Birmingham, Birmingham, United Kingdom
| | - Andrei V. Krassioukov
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, Canada
- Department of Medicine, Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, Canada
- GF Strong Rehabilitation Centre, Vancouver Coastal Health, Vancouver, Canada
| | - Tom E. Nightingale
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, United Kingdom
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, Canada
- Centre for Trauma Science Research, University of Birmingham, Birmingham, United Kingdom
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Pradat PF, Hayon D, Blancho S, Neveu P, Khamaysa M, Guerout N. Advances in Spinal Cord Neuromodulation: The Integration of Neuroengineering, Computational Approaches, and Innovative Conceptual Frameworks. J Pers Med 2023; 13:993. [PMID: 37373982 DOI: 10.3390/jpm13060993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 06/07/2023] [Accepted: 06/11/2023] [Indexed: 06/29/2023] Open
Abstract
Spinal cord stimulation (SCS) is an approved treatment for intractable pain and has recently emerged as a promising area of research for restoring function after spinal cord lesion. This review will focus on the historical evolution of this transition and the path that remains to be taken for these methods to be rigorously evaluated for application in clinical practice. New developments in SCS are being driven by advances in the understanding of spinal cord lesions at the molecular, cellular, and neuronal levels, as well as the understanding of compensatory mechanisms. Advances in neuroengineering and the computational neurosciences have enabled the development of new conceptual SCS strategies, such as spatiotemporal neuromodulation, which allows spatially selective stimulation at precise time points during anticipated movement. It has also become increasingly clear that these methods are only effective when combined with intensive rehabilitation techniques, such as new task-oriented methods and robotic aids. The emergence of innovative approaches to spinal cord neuromodulation has sparked significant enthusiasm among patients and in the media. Non-invasive methods are perceived to offer improved safety, patient acceptance, and cost-effectiveness. There is an immediate need for well-designed clinical trials involving consumer or advocacy groups to evaluate and compare the effectiveness of various treatment modalities, assess safety considerations, and establish outcome priorities.
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Affiliation(s)
- Pierre-François Pradat
- Laboratoire d'Imagerie Biomédicale, Sorbonne Université, CNRS, INSERM, 75013 Paris, France
- APHP, Département de Neurologie, Hôpital Pitié-Salpêtrière, Centre Référent SLA, 75013 Paris, France
- Northern Ireland Centre for Stratified Medicine, Biomedical Sciences Research Institute Ulster University, C-TRIC, Altnagelvin Hospital, Derry/Londonderry BT47 6SB, UK
- Institut Pour la Recherche Sur la Moelle Epiniere et l'Encéphale (IRME), 25 Rue Duranton, 75015 Paris, France
| | - David Hayon
- Clinique Saint-Roch, Service d'Anesthésie, 56 Rue de Lille, 59223 Roncq, France
| | - Sophie Blancho
- Institut Pour la Recherche Sur la Moelle Epiniere et l'Encéphale (IRME), 25 Rue Duranton, 75015 Paris, France
| | - Pauline Neveu
- Saints Pères Paris Institute for the Neurosciences, Université Paris Cité, CNRS UMR8003, 75006 Paris, France
| | - Mohammed Khamaysa
- Laboratoire d'Imagerie Biomédicale, Sorbonne Université, CNRS, INSERM, 75013 Paris, France
| | - Nicolas Guerout
- Saints Pères Paris Institute for the Neurosciences, Université Paris Cité, CNRS UMR8003, 75006 Paris, France
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Walia S, Kumar P, Kataria C. Interventions to Improve Standing Balance in Individuals With Incomplete Spinal Cord Injury: A Systematic Review and Meta-Analysis. Top Spinal Cord Inj Rehabil 2023; 29:56-83. [PMID: 37235196 PMCID: PMC10208260 DOI: 10.46292/sci21-00065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Background Incomplete spinal cord injury (iSCI) often results in impaired balance leading to functional impairments. Recovery of standing balance ability is an important aim of rehabilitative programs. However, limited information is available on effective balance training protocols for individuals with iSCI. Objectives To assess the methodological quality and effectiveness of various rehabilitation interventions for improving standing balance in individuals with iSCI. Methods A systematic search was performed in SCOPUS, PEDro, PubMed, and Web of Science from inception until March 2021. Two independent reviewers screened articles for inclusion, extracted data, and evaluated methodological quality of the trials. PEDro Scale was used to assess the quality of randomized controlled trials (RCT) and crossover studies while pre-post trials were assessed using the modified Downs and Black tool. A meta-analysis was performed to quantitatively describe the results. The random effects model was applied to present the pooled effect. Results Ten RCTs with a total of 222 participants and 15 pre-post trials with 967 participants were analyzed. The mean PEDro score and modified Downs and Black score was 7/10 and 6/9, respectively. The pooled standardized mean difference (SMD) for controlled and uncontrolled trials of body weight-supported training (BWST) interventions was -0.26 (95% CI, -0.70 to 0.18; p = .25) and 0.46 (95% CI, 0.33 to 0.59; p < .001), respectively. The pooled effect size of -0.98 (95% CI, -1.93 to -0.03; p = .04) indicated significant improvements in balance after a combination of BWST and stimulation. Pre-post studies analyzing the effect of virtual reality (VR) training interventions on Berg Balance Scale (BBS) scores in individuals with iSCI reported a mean difference (MD) of 4.22 (95% CI, 1.78 to 6.66; p = .0007). Small effect sizes were seen in pre-post studies of VR+stimulation and aerobic exercise training interventions indicating no significant improvements after training on standing balance measures. Conclusion This study demonstrated weak evidence to support the use of BWST interventions for overground training for balance rehabilitation in individuals with iSCI. A combination of BWST with stimulation however showed promising results. There is a need for further RCTs in this field to generalize findings. Virtual reality-based balance training has shown significant improvement in standing balance post iSCI. However, these results are based on single group pre-post trials and lack appropriately powered RCTs involving a larger sample size to support this intervention. Given the importance of balance control underpinning all aspects of daily activities, there is a need for further well-designed and appropriately powered RCTs to evaluate specific features of training interventions to improve standing balance function in iSCI.
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Affiliation(s)
- Shefali Walia
- Amity Institute of Physiotherapy, Amity University, Noida, Uttar Pradesh, India
- Indian Spinal Injuries Centre, New Delhi, India
| | - Pragya Kumar
- Amity Institute of Physiotherapy, Amity University, Noida, Uttar Pradesh, India
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11
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Weismer G. Oromotor Nonverbal Performance and Speech Motor Control: Theory and Review of Empirical Evidence. Brain Sci 2023; 13:brainsci13050768. [PMID: 37239240 DOI: 10.3390/brainsci13050768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 04/20/2023] [Accepted: 04/27/2023] [Indexed: 05/28/2023] Open
Abstract
This position paper offers a perspective on the long-standing debate concerning the role of oromotor, nonverbal gestures in understanding typical and disordered speech motor control secondary to neurological disease. Oromotor nonverbal tasks are employed routinely in clinical and research settings, but a coherent rationale for their use is needed. The use of oromotor nonverbal performance to diagnose disease or dysarthria type, versus specific aspects of speech production deficits that contribute to loss of speech intelligibility, is argued to be an important part of the debate. Framing these issues are two models of speech motor control, the Integrative Model (IM) and Task-Dependent Model (TDM), which yield contrasting predictions of the relationship between oromotor nonverbal performance and speech motor control. Theoretical and empirical literature on task specificity in limb, hand, and eye motor control is reviewed to demonstrate its relevance to speech motor control. The IM rejects task specificity in speech motor control, whereas the TDM is defined by it. The theoretical claim of the IM proponents that the TDM requires a special, dedicated neural mechanism for speech production is rejected. Based on theoretical and empirical information, the utility of oromotor nonverbal tasks as a window into speech motor control is questionable.
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Affiliation(s)
- Gary Weismer
- Department of Communication Sciences & Disorders, University of Wisconsin-Madison, Madison, WI 53706, USA
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12
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Combined Transcutaneous Electrical Spinal Cord Stimulation and Task-Specific Rehabilitation Improves Trunk and Sitting Functions in People with Chronic Tetraplegia. Biomedicines 2022; 11:biomedicines11010034. [PMID: 36672542 PMCID: PMC9855778 DOI: 10.3390/biomedicines11010034] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 12/19/2022] [Accepted: 12/20/2022] [Indexed: 12/28/2022] Open
Abstract
The aim of this study was to examine the effects of transcutaneous electrical spinal cord stimulation (TSCS) and conventional task-specific rehabilitation (TSR) on trunk control and sitting stability in people with chronic tetraplegia secondary to a spinal cord injury (SCI). Five individuals with complete cervical (C4-C7) cord injury participated in 24-week therapy that combined TSCS and TSR in the first 12 weeks, followed by TSR alone for another 12 weeks. The TSCS was delivered simultaneously at T11 and L1 spinal levels, at a frequency ranging from 20-30 Hz with 0.1-1.0 ms. pulse width biphasically. Although the neurological prognosis did not manifest after either treatment, the results show that there were significant increases in forward reach distance (10.3 ± 4.5 cm), right lateral reach distance (3.7 ± 1.8 cm), and left lateral reach distance (3.0 ± 0.9 cm) after the combinational treatment (TSCS+TSR). The stimulation also significantly improved the participants' trunk control and function in sitting. Additionally, the trunk range of motion and the electromyographic response of the trunk muscles were significantly elevated after TSCS+TSR. The TSCS+TSR intervention improved independent trunk control with significantly increased static and dynamic sitting balance, which were maintained throughout the TSR period and the follow-up period, indicating long-term sustainable recovery.
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Santamaria V, Ai X, Agrawal SK. A motor learning-based postural intervention with a robotic trunk support trainer to improve functional sitting in spinal cord injury: case report. Spinal Cord Ser Cases 2022; 8:88. [PMID: 36433944 PMCID: PMC9700847 DOI: 10.1038/s41394-022-00554-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 11/08/2022] [Indexed: 11/26/2022] Open
Abstract
STUDY DESIGN Single-subject-research-design. OBJECTIVES To improve seated postural control in a participant with spinal cord injury (SCI) with a robotic Trunk-Support-Trainer (TruST). SETTING Laboratory. METHODS TruST delivered "assist-as-needed" forces on the participant's torso during a motor learning-and-control-based intervention (TruST-intervention). TruST-assistive forces were progressed and matched to the participant's postural trunk control gains across six intervention sessions. The T-shirt test was used to capture functional improvements while dressing the upper body. Kinematics were used to compute upper body excursions (cm) and velocity (cm2), and sitting workspace area (cm2). Functional trunk dynamometry was used to examine muscle force (Kg). Surface electromyography (sEMG) was applied to measure trunk muscle activity. The Borg Rating of Perceived Exertion (RPE) was used to monitor physical exertion during TruST-intervention. A two-standard-deviation bandwidth method was adopted for data interpretation. RESULTS After TruST-intervention, the participant halved the time needed to don and doff a T-shirt, increased muscle force of trunk muscles (mean = 3 kg), acquired a steadier postural sitting control without vision (mean excursion baseline: 76.0 ± 2 SD = 5.25 cm and post-intervention: 44.1 cm; and mean velocity baseline: 3.0 ± 2 SD = 0.2 cm/s and post-intervention: 1.8 cm/s), and expanded his sitting workspace area (mean baseline: 36.7 ± 2 SD = 36.6 cm2 and post-intervention: 419.2 cm2). The participant increased his tolerance to counteract greater TruST-force perturbations in lateral and posterior directions. Furthermore, abdominal muscle activity substantially augmented after completion of TruST-intervention across all perturbation directions. CONCLUSIONS Our data indicate a potential effectiveness of TruST-intervention to promote functional sitting in SCI.
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Affiliation(s)
- V Santamaria
- Department of Physical Therapy, New York Medical College, New York, NY, USA
| | - X Ai
- Department of Mechanical Engineering, Columbia University, New York, NY, USA
| | - S K Agrawal
- Department of Mechanical Engineering, Columbia University, New York, NY, USA.
- Department of Rehabilitation and Regenerative Medicine, Columbia University, New York, NY, USA.
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14
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Evans NH, Field-Fote EC. A Pilot Study of Intensive Locomotor-Related Skill Training and Transcranial Direct Current Stimulation in Chronic Spinal Cord Injury. J Neurol Phys Ther 2022; 46:281-292. [PMID: 35544283 DOI: 10.1097/npt.0000000000000403] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND PURPOSE Improved walking function is a priority among persons with motor-incomplete spinal cord injury (PwMISCI). Accessibility and cost limit long-term participation in locomotor training offered in specialized centers. Intensive motor training that facilitates neuroplastic mechanisms that support skill learning and can be implemented in the home/community may be advantageous for promoting long-term restoration of walking function. Additionally, increasing corticospinal drive via transcranial direct current stimulation (tDCS) may enhance training effects. In this pilot study, we investigated whether a moderate-intensity motor skill training (MST) circuit improved walking function in PwMISCI and whether augmenting training with tDCS influenced outcomes. METHODS Twenty-five adults (chronic, motor-incomplete spinal cord injury) were randomized to a 3-day intervention of a locomotor-related MST circuit and concurrent application of sham tDCS (MST+tDCS sham ) or active tDCS (MST+tDCS). The primary outcome was overground walking speed. Secondary outcomes included walking distance, cadence, stride length, and step symmetry index (SI). RESULTS Analyses revealed significant effects of the MST circuit on walking speed, walking distance, cadence, and bilateral stride length but no effect on interlimb SI. No significant between-groups differences were observed. Post hoc analyses revealed within-groups change in walking speed (ΔM = 0.13 m/s, SD = 0.13) that app-roached the minimally clinically important difference of 0.15 m/s. DISCUSSION AND CONCLUSIONS Brief, intensive MST involving locomotor-related activities significantly increased walking speed, walking distance, and spatiotemporal measures in PwMISCI. Significant additive effects of tDCS were not observed; however, participation in only 3 days of MST was associated with changes in walking speed that were comparable to longer locomotor training studies.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A386 ).
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Affiliation(s)
- Nicholas H Evans
- Crawford Research Institute, Shepherd Center, Atlanta, Georgia (N.H.E., E.F.F.); Program in Applied Physiology, Georgia Institute of Technology, Atlanta (N.H.E., E.F.F.); and Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, Georgia (E.F.F.)
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15
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Linking gait mechanics with perceived quality of life and participation after stroke. PLoS One 2022; 17:e0274511. [PMID: 36129881 PMCID: PMC9491527 DOI: 10.1371/journal.pone.0274511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 08/26/2022] [Indexed: 11/19/2022] Open
Abstract
Background
Individuals with hemiparesis following stroke often experience a decline in the paretic limb’s anteriorly directed ground reaction force during walking (i.e., limb propulsive force). Gait speed and walking capacity have been independently associated with paretic limb propulsion, quality of life, and participation in people with stroke. However, it is unclear as to the extent that underlying limb mechanics (i.e., propulsion) play in influencing perceptions of quality of life and participation. We therefore sought to determine the role of limb propulsion during gait on the perception of quality of life and participation in people following stroke.
Methods
This study is a secondary analysis of individuals involved in a gait retraining randomized control trial. Gait speed, walking capacity, limb propulsion, Stroke Impact Scale, and average daily step counts were assessed prior to and following 6 weeks of training. The pre-training data from 40 individuals were analyzed cross-sectionally using Pearson and Spearman correlations, to evaluate the potential relationship between limb propulsion (ratio of paretic limb propulsion to total propulsion) with gait speed, gait capacity, perceived quality of life domains, and average daily step counts. Partial correlations were used to control for gait speed. Thirty-one individuals were assessed longitudinally for the same relationships.
Results
We observed a training effect for gait speed, walking capacity, and some quality of life measures. However, after controlling for gait speed, we observed no significant (p≤0.05) correlations in the cross-sectional and longitudinal analyses.
Significance
After controlling for the influence of gait speed, paretic limb propulsion is not directly related to perceived quality of life or participation. Although limb propulsion may not have a direct effect on participant’s perceived quality of life, it appears to be an important factor to enhance gait performance, and therefore may be important to target in rehabilitation, when feasible.
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16
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Henderson CE, Plawecki A, Lucas E, Lotter JK, Scofield M, Carbone A, Jang JH, Hornby TG. Increasing the Amount and Intensity of Stepping Training During Inpatient Stroke Rehabilitation Improves Locomotor and Non-Locomotor Outcomes. Neurorehabil Neural Repair 2022; 36:621-632. [PMID: 36004813 DOI: 10.1177/15459683221119759] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The efficacy of traditional rehabilitation interventions to improve locomotion post-stroke, including providing multiple exercises targeting impairments and activity limitations, is uncertain. Emerging evidence rather suggests attempts to prioritize stepping practice at higher cardiovascular intensities may facilitate greater locomotor outcomes. OBJECTIVE The present study was designed to evaluate the comparative effectiveness of high-intensity training (HIT) to usual care during inpatient rehabilitation post-stroke. METHODS Changes in stepping activity and functional outcomes were compared over 9 months during usual-care (n = 131 patients < 2 months post-stroke), during an 18-month transition phase with attempts to implement HIT (n = 317), and over 12 months following HIT implementation (n = 208). The transition phase began with didactic and hands-on education, and continued with meetings, mentoring, and audit and feedback. Fidelity metrics included percentage of sessions prioritizing gait interventions and documenting intensity. Demographics, training measures, and outcomes were compared across phases using linear or logistic regression analysis, Kruskal-Wallis tests, or χ2 analysis. RESULTS Across all phases, admission scores were similar except for balance (usual-care>HIT; P < .02). Efforts to prioritize stepping and achieve targeted intensities during HIT vs transition or usual-care phases led to increased steps/day (P < .01). During HIT, gains in 10-m walk [HIT median = 0.13 m/s (interquartile range: 0-0.35) vs usual-care = 0.07 m/s (0-0.24), P = .01] and 6-min walk [50 (9.3-116) vs 2.1 (0-56) m, P < .01] were observed, with additional improvements in transfers and stair-climbing. CONCLUSIONS Greater efforts to prioritize walking and reach higher intensities during HIT led to increased steps/day, resulting in greater gains in locomotor and non-locomotor outcomes.
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Affiliation(s)
- Christopher E Henderson
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis, IN, USA
- Rehabilitation Hospital of Indiana, Indianapolis, IN, USA
| | - Abbey Plawecki
- Rehabilitation Hospital of Indiana, Indianapolis, IN, USA
| | - Emily Lucas
- Rehabilitation Hospital of Indiana, Indianapolis, IN, USA
| | | | - Molly Scofield
- Rehabilitation Hospital of Indiana, Indianapolis, IN, USA
| | - Angela Carbone
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis, IN, USA
- Rehabilitation Hospital of Indiana, Indianapolis, IN, USA
| | - Jeong H Jang
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - T George Hornby
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis, IN, USA
- Rehabilitation Hospital of Indiana, Indianapolis, IN, USA
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Lin JT, Hsu CJ, Dee W, Chen D, Rymer WZ, Wu M. Anodal transcutaneous DC stimulation enhances learning of dynamic balance control during walking in humans with spinal cord injury. Exp Brain Res 2022; 240:1943-1955. [PMID: 35622090 PMCID: PMC9297533 DOI: 10.1007/s00221-022-06388-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 05/12/2022] [Indexed: 11/29/2022]
Abstract
Deficits in locomotor function, including impairments in walking speed and balance, are major problems for many individuals with incomplete spinal cord injury (iSCI). However, it remains unclear which type of training paradigms are more effective in improving balance, particularly dynamic balance, in individuals with iSCI. The purpose of this study was to determine whether anodal transcutaneous spinal direct current stimulation (tsDCS) can facilitate learning of balance control during walking in individuals with iSCI. Fifteen individuals with iSCI participated in this study and were tested in two sessions (i.e., tsDCS and sham conditions). Each session consisted of 1 min of treadmill walking without stimulation or perturbation (baseline), 10 min of walking with either anodal tsDCS or sham stimulation, paired with bilateral pelvis perturbation (adaptation), and finally 2 min of walking without stimulation and perturbation (post-adaptation). The outcome measures were the dynamic balance, assessed using the minimal margin of stability (MoS), and electromyography of leg muscles. Participants demonstrated a smaller MoS during the late adaptation period for the anodal tsDCS condition compared to sham (p = 0.041), and this MoS intended to retain during the early post-adaptation period (p = 0.05). In addition, muscle activity of hip abductors was greater for the anodal tsDCS condition compared to sham during the late adaptation period and post-adaptation period (p < 0.05). Results from this study suggest that anodal tsDCS may modulate motor adaptation to pelvis perturbation and facilitate learning of dynamic balance control in individuals with iSCI.
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Affiliation(s)
- Jui-Te Lin
- Legs and Walking Lab, Shirley Ryan AbilityLab, 355 E. Erie Street, Chicago, IL, 60611, USA.,Seton Hall University, South Orange, NJ, USA
| | - Chao-Jung Hsu
- Legs and Walking Lab, Shirley Ryan AbilityLab, 355 E. Erie Street, Chicago, IL, 60611, USA
| | - Weena Dee
- Legs and Walking Lab, Shirley Ryan AbilityLab, 355 E. Erie Street, Chicago, IL, 60611, USA
| | - David Chen
- Legs and Walking Lab, Shirley Ryan AbilityLab, 355 E. Erie Street, Chicago, IL, 60611, USA
| | - W Zev Rymer
- Legs and Walking Lab, Shirley Ryan AbilityLab, 355 E. Erie Street, Chicago, IL, 60611, USA.,Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, IL, USA
| | - Ming Wu
- Legs and Walking Lab, Shirley Ryan AbilityLab, 355 E. Erie Street, Chicago, IL, 60611, USA. .,Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, IL, USA. .,Department of Biomedical Engineering, University of Illinois at Chicago, Chicago, IL, USA.
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18
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Evans NH, Suri C, Field-Fote EC. Walking and Balance Outcomes Are Improved Following Brief Intensive Locomotor Skill Training but Are Not Augmented by Transcranial Direct Current Stimulation in Persons With Chronic Spinal Cord Injury. Front Hum Neurosci 2022; 16:849297. [PMID: 35634208 PMCID: PMC9130633 DOI: 10.3389/fnhum.2022.849297] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 03/25/2022] [Indexed: 11/30/2022] Open
Abstract
Motor training to improve walking and balance function is a common aspect of rehabilitation following motor-incomplete spinal cord injury (MISCI). Evidence suggests that moderate- to high-intensity exercise facilitates neuroplastic mechanisms that support motor skill acquisition and learning. Furthermore, enhancing corticospinal drive via transcranial direct current stimulation (tDCS) may augment the effects of motor training. In this pilot study, we investigated whether a brief moderate-intensity locomotor-related motor skill training (MST) circuit, with and without tDCS, improved walking and balance outcomes in persons with MISCI. In addition, we examined potential differences between within-day (online) and between-day (offline) effects of MST. Twenty-six adults with chronic MISCI, who had some walking ability, were enrolled in a 5-day double-blind, randomized study with a 3-day intervention period. Participants were assigned to an intensive locomotor MST circuit and concurrent application of either sham tDCS (MST+tDCSsham) or active tDCS (MST+tDCS). The primary outcome was overground walking speed measured during the 10-meter walk test. Secondary outcomes included spatiotemporal gait characteristics (cadence and stride length), peak trailing limb angle (TLA), intralimb coordination (ACC), the Berg Balance Scale (BBS), and the Falls Efficacy Scale-International (FES-I) questionnaire. Analyses revealed a significant effect of the MST circuit, with improvements in walking speed, cadence, bilateral stride length, stronger limb TLA, weaker limb ACC, BBS, and FES-I observed in both the MST+tDCSsham and MST+tDCS groups. No differences in outcomes were observed between groups. Between-day change accounted for a greater percentage of the overall change in walking outcomes. In persons with MISCI, brief intensive MST involving a circuit of ballistic, cyclic locomotor-related skill activities improved walking outcomes, and selected strength and balance outcomes; however, concurrent application of tDCS did not further enhance the effects of MST.
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Affiliation(s)
- Nicholas H. Evans
- Shepherd Center, Crawford Research Institute, Atlanta, GA, United States
- Department of Applied Physiology, Georgia Institute of Technology, Atlanta, GA, United States
| | - Cazmon Suri
- Shepherd Center, Crawford Research Institute, Atlanta, GA, United States
| | - Edelle C. Field-Fote
- Shepherd Center, Crawford Research Institute, Atlanta, GA, United States
- Department of Applied Physiology, Georgia Institute of Technology, Atlanta, GA, United States
- Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, GA, United States
- *Correspondence: Edelle C. Field-Fote,
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Iddings JA, Zarkou A, Field-Fote EC. Noninvasive neuromodulation and rehabilitation to promote functional restoration in persons with spinal cord injury. Curr Opin Neurol 2021; 34:812-818. [PMID: 34766554 PMCID: PMC8597924 DOI: 10.1097/wco.0000000000000997] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE OF REVIEW This review will focus on the use of clinically accessible neuromodulatory approaches for functional restoration in persons with spinal cord injury (SCI). RECENT FINDINGS Functional restoration is a primary rehabilitation priority for individuals with SCI. High-tech neuromodulatory modalities have been used in laboratory settings to improve hand and walking function as well as to reduce spasticity and pain in persons with SCI. However, the cost, limited accessibility, and required expertise are prohibitive for clinical applicability of these high-tech modalities. Recent literature indicates that noninvasive and clinically accessible approaches targeting supraspinal, spinal, and peripheral neural structures can modulate neural excitability. Although a limited number of studies have examined the use of these approaches for functional restoration and amelioration of secondary complications in SCI, early evidence investigating their efficacy when combined with training is encouraging. SUMMARY Larger sample studies addressing both biomarker identification and dosing are crucial next steps in the field of neurorehabilitation research before novel noninvasive stimulation approaches can be incorporated into standard clinical practice.
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Affiliation(s)
- Jennifer A Iddings
- Spinal Cord Injury Research Laboratory, Crawford Research Institute, Shepherd Center
| | - Anastasia Zarkou
- Spinal Cord Injury Research Laboratory, Crawford Research Institute, Shepherd Center
| | - Edelle C Field-Fote
- Spinal Cord Injury Research Laboratory, Crawford Research Institute, Shepherd Center
- Division of Physical Therapy, School of Medicine, Emory University
- Program in Applied Physiology, School of Biological Sciences, Georgia Institute of Technology, Atlanta, Georgia, USA
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20
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Feasibility and tolerance of a robotic postural training to improve standing in a person with ambulatory spinal cord injury. Spinal Cord Ser Cases 2021; 7:94. [PMID: 34620833 PMCID: PMC8497530 DOI: 10.1038/s41394-021-00454-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 09/18/2021] [Accepted: 09/19/2021] [Indexed: 11/08/2022] Open
Abstract
An ambulatory elder with SCI, AIS C, balance deficits, and right ankle-foot-orthosis participated. RobUST-intervention comprised six 90 min-sessions of postural tasks with pelvic assistance and trunk perturbations. We collected three baselines and two 1 week post-training assessments-after the first four sessions (PT1) and after the last two sessions (PT2). We measured Berg Balance Scale (BBS), four-stage balance test (4SBT)-including a 30 s-window with and without vision-standing workspace area, and reactive balance (measured as body weight%). Kinematics, center-of-pressure (COP), and electromyography (EMG) were analyzed to compute root-mean-square-COP (RMS-COP), the margin of stability (MoS), ankle range of motion, and integrated EMG (iEMG) normalized to baseline. The Borg Rating of Perceived Exertion (BRPE), and change in the Mean Arterial Pressure (MAP) and heart rate (HR) compared with baseline were collected to address training tolerance. A 2SD-bandwidth method was selected for data interpretation. The maximum BBS was achieved (1-point improvement). In the 4SBT, the participant completed 30 s (baseline = 20 s) with reduced balance variability during semi-tandem position without vision (RMS-COP baseline = 50.32 ± 2 SD = 19.64 mm; PT1 = 21.29 mm; PT2 = 19.34 mm). A trend toward increase was found in workspace area (baseline = 996 ± 359 cm2; PT1 = 1539 cm2; PT2 = 1138 cm2). The participant tolerated higher perturbation intensities (baseline mean = 25%body weight, PT2 mean = 44% body weight), and on average improved his MoS (3 cm), ankle range of motion (4°), and gluteus medius activity (iEMG = 10). RobuST-intervention was moderate-sort of hard (BRPE = 3-4). A substantial reduction in MAP (9%) and HR (30%) were observed. In conclusion, RobUST-intervention might be effective in ambulatory SCI.
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Syed MUS, Khan Z, Zulfiqar A, Basham MA, Abdul Haseeb H, Azizullah S, Ismail H, Elbahnasawy M, Nadeem Z, Karimi S. Electrocardiographic Abnormalities in Patients With Spinal Cord Injury With Deranged Lipid Profile. Cureus 2021; 13:e18246. [PMID: 34722039 PMCID: PMC8544921 DOI: 10.7759/cureus.18246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2021] [Indexed: 11/05/2022] Open
Abstract
Introduction Spinal cord injury (SCI) can lead to severe disability and neurogenic shock, arrhythmias, autonomic dysfunction, pressure ulcers, etc., of the autonomic nervous system. Therefore, in these patients, cardiovascular problems should be investigated frequently. This study was conducted to evaluate the electrocardiographic (ECG) abnormalities in patients with spinal cord injury having inappropriate lipid profiles and their relationship with each other. Materials and methods This cross-sectional study was held in the Internal Medicine Department of Mayo Hospital, Lahore, for a one-year duration from May 2020 to May 2021. It included 58 patients with spinal cord injury, 35 of whom had paraplegia, and 23 had tetraplegia. Fasting blood samples were taken for lipid profile analysis. Twelve-lead ECGs three times a day for one month were taken and analyzed in the context of previously available ECGs. Results Out of 58, the lipid profiles were found abnormal in 47 patients, 18 of whom had a normal ECG. The lipid profile was normal in 12, of which only one patient had ECG abnormalities. Cholesterol levels were found normal in 39 patients and deranged in 19 patients; low-density lipoproteins in nine patients, triglycerides in 18 patients, and high-density lipoprotein values in one patient were abnormal. Conclusions Sinus bradycardia was the most common ECG abnormality found in SCI patients with deranged lipid profiles. Further studies are needed in the future to validate the findings of this study.
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Affiliation(s)
| | - Zunaira Khan
- Accident and Emergency, Kingston Hospital, London, GBR
| | - Arif Zulfiqar
- Internal Medicine, Dow Medical College, Karachi, PAK
| | | | | | - Saad Azizullah
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
| | - Hebatalla Ismail
- Medicine and Surgery, Royal College of Surgeons in Ireland, Dublin, IRL
| | - Mohammad Elbahnasawy
- Internal Medicine, Alexandria Faculty of Medicine, Alexandria University, Alexandria, EGY
| | - Zubia Nadeem
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
| | - Sundas Karimi
- Orthopedic Surgery, Dow University of Health Sciences, Karachi, PAK
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Fahey M, Brazg G, Henderson CE, Plawecki A, Lucas E, Reisman DS, Schmit BD, Hornby TG. The Value of High Intensity Locomotor Training Applied to Patients With Acute-Onset Neurologic Injury. Arch Phys Med Rehabil 2020; 103:S178-S188. [PMID: 33383032 DOI: 10.1016/j.apmr.2020.09.399] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 08/31/2020] [Accepted: 09/17/2020] [Indexed: 11/02/2022]
Abstract
Long-standing research in animal models and humans with stroke or incomplete spinal cord injury (iSCI) indicate that specific physical training variables, such as the specificity and amount of practice, may influence neurologic recovery and locomotor function. More recent data highlight the contributions of exercise intensity, as estimated indirectly by cardiovascular exertion, as potentially more important than previously considered. The effects of exercise intensity are well described in neurologically intact individuals, although confusion regarding the definitions of intensity and safety concerns have limited its implementation during physical rehabilitation of patients with neurologic injury. The purpose of this review is to delineate some of the evidence regarding the effects of exercise intensity during locomotor training in patients with stroke and iSCI. We provide specific definitions of exercise intensity used within the literature, describe methods used to ensure appropriate levels of exertion, and discuss potential adverse events and safety concerns during its application. Further details on the effects of locomotor training intensity on clinical outcomes, and on neuromuscular and cardiovascular function will be addressed as available. Existing literature across multiple studies and meta-analyses reveals that exercise training intensity is likely a major factor that can influence locomotor function after neurologic injury. To extend these findings, we describe previous attempts to implement moderate to high intensity interventions during physical rehabilitation of patients with neurologic injury, including the utility of specific strategies to facilitate implementation, and to navigate potential barriers that may arise during implementation efforts.
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Affiliation(s)
- Meghan Fahey
- Rehabilitation Institute of Chicago, Chicago, IL
| | | | - Christopher E Henderson
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis, IN; Rehabilitation Hospital of Indiana, Indianapolis, IN
| | | | - Emily Lucas
- Rehabilitation Hospital of Indiana, Indianapolis, IN
| | - Darcy S Reisman
- Department of Physical Therapy, University of Delaware, Newark, DE
| | - Brian D Schmit
- Department of Biomedical Engineering, Marquette University, Milwaukee, WI
| | - T George Hornby
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis, IN; Rehabilitation Hospital of Indiana, Indianapolis, IN.
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