Training to achieve over ground walking after spinal cord injury: a review of who, what, when, and how

Effects of Anodal Transcranial Direct Current Stimulation With Overground Gait Training on Lower Limb Performance in Individuals With Incomplete Spinal Cord Injury

OBJECTIVE

To determine the effects of anodal transcranial direct current stimulation (tDCS) combined with overground gait training on gait performance, dynamic balance, sit-to-stand performance, and quality of life in individuals with incomplete spinal cord injuries (iSCI).

DESIGN

Double-blind sham-controlled trial with a matched-pair design.

SETTING

Sirindhorn National Medical Rehabilitation Institute, Thailand.

PARTICIPANTS

Individuals with iSCI (n=34) were allocated to the anodal or sham groups.

INTERVENTION

Anodal tDCS was administered over the M1 lower-limb motor area at an intensity of 2 mA for 20 min in the anodal group, while the sham group received a 30-s stimulation. Both groups received 40 min of overground gait training after tDCS for 5 consecutive daily sessions.

MAIN OUTCOME MEASURES

The 10-meter walk test (10MWT) was the primary outcome, while spatiotemporal gait parameters, the timed Up and Go test, Five-Time Sit-to-Stand Test, and World Health Organization Quality of Life-BREF were secondary outcomes. Outcomes were assessed at baseline, post-intervention, and at 1-month (1M) and 2-month (2M) follow-ups.

RESULT

Improvements in walking speed measured using the 10MWT were observed in both groups. However, the anodal group showed a greater improvement than the sham group. For fast speed, the mean between-group differences were 0.10 m/s, 95% CI (0.02 to 0.17) (post-intervention), 0.11 m/s, (0.03 to 0.19) (1M), and 0.11 m/s, (0.03 to 0.20) (2M), while for self-selected speed, the median differences were 0.10 m/s, 95% CI (0.06 to 0.14) (post-intervention) and 0.09 m/s, (0.01 to 0.19) (2M). The anodal group also had a greater stride length difference post-intervention (median difference: 0.07 m, 95% CI (0.01 to 0.14)). No significant between-group differences were found for other outcomes.

CONCLUSION

Five-session of anodal tDCS with gait training slightly improved walking speed, sustained for 2 months post-intervention. However, effect on spatiotemporal gait parameters was limited and dynamic balance, functional tasks (ie, sit-to-stand), and quality of life were unaffected compared with overground gait training.

Electrical stimulation of the cuneiform nucleus enhances the effects of rehabilitative training on locomotor recovery after incomplete spinal cord injury

Most human spinal cord injuries are anatomically incomplete, leaving some fibers still connecting the brain with the sublesional spinal cord. Spared descending fibers of the brainstem motor control system can be activated by deep brain stimulation (DBS) of the cuneiform nucleus (CnF), a subnucleus of the mesencephalic locomotor region (MLR). The MLR is an evolutionarily highly conserved structure which initiates and controls locomotion in all vertebrates. Acute electrical stimulation experiments in female adult rats with incomplete spinal cord injury conducted in our lab showed that CnF-DBS was able to re-establish a high degree of locomotion five weeks after injury, even in animals with initially very severe functional deficits and white matter lesions up to 80-95%. Here, we analyzed whether CnF-DBS can be used to support medium-intensity locomotor training and long-term recovery in rats with large but incomplete spinal cord injuries. Rats underwent rehabilitative training sessions three times per week in an enriched environment, either with or without CnF-DBS supported hindlimb stepping. After 4 weeks, animals that trained under CnF-DBS showed a higher level of locomotor performance than rats that trained comparable distances under non-stimulated conditions. The MLR does not project to the spinal cord directly; one of its main output targets is the gigantocellular reticular nucleus in the medulla oblongata. Long-term electrical stimulation of spared reticulospinal fibers after incomplete spinal cord injury via the CnF could enhance reticulospinal anatomical rearrangement and in this way lead to persistent improvement of motor function. By analyzing the spared, BDA-labeled giganto-spinal fibers we found that their gray matter arborization density after discontinuation of CnF-DBS enhanced training was lower in the lumbar L2 and L5 spinal cord in stimulated as compared to unstimulated animals, suggesting improved pruning with stimulation-enhanced training. An on-going clinical study in chronic paraplegic patients investigates the effects of CnF-DBS on locomotor capacity.

Predicting inpatient rehabilitation length of stay for adults with traumatic spinal cord injury

INTRODUCTION

Most post-injury traumatic spinal cord injury (TSCI) care occurs in the inpatient rehabilitation setting. The inpatient rehabilitation length of stay (R-LOS) has been shown to be a significant predictor of motor function restoration in persons with TSCI. Due to the complexity, and heterogeneity of individuals with TSCI, the R-LOS is challenging to predict at admission.

PURPOSE

To identify the main predictors of R-LOS and derive an equation to estimate R-LOS in persons with TSCI.

METHODS

This is a retrospective analysis of data from adults with TSCI from The Rick Hansen Spinal Cord Injury Registry in Alberta, Canada, who received rehabilitation care between May 10, 2005, and January 28, 2020. Multiple linear regression analysis was used to determine significant relationships between R-LOS and measures of participant demographics, length of stay, impairment and injury classification, and comorbidities.

RESULTS

The analysis included 736 adults with TSCI from an eligible cohort of 1365. The median R-LOS was 65 days (IQR 39-99 days), ranging from 1 to 469 days. Multivariate linear regression analysis identified two significant predictors of R-LOS, total FIM score and the injury classification. This model was used to derive a R-LOS prediction equation, which explained 34% of the variance in R-LOS.

CONCLUSION

We developed a simple equation to predict R-LOS based on the level of impairment and total FIM scores in persons with TSCI. These data have implications for health system planning, improvement, and innovation, and provide insights to support further research into the predictors of R-LOS, identification of higher-risk individuals.

Transcutaneous spinal cord stimulation combined with locomotor training to improve walking ability in people with chronic spinal cord injury: study protocol for an international multi-centred double-blinded randomised sham-controlled trial (eWALK)

STUDY DESIGN

An international multi-centred, double-blinded, randomised sham-controlled trial (eWALK).

OBJECTIVE

To determine the effect of 12 weeks of transcutaneous spinal stimulation (TSS) combined with locomotor training on walking ability in people with spinal cord injury (SCI).

SETTING

Dedicated SCI research centres in Australia, Spain, USA and Scotland.

METHODS

Fifty community-dwelling individuals with chronic SCI will be recruited. Participants will be eligible if they have bilateral motor levels between T1 and T11, a reproducible lower limb muscle contraction in at least one muscle group, and a Walking Index for SCI II (WISCI II) between 1 and 6. Eligible participants will be randomised to one of two groups, either the active stimulation group or the sham stimulation group. Participants allocated to the stimulation group will receive TSS combined with locomotor training for three 30-min sessions a week for 12 weeks. The locomotor sessions will include walking on a treadmill and overground. Participants allocated to the sham stimulation group will receive the same locomotor training combined with sham stimulation. The primary outcome will be walking ability with stimulation using the WISCI II. Secondary outcomes will record sensation, strength, spasticity, bowel function and quality of life.

TRIAL REGISTRATION

ANZCTR.org.au identifier ACTRN12620001241921.

Stimulation of the cuneiform nucleus enables training and boosts recovery after spinal cord injury

Severe spinal cord injuries result in permanent paraparesis in spite of the frequent sparing of small portions of white matter. Spared fibre tracts are often incapable of maintaining and modulating the activity of lower spinal motor centres. Effects of rehabilitative training thus remain limited.

Here, we activated spared descending brainstem fibres by electrical deep brain stimulation of the cuneiform nucleus of the mesencephalic locomotor region, the main control centre for locomotion in the brainstem, in adult female Lewis rats.

We show that deep brain stimulation of the cuneiform nucleus enhances the weak remaining motor drive in highly paraparetic rats with severe, incomplete spinal cord injuries and enables high-intensity locomotor training. Stimulation of the cuneiform nucleus during rehabilitative aquatraining after subchronic (n = 8 stimulated versus n = 7 unstimulated versus n = 7 untrained rats) and chronic (n = 14 stimulated versus n = 9 unstimulated versus n = 9 untrained rats) spinal cord injury re-established substantial locomotion and improved long-term recovery of motor function. We additionally identified a safety window of stimulation parameters ensuring context-specific locomotor control in intact rats (n = 18) and illustrate the importance of timing of treatment initiation after spinal cord injury (n = 14).

This study highlights stimulation of the cuneiform nucleus as a highly promising therapeutic strategy to enhance motor recovery after subchronic and chronic incomplete spinal cord injury with direct clinical applicability.

Effect of Age at Injury on Walking Ability Following Incomplete Cervical Spinal Cord Injury: A Retrospective Cohort Study

Introduction

Recently, the cases of elderly individuals with spinal cord injuries are increasing in Japan. For individuals with spinal cord injury, regaining the ability to walk independently after an injury is one of the most important aspects of rehabilitation. Nevertheless, instead of age-optimized programs, uniform rehabilitation programs are currently provided to all patients because there is no information available for predicting prognosis based on age at the time of injury. This study aimed to elucidate the effect of age at the time of injury on the walking ability of patients with incomplete cervical spinal cord injury.

Methods

Of the 1,195 patients registered in the Japan single-center study for spinal cord injury database, those hospitalized within 28 days after injury, followed up for >180 days, had a cervical spinal cord injury, and had a lower extremity motor score of ≥42 points were examined. Patients were stratified into three groups according to the age at the time of injury (≤59, 60-69, or ≥70 years). The walking ability scores and independence levels of mobility were compared; these data were evaluated based on indoor mobility (item 12) and outdoor mobility (item 14) in the Spinal Cord Independence Measure III and Walking Index for Spinal Cord Injury II. All comparisons used data at discharge.

Results

The walking ability scores and independence levels of mobility were significantly lower in the group aged ≥70 years than those in the remaining two groups.

Conclusions

In patients with cervical spinal cord injuries with the same limb function, if the age at the time of injury was ≥70 years, the decline in physical function due to aging exerted a substantial effect on walking ability.

Spinal cord bioelectronic interfaces: opportunities in neural recording and clinical challenges

Bioelectronic stimulation of the spinal cord has demonstrated significant progress in restoration of motor function in spinal cord injury (SCI). The proximal, uninjured spinal cord presents a viable target for the recording and generation of control signals to drive targeted stimulation. Signals have been directly recorded from the spinal cord in behaving animals and correlated with limb kinematics. Advances in flexible materials, electrode impedance and signal analysis will allow SCR to be used in next-generation neuroprosthetics. In this review, we summarize the technological advances enabling progress in SCR and describe systematically the clinical challenges facing spinal cord bioelectronic interfaces and potential solutions, from device manufacture, surgical implantation to chronic effects of foreign body reaction and stress-strain mismatches between electrodes and neural tissue. Finally, we establish our vision of bi-directional closed-loop spinal cord bioelectronic bypass interfaces that enable the communication of disrupted sensory signals and restoration of motor function in SCI.

The effects of lower extremity deep sensory impairments on walking capability in patients with incomplete cervical spinal cord injury

Objective: To analyze the impact of lower extremity deep sensory impairment on the walking capability of patients with incomplete cervical spinal cord injury.Design: Retrospective cohort study.Setting: Spinal Injuries Center, Fukuoka, Japan.Participants: Patients with incomplete cervical spinal cord injury who were transferred to the Spinal Injuries Center within 2 weeks of injury and whose progress was monitored for 6 months postinjury were included. Sixty-three patients with a lower extremity motor score of 42 points or more were enrolled. They were divided into lower extremity deep sensory impairment (16 patients) and normal (47 patients) groups, and their walking capability was compared.Interventions: Not applicable.Outcome Measures: Upper and lower extremity motor scores, the presence or absence of deep sensation impairment, and walking capability indices at 6 months postinjury were evaluated.Results: The deep sensory impairment group performed significantly worse than the normal group across items in the Walking Index for Spinal Cord Injury II and in the indoor and outdoor mobility items of the Spinal Cord Independence Measure III. Indoor and outdoor mobility independence levels decreased further in the lower extremity deep sensory impairment group than in the normal group.Conclusions: The presence of lower extremity deep sensation impairments was an important factor affecting the achievement of independent walking capabilities in patients with incomplete cervical spinal cord injury. Hence, when patients with incomplete cervical spinal cord injury undergo walking training, not only their lower extremity muscle strength but also their level of deep sensation impairment must be evaluated.

Neurorehabilitation using a voluntary driven exoskeletal robot improves trunk function in patients with chronic spinal cord injury: a single-arm study

Body weight-supported treadmill training with the voluntary driven exoskeleton (VDE-BWSTT) has been shown to improve the gait function of patients with chronic spinal cord injury. However, little is known whether VDE-BWSTT can effectively improve the trunk function of patients with chronic spinal cord injury. In this open-label, single-arm study, nine patients with chronic spinal cord injury at the cervical or thoracic level (six males and three females, aged 37.8 ± 15.6 years, and time since injury 51.1 ± 31.8 months) who underwent outpatient VDE-BWSTT training program at Keio University Hospital, Japan from September 2017 to March 2019 were included. All patients underwent twenty 60-minute gait training sessions using VDE. Trunk muscular strength, i.e., the maximum force against which patient could maintain a sitting posture without any support, was evaluated in four directions: anterior, posterior, and lateral (right and left) after 10 and 20 training sessions. After intervention, lateral muscular strength significantly improved. In addition, a significant positive correlation was detected between the change in lateral trunk muscular strength after 20 training sessions relative to baseline and gait speed. The change in trunk muscular strength after 20 training sessions relative to baseline was greatly correlated with patient age. This suggests that older adult patients with chronic spinal cord injury achieved a greater improvement in trunk muscle strength following VDE-BWSTT. All these findings suggest that VDE-BWSTT can improve the trunk function of patients with chronic spinal cord injury and the effect might be greater in older adult patients. The study was approved by the Keio University of Medicine Ethics Committee (IRB No. 20150355-3) on September 26, 2017.

When Spinal Neuromodulation Meets Sensorimotor Rehabilitation: Lessons Learned From Animal Models to Regain Manual Dexterity After a Spinal Cord Injury

Electrical neuromodulation has strongly hit the foundations of spinal cord injury and repair. Clinical and experimental studies have demonstrated the ability to neuromodulate and engage spinal cord circuits to recover volitional motor functions lost after the injury. Although the science and technology behind electrical neuromodulation has attracted much of the attention, it cannot be obviated that electrical stimulation must be applied concomitantly to sensorimotor rehabilitation, and one would be very difficult to understand without the other, as both need to be finely tuned to efficiently execute movements. The present review explores the difficulties faced by experimental and clinical neuroscientists when attempting to neuromodulate and rehabilitate manual dexterity in spinal cord injured subjects. From a translational point of view, we will describe the major rehabilitation interventions employed in animal research to promote recovery of forelimb motor function. On the other hand, we will outline some of the state-of-the-art findings when applying electrical neuromodulation to the spinal cord in animal models and human patients, highlighting how evidences from lumbar stimulation are paving the path to cervical neuromodulation.

Locomotion Synchronization and Gait Performance While Walking With an Overground Body Weight Support System

Rehabilitation robotics offers new alternatives to patients and therapists to efficiently support walking training using Body Weight Support (BWS) systems. Automating the locomotion of overground BWS systems is one of the feasible approaches to free therapists from manual operation. However, the effect of locomotion control strategies of BWS system on participant's gait performance have not been studied sufficiently. For this reason, in this paper we introduced locomotion synchronization between a participant, a therapist, and a BWS system as control criteria, and investigated its effect on participant's gait performance during walking with an overground BWS system. In the experiment, four healthy participants walked with a BWS system under different BWS conditions, and with/without wearing orthosis which simulates asymmetric gait of actual patients. As the result, it was observed a significant relationship between locomotion synchronization and participants' gait performance, such as walking speed and step time.Clinical relevance - Controlling an overground BWS system's locomotion in synchronizing with the participant's gait has the potential to facilitate the effect of gait rehabilitation.

A qualitative interview study on how people with incomplete spinal cord injury experience high-intensity walking exercise

STUDY DESIGN

Qualitative, in-depth research interviews.

OBJECTIVE

To provide new insight into how people with a recent incomplete spinal cord injury (SCI) experience high-intensity walking exercise after discharge from subacute inpatient rehabilitation.

SETTING

Informants for this interview study participated in a previous randomized controlled trial (RCT) that was conducted at Sunnaas Rehabilitation Hospital, Norway.

METHODS

Four individual face-to-face interviews were conducted with the participants in natural setting. The interviews were analyzed through systematic text condensation and discussed in the context of experiences of bodily changes.

RESULTS

Four themes emerged that described positive but also challenging bodily experiences related to performing high-intensity walking exercise: "Expectations and motivation"-reasons for participating, "Challenging bodily changes"-impacts on walking ability, "Adaptation strategies"-achieving the high-intensity target level, and "Integrating exercise into a new daily life"-combining participation, new body and new life.

CONCLUSIONS

This study indicates the importance of participating in a specific exercise program at discharge from subacute inpatient rehabilitation for ambulant people with SCI. However, high-intensity walking exercise may be too demanding to perform during this time period. The insights from the study provide new knowledge that can contribute to improving clinical rehabilitation practice.

Motorized Treadmill and Optical Recording System for Gait Analysis of Grasshoppers

(1) Background: Insects, which serve as model systems for many disciplines with their unique advantages, have not been extensively studied in gait research because of the lack of appropriate tools and insect models to properly study the insect gaits. (2) Methods: In this study, we present a gait analysis of grasshoppers with a closed-loop custom-designed motorized insect treadmill with an optical recording system for quantitative gait analysis. We used the eastern lubber grasshopper, a flightless and large-bodied species, as our insect model. Gait kinematics were recorded and analyzed by making three grasshoppers walk on the treadmill with various speeds from 0.1 to 1.5 m/s. (3) Results: Stance duty factor was measured as 70–95% and decreased as walking speed increased. As the walking speed increased, the number of contact legs decreased, and diagonal arrangement of contact was observed at walking speed of 1.1 cm/s. (4) Conclusions: This pilot study of gait analysis of grasshoppers using the custom-designed motorized insect treadmill with the optical recording system demonstrates the feasibility of quantitative, repeatable, and real-time insect gait analysis.

The Effect of Perturbation-Based Balance Training and Conventional Intensive Balance Training on Reactive Stepping Ability in Individuals With Incomplete Spinal Cord Injury or Disease: A Randomized Clinical Trial

Introduction: Impaired balance leads to falls in individuals with motor incomplete spinal cord injury or disease (iSCI/D). Reactive stepping is a strategy used to prevent falls and Perturbation-based Balance Training (PBT) can improve this ability.

Objective: The objective of this study was to determine if PBT results in greater improvements in reactive stepping ability than frequency-matched Conventional Intensive Balance Training (CIBT) in adults with iSCI/D.

Design: Randomized clinical trial.

Setting: Tertiary SCI/D rehabilitation center.

Participants: Twenty-one adults with chronic (>1 year) iSCI/D were randomized. Due to one drop out 20 participants completed the study.

Methods: Participants were randomly allocated to complete either PBT or CIBT three times per week for 8 weeks. Both programs included challenging static and dynamic balance tasks, but the PBT group also experienced manual external balance perturbations.

Main Outcome Measures: Assessments of reactive stepping ability using the Lean-and-Release test were completed at baseline, and after 4 and 8 weeks of training, and 3 and 6 months after training completion. A blinded assessor evaluated secondary outcomes.

Results: Twenty-five participants were screened and 21 consented; one withdrew. Ten PBT and 10 CIBT participants were included in analyses. Across all participants there were improvements in reactive stepping ability (p = 0.049), with retention of improvements at follow up assessments. There were no differences in reactive stepping ability between groups [median (interquartile range): PBT 0.08 (0.68); CIBT 0.00 (0.22)]. One participant in the PBT group experienced a non-injurious fall during training.

Conclusions: Balance training is beneficial for individuals with iSCI/D, but the addition of manual perturbations (i.e., PBT) did not prove advantageous for performance on a measure of reactive stepping ability.

Clinical Trial Registration:www.ClinicalTrials.gov, identifier: NCT02960178.

Self-directed rehabilitation training intensity thresholds for efficient recovery of skilled forelimb function in rats with cervical spinal cord injury

Task specific rehabilitation training is commonly used to treat motor dysfunction after neurological injures such as spinal cord injury (SCI), yet the use of task specific training in preclinical animal studies of SCI is not common. This is due in part to the difficulty in training animals to perform specific motor tasks, but also due to the lack of knowledge about optimal rehabilitation training parameters to maximize recovery. The single pellet reaching, grasping and retrieval (SPRGR) task (a.k.a. single pellet reaching task or Whishaw task) is a skilled forelimb motor task used to provide rehabilitation training and test motor recovery in rodents with cervical SCI. However, the relationships between the amount, duration, intensity, and timing of training remain poorly understood. In this study, using automated robots that allow rats with cervical SCI ad libitum access to self-directed SPRGR rehabilitation training, we show clear relationships between the total amount of rehabilitation training, the intensity of training (i.e., number of attempts/h), and performance in the task. Specifically, we found that rats naturally segregate into High and Low performance groups based on training strategy and performance in the task. Analysis of the different training strategies showed that more training (i.e., increased number of attempts in the SPRGR task throughout rehabilitation training) at higher intensities (i.e., number of attempts per hour) increased performance in the task, and that improved performance in the SPRGR task was linked to differences in corticospinal tract axon collateral densities in the injured spinal cords. Importantly, however, our data also indicate that rehabilitation training becomes progressively less efficient (i.e., less recovery for each attempt) as both the amount and intensity of rehabilitation training increases. Finally, we found that Low performing animals could increase their training intensity and transition to High performing animals in chronic SCI. These results highlight the rehabilitation training strategies that are most effective to regain skilled forelimb motor function after SCI, which will facilitate pre-clinical rehabilitation studies using animal models and could be beneficial in the development of more efficient clinical rehabilitation training strategies.

The effects of walking training onset on motor evoked potentials after acute spinal cord injury

AIM

The purposes of this study were to explore the optimal time for starting walking training in the first month after spinal cord injury (SCI) in rats and to discuss the relationship between changes in motor function and transcranial electrical motor evoked potentials (tceMEPs).

METHODS

Four groups of rats with SCI (BSWTT-3, 7, 14, 12) performed body-weight-supported treadmill training (BWSTT) for three weeks beginning at 3, 7, 14, and 21 days after SCI, respectively. The Basso, Beattie, and Bresnahan (BBB) score and tceMEPs were assessed weekly. Weekly repeated measures and multiple comparisons between groups were performed to identify differences in motor function and tceMEPs. Correlation analysis was performed to clarify the relationship between BBB scores and tceMEPs over time.

RESULTS

Although there was no significant difference between the BWSTT-14 group and the other three BWSTT groups at the end of the experiment in terms of BBB scores and the latency of tceMEPs, the BWSTT-14 group obtained the best trends in improvement of BBB scores and the latencies and amplitudes of tceMEPs over time. The BBB scores of rats with SCI were strongly negatively correlated with tceMEPs latency. The BBB scores of rats with SCI, except for the rats in the BWSTT-3 group, were strongly positively correlated with the tceMEPs amplitude.

CONCLUSIONS

The preliminary conclusion was that based on a rat model, 14 days after SCI was the optimal time for starting BWSTT. tceMEPs were an objective indicator of spinal cord nerve function, which was strongly correlated with motor function recovery. However, one limitation of this study was that the rats in the Sham group did not undergo BWSTT, which made the training itself a confounding factor for the results.

Novel innovations in cell and gene therapies for spinal cord injury

Spinal cord injury (SCI) leads to chronic and multifaceted disability, which severely impacts the physical and mental health as well as the socio-economic status of affected individuals. Permanent disabilities following SCI result from the failure of injured neurons to regenerate and rebuild functional connections with their original targets. Inhibitory factors present in the SCI microenvironment and the poor intrinsic regenerative capacity of adult spinal cord neurons are obstacles for regeneration and functional recovery. Considerable progress has been made in recent years in developing cell and molecular approaches to enable the regeneration of damaged spinal cord tissue. In this review, we highlight several potent cell-based approaches and genetic manipulation strategies (gene therapy) that are being investigated to reconstruct damaged or lost spinal neural circuits and explore emerging novel combinatorial approaches for enhancing recovery from SCI.

Exoskeletal-Assisted Walking During Acute Inpatient Rehabilitation Leads to Motor and Functional Improvement in Persons With Spinal Cord Injury: A Pilot Study

OBJECTIVE

To explore the potential effects of incorporating exoskeletal-assisted walking (EAW) into spinal cord injury (SCI) acute inpatient rehabilitation (AIR) on facilitating functional and motor recovery when compared with standard of care AIR.

DESIGN

A quasi-experimental design with a prospective intervention group (AIR with EAW) and a retrospective control group (AIR only).

SETTING

SCI AIR facility.

PARTICIPANTS

Ten acute inpatient participants with SCI who were eligible for locomotor training were recruited in the intervention group. Twenty inpatients with SCI were identified as matched controls by reviewing an AIR database, Uniform Data System for Medical Rehabilitation, by an individual blinded to the study. Both groups (N=30) were matched based on etiology, paraplegia/tetraplegia, completeness of injury, age, and sex.

INTERVENTION

EAW incorporated into SCI AIR.

MAIN OUTCOME MEASURES

FIM score, International Standards for Neurological Classification of Spinal Cord Injury Upper Extremity Motor Score and Lower Extremity Motor Scores (LEMS), and EAW session results, including adverse events, walking time, and steps.

RESULTS

Changes from admission to discharge LEMS and FIM scores were significantly greater in the intervention group (LEMS change: 14.3±10.1; FIM change: 37.8±10.8) compared with the control group (LEMS change: 4.6±6.1; FIM change: 26.5±14.3; Mann-Whitney U tests: LEMS, P<.01 and FIM, P<.05). One adverse event (minor skin abrasion) occurred during 42 walking sessions. Participants on average achieved 31.5 minutes of up time and 18.2 minutes of walk time with 456 steps in one EAW session.

CONCLUSIONS

Incorporation of EAW into standard of care AIR is possible. AIR with incorporated EAW has the potential to facilitate functional and motor recovery compared with AIR without EAW.

Development of Walking indicators to advance the quality of spinal cord injury rehabilitation: SCI-High Project

Objective: To describe the development of structure, process and outcome indicators that will advance the quality of walking rehabilitation for Canadians with spinal cord injury or disease (SCI/D) by 2020. Method: A framework for the evaluation of the quality of walking rehabilitation was developed by experts in walking after SCI/D. A systematic literature review identified factors influencing walking outcomes and potential walking indicators. A Driver diagram analysis summarized the factors affecting walking outcomes and subsequently informed the selection of structure and process indicators. Psychometric properties and clinical utility of potential walking indicators were considered during the selection of outcome indicators. Results: The structure indicator is the number of physical therapists using evidence-based walking interventions per number of ambulatory individuals with SCI/D. The process indicator is the number of received hours of walking interventions during inpatient rehabilitation per number of ambulatory individuals with SCI/D. The intermediary outcome indicator, which is collected at discharge from inpatient rehabilitation, is either the modified Timed Up and Go or the 10-Meter Walk Test, the choice of measure is dictated by the stage of walking recovery, as defined by the Standing and Walking Assessment Tool. The final outcome indicator, collected at 18 months post-discharge, is the Spinal Cord Independence Measure III-Mobility subscale. Conclusion: The selected indicators align with current clinical practice in Canada. The indicators will direct the timing and enhance the volume of walking therapy delivered, to ultimately increase the proportion of patients who achieve their walking potential by 18 months post-rehabilitation.

The effects of locomotor training in children with spinal cord injury: a systematic review

PURPOSE

Discuss the effectiveness of locomotor training (LT) in children following spinal cord injury (SCI). This intervention was assessed following an exhaustive search of the literature using the Preferred Reporting Items for Systematic Reviews and Meta- Analyses: The PRISMA Statement as a guideline.

METHOD

Six databases were searched including PubMed, PEDro, CINAHL, Cochrane, PsycINFO, and Web of Knowledge in January 2016 and November 2016, without date restrictions. Inclusion criteria were: studies in English and peer-reviewed and journal articles with a primary intervention of LT in children following SCI.

RESULTS

Twelve articles, reporting eleven studies, were included. A systematic review assessing locomotor training in children with SCI published in April 2016 was also included. Participants were ages 15 months to 18 years old. Forms of LT included body-weight supported treadmill or over ground training, functional electrical stimulation, robotics, and virtual reality. Protocols differed in set-up and delivery mode, with improvements seen in ambulation for all 41 participants following LT.

CONCLUSION

Children might benefit from LT to develop or restore ambulation following SCI. Age, completeness, and level of injury remain the most important prognostic factors to consider with this intervention. Additional benefits include improved bowel/ bladder management and control, bone density, cardiovascular endurance, and overall quality of life. Looking beyond the effects LT has just on ambulation is crucial because it can offer benefits to all children sustaining a SCI, even if restoration or development of walking is not the primary goal. Further rigorous research is required to determine the overall effectiveness of LT.

Motor Adaptation to Weight Shifting Assistance Transfers to Overground Walking in People with Spinal Cord Injury

BACKGROUND

Locomotor training has been used to improve walking function in people with incomplete spinal cord injury (iSCI), but functional gains are relatively small for some patients, which may be due to the lack of weight shifting training.

OBJECTIVE

To determine whether applying a pelvis assistance force in the coronal plane during walking would improve weight shifting and stepping in people with iSCI.

DESIGN

Repeated measures study.

SETTING

Rehabilitation hospital.

PARTICIPANTS

Seventeen people with iSCI.

INTERVENTIONS

A controlled assistance force was bilaterally applied to the pelvis in the medial-lateral direction to facilitate weight shifting, which gradually increased during the course of treadmill walking.

MAIN OUTCOME MEASURES

Weight shifting, step length, margin of stability, and muscle activities of the weaker leg were used to quantify gait performance. The spatial-temporal gait parameters during overground walking were collected pre, post, and 10 minutes after treadmill training.

RESULTS

During treadmill walking, participants significantly improved weight shifting (ie, center of mass [CoM] lateral distance reduced from 0.16 ± 0.06 m to 0.12 ± 0.07 m, P = .012), and increased step length (from 0.35 ± 0.08 m to 0.37 ± 0.09 m, P = .037) on the stronger side when the force was applied, which were partially retained (ie, CoM distance was 0.14 ± 0.06, P = .019, and step length was 0.37 ± 0.09 m, P = .005) during the late postadaptation period when the force was removed. In addition, weight shifting and step length on the weaker side during overground walking also improved (support base reduced from 0.13 ± 0.06 m to 0.12 ± 0.06 m, P = .042, and step length increased from 0.48 ± 0.12 m to 0.51 ± 0.09 m, P = .045) after treadmill training.

CONCLUSIONS

Applying pelvis assistance during treadmill walking may facilitate weight shifting and improve step length in people with SCI, which may partially transfer to overground walking.

LEVEL OF EVIDENCE

III.

Intensive Balance Training for Adults With Incomplete Spinal Cord Injuries: Protocol for an Assessor-Blinded Randomized Clinical Trial

BACKGROUND

Impaired reactive balance control can lead to increased falls in people with neurological impairments. Perturbation-based balance training (PBT), which involves repetitive exposure to destabilizing external perturbations, improves the ability to take reactive steps in older adults and individuals who have had a stroke.

OBJECTIVE

The objective is to investigate whether PBT or conventional intensive balance training (CIBT) results in greater improvements in reactive stepping ability in individuals with chronic incomplete spinal cord injury (iSCI).

DESIGN

The design consists of an assessor-blind randomized clinical trial comparing the efficacy of 2 balance training programs (PBT and CIBT) matched for training duration (thrice weekly for 8 weeks).

SETTING

A tertiary spinal cord injury rehabilitation center is used as the setting.

PARTICIPANTS

Participants include 24 adults with iSCI classified as a C or D on the American Spinal Association Impairment Scale, who are able to stand independently and exhibit moderate trunk control.

INTERVENTION

Both PBT and CIBT involve 24 sessions, each 1 hour long, of individualized static and dynamic balance tasks. However, PBT includes external, unexpected balance perturbations provided manually by the trainer at a frequency of roughly 1 per training minute.

MEASUREMENTS

The primary outcome is the ability to recover balance using a single step during the Lean-and-Release test, a novel method of assessing reactive balance. Secondary outcomes include a number of clinical balance and gait assessments, and the number of falls experienced in a 6-month follow-up period. Semi-structured interviews are conducted 3 months after training completion to gain insight into the participants' perceptions of the impact of the interventions.

LIMITATIONS

A control group receiving "standard care" for balance training is not included.

CONCLUSIONS

This trial will provide physical therapists with insight into the efficacy of 2 forms of balance training for individuals with iSCI.

Test–retest reliability of the 10-meter walk test in ambulatory adults with motor-complete spinal cord injury

Background/Aims:

To verify the test retest reliability of 10-meter walk test for ambulatory adults with motor complete spinal cord injury.

Methods:

This study was conducted in the department of Physical Medicine and Rehabilitation, Christian Medical College, India. We studied 25 (22 males and 3 females) adults with lower thoracic level of spinal cord injury who were trained to walk with bilateral solid polypropylene knee ankle foot orthoses and elbow crutches. Their median age was 27 years and the median time since injury was 5.5 years. Participants underwent two trials of 10-meter walk test at their self-selected walking speed. They were tested for static and dynamic 10-meter walk test start methods separately.

Findings:

There was an excellent test retest reliability found in both the testing methods with the intra-class correlation coefficient of 0.99 (95% CI 0.98 to 0.99)] with a standard error of measure of 0.01. The minimum detectable change of static and dynamic start method was 0.02 sec and 0.03 seconds respectively. Bland Altman graphs showed excellent agreement between the trials. The comparison between static and dynamic testing methods showed that both the methods are highly comparable. (ICC 1 [95% CI 0.99–1]).

Conclusions:

The 10-meter walk test has excellent test retest reliability in assessing walking speed of ambulatory adults with complete spinal cord injury who use knee ankle foot orthoses for walking. Static and dynamic testing methods of the 10-meter walk test are comparable.

Movement augmentation to evaluate human control of locomotor stability

Controlling center of mass (COM) position and velocity within a dynamic base of support is essential for gait stability. This skill is often compromised following neurologic injury, creating a need to develop effective interventions to enhance gait stability. A movement augmentation paradigm applied to walking could potentially be used to improve control of COM dynamics. We have developed a cable robot system, the Agility Trainer, to apply continuous frontal-plane forces to the pelvis during treadmill walking. This cable robot system uses a set of series elastic actuators powered by linear motors to create bilateral forces. Here we use the Agility Trainer to create a negative viscosity force field proportional to the subject's lateral velocity. Two healthy young subjects performed two 10-minute walking trials, Baseline and Negative Viscosity. During the first minute of walking in the Negative Viscosity field, participants' lateral COM motion became less controlled when compared to the rhythmic sinusoidal motion observed during Baseline walking. By the 10th minute of walking in the Negative Viscosity field the participants had adapted their gait patterns, decreasing their variation in peak lateral COM speed each stride. These results demonstrate that it is feasible to use the Agility Trainer to apply a movement augmentation paradigm to human walking.

Fatigability during volitional walking in incomplete spinal cord injury: cardiorespiratory and motor performance considerations

Fatigability describes the decline in force production (i.e., performance fatigability) and/or changes in sensations regulating performance (i.e., perceived fatigability) during whole-body activity and poses a major challenge to those living with spinal cord injuries (SCI). After SCI, the inability to overcome disruptions to metabolic homeostasis due to cardiorespiratory limitations and physical deconditioning may contribute to increased fatigability severity. The increased susceptibility to fatigability may have implications for motor control strategies and motor learning. Locomotor training approaches designed to reduce fatigability and enhance aerobic capacity in combination with motor learning may be advantageous for promoting functional recovery after SCI. Future research is required to advance the understanding of the relationship between fatigability, cardiorespiratory function and motor performance following SCI.

Retraining walking adaptability following incomplete spinal cord injury

Introduction

Functional walking requires the ability to modify one’s gait pattern to environmental demands and task goals—gait adaptability. Following incomplete spinal cord injury (ISCI), gait rehabilitation such as locomotor training (Basic-LT) emphasizes intense, repetitive stepping practice. Rehabilitation approaches focusing on practice of gait adaptability tasks have not been established for individuals with ISCIs but may promote recovery of higher level walking skills. The primary purpose of this case series was to describe and determine the feasibility of administering a gait adaptability retraining approach—Adapt-LT—by comparing the dose and intensity of Adapt-LT to Basic-LT.

Case presentation

Three individuals with ISCIs (>1 year, AIS C or D) completed three weeks each (15 sessions) of Basic-LT and Adapt-LT. Interventions included practice on a treadmill with body weight support and practice overground (≥30 mins total). Adapt-LT focused on speed changes, obstacle negotiation, and backward walking. Training parameters (step counts, speeds, perceived exertion) were compared and outcomes assessed pre and post interventions. Based on completion of the protocol and similarities in training parameters in the two interventions, it was feasible to administer Adapt-LT with a similar dosage and intensity as Basic-LT. Additionally, the participants demonstrated gains in walking function and balance following each training type.

Discussion

Rehabilitation that includes stepping practice with adaptability tasks is feasible for individuals with ISCIs. Further investigation is needed to determine the efficacy of Adapt-LT.

Evaluating the efficacy of functional electrical stimulation therapy assisted walking after chronic motor incomplete spinal cord injury: effects on bone biomarkers and bone strength

OBJECTIVES

To determine the efficacy of functional electrical stimulation therapy assisted walking (FES-T) compared to a conventional aerobic and resistance training (CONV) with respect to bone biomarkers and lower extremity bone strength outcomes among adults with chronic motor incomplete spinal cord injury (SCI).

DESIGN

Parallel group randomized controlled trial ( www.clinicaltrials.gov - NCT0020196819). Site: Tertiary academic rehabilitation centre in Canada.

METHODS

Adults with chronic (≥18 months) motor incomplete SCI (C2-T12 AIS C-D) were consented and randomized to FES-T or CONV training for 45 minutes thrice-weekly for 4 months. Osteocalcin (OC), β-cross laps (CTX) and sclerostin were assessed at baseline, and 4 months. Similarly, total hip, distal femur and proximal tibia region bone mineral density (BMD) via DXA (4500A, Hologic Inc. Waltham, MA, USA) and tibia bone quality via pQCT (Stratec XCT-2000, Mezintecknik, Pforzheim, Germany) were assessed at baseline, 4, and 12 months. Between group differences were analyzed using repeated measures general linear models.

RESULTS

Thirty-four participants (17 FES-T, 17 CONV) consented and were randomized, 27 participants completed the 4-month intervention and 12-month outcome assessments. Participants in the FES-T arm had a decrease in CTX and a significant increase in OC at intervention completion (P<0.05). Significant biomarker changes were not observed in the CONV group. No within or between group differences from baseline were observed in sclerostin or bone strength.

CONCLUSIONS

Four months of FES-T improved bone turnover (increase in OC and decrease in CTX) but not bone strength among individuals with chronic SCI. Future, long term FES-T may augment lower extremity bone strength.

Results of the first interim analysis of the RAPPER II trial in patients with spinal cord injury: ambulation and functional exercise programs in the REX powered walking aid

BACKGROUND

The RAPPER II study investigates the feasibility, safety and acceptability of using the REX self-stabilising robotic exoskeleton in people with spinal cord injury (SCI) who are obligatory wheelchair users. Feasibility is assessed by the completion of transfer into the REX device, competency in achieving autonomous control and completion of upper body exercise in an upright position in the REX device. Safety is measured by the occurrence of serious adverse events. Device acceptability is assessed with a user questionnaire.

METHODS

RAPPER II is a prospective, multi-centre, open label, non-randomised, non-comparative cohort study in people with SCI recruited from neurological rehabilitation centres in the United Kingdom, Australia and New Zealand. This is the planned interim report of the first 20 participants. Each completed a transfer into the REX, were trained to achieve machine control and completed Timed Up and Go (TUG) tests as well as upper body exercises in standing in a single first time session. The time to achieve each task as well as the amount of assistance required was recorded. After finishing the trial tasks a User Experience questionnaire, exploring device acceptability, was completed.

RESULTS

All participants could transfer into the REX. The mean transfer time was 439 s. Nineteen completed the exercise regime. Eighteen could achieve autonomous control of the REX, 17 of whom needed either no assistance or the help of just one therapist. Eighteen participants completed at least one TUG test in a mean time of 313 s, 15 with the assistance of just one therapist. The questionnaire demonstrated high levels of acceptability amongst users. There were no Serious Adverse Events.

CONCLUSIONS

This first interim analysis of RAPPER II shows that it is feasible and safe for people with SCI to use the REX powered assisted walking device to ambulate and exercise in. Participants with tetraplegia and paraplegia could walk and perform a functional exercise program when standing needing only modest levels of assistance in most cases. User acceptability was high.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT02417532 . Registered 11 April 2015.

Longitudinal estimation of intramuscular Tibialis Anterior coherence during subacute spinal cord injury: relationship with neurophysiological, functional and clinical outcome measures

Background

Estimation of surface intramuscular coherence has been used to indirectly assess pyramidal tract activity following spinal cord injury (SCI), especially within the 15-30 Hz bandwidth. However, change in higher frequency (>40 Hz) muscle coherence during SCI has not been characterised. Thus, the objective of this study was to identify change of high and low frequency intramuscular Tibialis Anterior (TA) coherence during incomplete subacute SCI.

Methods

Fifteen healthy subjects and 22 subjects with motor incomplete SCI (American Spinal Injury Association Impairment Scale, AIS, C or D grade) were recruited and tested during 4 sessions performed at 2-week intervals up to 8 months after SCI. Intramuscular TA coherence estimation was calculated within the 10–60 Hz bandwidth during controlled maximal isometric and isokinetic foot dorsiflexion. Maximal voluntary dorsiflexion torque, gait function measured with the WISCI II scale, and TA motor evoked potentials (MEP) were recorded.

Results

During subacute SCI, significant improvement in total lower limb manual muscle score, TA muscle strength and gait function were observed. No change in TA MEP amplitude was identified. Significant increase in TA coherence was detected in the 40–60 Hz, but not the 15–30 Hz bandwidth. The spasticity syndrome was associated with lower 15-30 Hz TA coherence during maximal isometric dorsiflexion and higher 10–60 Hz coherence during fast isokinetic movement (p < 0.05).

Conclusions

Longitudinal estimation of neurophysiological and clinical measures during subacute SCI suggest that estimation of TA muscle coherence during controlled movement provides indirect information regarding adaptive and maladaptive motor control mechanisms during neurorehabilitation.

Control of locomotor stability in stabilizing and destabilizing environments

To develop effective interventions targeting locomotor stability, it is crucial to understand how people control and modify gait in response to changes in stabilization requirements. Our purpose was to examine how individuals with and without incomplete spinal cord injury (iSCI) control lateral stability in haptic walking environments that increase or decrease stabilization demands. We hypothesized that people would adapt to walking in a predictable, stabilizing viscous force field and unpredictable destabilizing force field by increasing and decreasing feedforward control of lateral stability, respectively. Adaptations in feedforward control were measured using after-effects when fields were removed. Both groups significantly (p<0.05) decreased step width in the stabilizing field. When the stabilizing field was removed, narrower steps persisted in both groups and subjects with iSCI significantly increased movement variability (p<0.05). The after-effect of walking in the stabilizing field was a suppression of ongoing general stabilization mechanisms. In the destabilizing field, subjects with iSCI took faster steps and increased lateral margins of stability (p<0.05). Step frequency increases persisted when the destabilizing field was removed (p<0.05), suggesting that subjects with iSCI made feedforward adaptions to increase control of lateral stability. In contrast, in the destabilizing field, non-impaired subjects increased movement variability (p<0.05) and did not change step width, step frequency, or lateral margin of stability (p>0.05). When the destabilizing field was removed, increases in movement variability persisted (p<0.05), suggesting that non-impaired subjects made feedforward decreases in resistance to perturbations.

Training to Improve Walking after Pediatric Spinal Cord Injury: A Systematic Review of Parameters and Walking Outcomes

Walking or locomotor training is often initiated following pediatric spinal cord injury (SCI). There is no synthesis of the literature on interventions targeting walking for pediatric SCI, although this would assist future clinical trials and interventions. To address this need, we completed a systematic review to summarize the who, what, when, and how of walking interventions in children with SCI. Participant characteristics, training parameters, and walking outcomes with training in pediatric SCI were identified and compared with training parameters and outcomes in adults with SCI. The PubMed, Medline, AMED, Embase, PsycInfo, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and CINAHL databases were searched for studies that included participants aged 1-17 years with a SCI acquired post-birth, physical interventions, and pre- and post-training walking measures. Two researchers evaluated each study's risk of bias using a domain-based approach. Training parameters and walking outcomes were extracted. Total training duration (duration × frequency × number of weeks) was calculated. Thirteen pediatric studies (n = 43 children) were included; all but one were case series/reports. Risk of bias was high in the pediatric studies. A 2012 adult review was updated (11 studies added). As with adults, the training durations, frequencies, and modes used with the children varied; however, overground walking practice was included in 10/13 pediatric studies. Improvements in walking capacity, speed, and distance were comparable between children and adults. There was a trend for greater gains with greater total training durations. There is a paucity of high-quality research examining interventions targeting walking after pediatric SCI; however, intensive training, including practice overground, results in notable improvements.

Robot-assisted gait training (Lokomat) improves walking function and activity in people with spinal cord injury: a systematic review

Abstract

Robot-assisted gait training (RAGT) after spinal cord injury (SCI) induces several different neurophysiological mechanisms to restore walking ability, including the activation of central pattern generators, task-specific stepping practice and massed exercise. However, there is no clear evidence for the optimal timing and efficacy of RAGT in people with SCI. The aim of our study was to assess the effects of RAGT on improvement in walking-related functional outcomes in patients with incomplete SCI compared with other rehabilitation modalities according to time elapsed since injury. This review included 10 trials involving 502 participants to meta-analysis. The acute RAGT groups showed significantly greater improvements in gait distance, leg strength, and functional level of mobility and independence than the over-ground training (OGT) groups. The pooled mean difference was 45.05 m (95% CI 13.81 to 76.29, P = 0.005, I² = 0%; two trials, 122 participants), 2.54 (LEMS, 95% CI 0.11 to 4.96, P = 0.04, I² = 0%; three trials, 211 participants) and 0.5 (WISCI-II and FIM-L, 95% CI 0.02 to 0.98, P = 0.04, I² = 67%; three trials, 211 participants), respectively. In the chronic RAGT group, significantly greater improvements in speed (pooled mean difference = 0.07 m/s, 95% CI 0.01 to 0.12, P = 0.01, I² = 0%; three trials, 124 participants) and balance measured by TUG (pooled mean difference = 9.25, 95% CI 2.76 to 15.73, P = 0.005, I² = 74%; three trials, 120 participants) were observed than in the group with no intervention. Thus, RAGT improves mobility-related outcomes to a greater degree than conventional OGT for patients with incomplete SCI, particularly during the acute stage. RAGT treatment is a promising technique to restore functional walking and improve locomotor ability, which might enable SCI patients to maintain a healthy lifestyle and increase their level of physical activity.

Trial registration

PROSPERO (CRD 42016037366). Registered 6 April 2016.

Spinal cord injury rehabilitation in Riyadh, Saudi Arabia: time to rehabilitation admission, length of stay and functional independence

OBJECTIVES

(1) To describe functional status, length of stay (LOS) and time to rehabilitation admission trends. (2) To identify independent predictors of motor function following rehabilitation.

STUDY DESIGN

Retrospective cohort study.

SETTING

Spinal injury rehabilitation unit at King Fahad Medical City, Riyadh, Saudi Arabia.

METHODS

From chart review of 312 traumatic and 106 nontraumatic adult patients with spinal cord injury (SCI) we extracted information on time from injury to rehabilitation admission, rehabilitation LOS, Functional Independence Measure (FIM) motor score (admission and discharge), American Spinal Injury Association Impairment Scale (AIS) grade and demographics. Hierarchical regression was employed to investigate variables associated with discharge FIM motor score for traumatic and nontraumatic SCI.

RESULTS

Mean±s.d., median days from injury to rehabilitation admission were 377±855, 150 days for traumatic SCI and 288±403, 176 days for nontraumatic SCI. For individuals with traumatic SCI, after accounting for admission FIM motor score, tetraplegia and time from injury to rehabilitation admission had a significant but small negative association with discharge FIM motor score. For individuals with nontraumatic SCI, increasing age and higher AIS grade had a significant negative association with discharge FIM motor score.

CONCLUSIONS

Shorter time from injury to rehabilitation admission may improve outcomes for those with traumatic SCI. As time spent in rehabilitation was shorter than in most other countries, a change in practice in this area may be warranted. Developing strategies to improve outcomes for older patients with nontraumatic SCI would also be beneficial.

Perspectives of individuals with sub-acute spinal cord injury after personalized adapted locomotor training

PURPOSE

Locomotor training after incomplete spinal cord injury can improve walking function, and cardiovascular and muscle health. Participants' perspectives about locomotor training, however, have not been extensively studied. This study describes the experiences of individuals with sub-acute incomplete spinal cord injury who completed personalized adapted locomotor training; a locomotor-focused rehabilitation tailored to individual goals. Specifically, we examined how participation in this training impacted their lives and what challenges they encountered.

MATERIALS AND METHODS

Following inpatient rehabilitation, seven participants completed 74-197 h of personalized adapted locomotor training. Using conventional content analysis, themes were identified from post-training interviews. Trustworthiness was enhanced through analysis trials, verbatim quotes, and triangulation.

RESULTS

Three themes emerged: motives for participating, perceived benefits, and perceived challenges. Beliefs that higher intensity leads to quicker recovery of prior function motivated participation. Physical and psychological health improvements, favorable training structure, and empowerment to self-manage their rehabilitation were perceived benefits. Neglect of other commitments, acquiring extra services to participate (e.g. accessible transportation), limited transferability to daily walking, and a rigid training structure were perceived challenges. Program recommendations were formed from the perceived challenges.

CONCLUSIONS

Personalized adapted locomotor training was positively regarded by participants. Addressing the perceived challenges may improve the training experience. Implications for Rehabilitation Personalized adapted locomotor training (PALT) is a high-intensity locomotor therapy tailored to an individual's goals. The experiences of individuals with iSCI highlight the impact of PALT on physical and psychological well-being. PALT has the potential to improve physical functioning and facilitate transitions from inpatient rehabilitation to community living. Findings suggest the need for adaptation of PALT to suit the unique needs of each individual.

Overground Locomotor Training in Spinal Cord Injury: A Performance-Based Framework

Background: Locomotor training (LT) is the most commonly used treatment to improve walking performance following spinal cord injury (SCI). The advancement of LT treatments requires the addition of integrative models accounting for the numerous systems responsible for the recovery of walking function following SCI. Objective: This perspective monograph aims to (a) describe a performance-based framework for overground LT (OLT), (b) describe principles of adaptation and motor learning used to inform OLT program design, and (c) present an example OLT program based on the proposed framework. Methods: Individuals with chronic motor-incomplete SCI (7 male, 1 female) classified according to the American Spinal Injury Association Impairment Scale (AIS) as C and D were included. OLT included two 90-minute sessions performed over 12 weeks for a total of 24 sessions. Outcomes measures included overground walking speed, walking economy, pulmonary oxygen uptake, and muscle oxygen extraction measured via near-infrared spectroscopy. Results: Preliminary findings demonstrate the potential of OLT, as describe here, to increase overground walking speed, improve walking economy, accelerate processes associated with oxygen delivery and utilization at the rest-to-work transition, and lower oxygen extraction requirements of skeletal muscle during walking in individuals with chronic motor-incomplete SCI. Conclusion: The proposed framework offers a valuable template for LT program design in both clinical and research settings. Further research is necessary to better understand the effects of OLT and how principles of specificity, progressive overload, and variation within the performance-based framework can be manipulated to maximize function, health, and quality of life in SCI.

Accelerometry-enabled measurement of walking performance with a robotic exoskeleton: a pilot study

Background

Clinical scores for evaluating walking skills with lower limb exoskeletons are often based on a single variable, such as distance walked or speed, even in cases where a host of features are measured. We investigated how to combine multiple features such that the resulting score has high discriminatory power, in particular with few patients. A new score is introduced that allows quantifying the walking ability of patients with spinal cord injury when using a powered exoskeleton.

Methods

Four spinal cord injury patients were trained to walk over ground with the ReWalk™ exoskeleton. Body accelerations during use of the device were recorded by a wearable accelerometer and 4 features to evaluate walking skills were computed. The new score is the Gaussian naïve Bayes surprise, which evaluates patients relative to the features’ distribution measured in 7 expert users of the ReWalk™. We compared our score based on all the features with a standard outcome measure, which is based on number of steps only.

Results

All 4 patients improved over the course of training, as their scores trended towards the expert users’ scores. The combined score (Gaussian naïve surprise) was considerably more discriminative than the one using only walked distance (steps). At the end of training, 3 out of 4 patients were significantly different from the experts, according to the combined score (p < .001, Wilcoxon Signed-Rank Test). In contrast, all but one patient were scored as experts when number of steps was the only feature.

Conclusion

Integrating multiple features could provide a more robust metric to measure patients’ skills while they learn to walk with a robotic exoskeleton. Testing this approach with other features and more subjects remains as future work.

Interventions to Reduce Spasticity and Improve Function in People With Chronic Incomplete Spinal Cord Injury: Distinctions Revealed by Different Analytical Methods

BACKGROUND

Spinal cord injury (SCI) results in impaired function, and ankle joint spasticity is a common secondary complication. Different interventions have been trialed with variable results.

OBJECTIVE

We investigated the effects of pharmacological and physical (locomotor training) interventions on function in people living with incomplete motor function loss caused by SCI and used different analytical techniques to understand whether functional levels affect recovery with different interventions.

METHODS

Participants with an incomplete SCI were assigned to 3 groups: no intervention, Lokomat, or tizanidine. Outcome measures were the 10-m walk test, 6-minute walk test, and the Timed Up and Go. Participants were classified in 2 ways: (1) based on achieving an improvement above the minimally important difference (MID) and (2) using growth mixture modeling (GMM). Functional levels of participants who achieved the MID were compared and random coefficient regression (RCR) was used to assess recovery in GMM classes.

RESULTS

Overall, walking speed and endurance improved, with no difference between interventions. Only a small number of participants achieved the MID. Both MID and GMM-RCR analyses revealed that tizanidine improved endurance in high-functioning participants. GMM-RCR classification also showed that speed and mobility improved after locomotor training.

CONCLUSIONS

Improvements in function were achieved in a limited number of people with SCI. Using the MID and GMM techniques, differences in responses to interventions between high-and low-functioning participants could be identified. These techniques may, therefore, have potential to be used for characterizing therapeutic effects resulting from different interventions.

Safety and efficacy of at-home robotic locomotion therapy in individuals with chronic incomplete spinal cord injury: a prospective, pre-post intervention, proof-of-concept study

BACKGROUND

The compact Motorized orthosis for home rehabilitation of Gait (MoreGait) was developed for continuation of locomotion training at home. MoreGait generates afferent stimuli of walking with the user in a semi-supine position and provides feedback about deviations from the reference walking pattern.

OBJECTIVE

Prospective, pre-post intervention, proof-of-concept study to test the feasibility of an unsupervised home-based application of five MoreGait prototypes in subjects with incomplete spinal cord injury (iSCI).

METHODS

Twenty-five (5 tetraplegia, 20 paraplegia) participants with chronic (mean time since injury: 5.8 ± 5.4 (standard deviation, SD) years) sensorimotor iSCI (7 ASIA Impairment Scale (AIS) C, 18 AIS D; Walking Index for Spinal Cord Injury (WISCI II): Interquartile range 9 to 16) completed the training (45 minutes / day, at least 4 days / week, 8 weeks). Baseline status was documented 4 and 2 weeks before and at training onset. Training effects were assessed after 4 and 8 weeks of therapy.

RESULTS

After therapy, 9 of 25 study participants improved with respect to the dependency on walking aids assessed by the WISCI II. For all individuals, the short-distance walking velocity measured by the 10-Meter Walk Test showed significant improvements compared to baseline (100%) for both self-selected (Mean 139.4% ± 35.5% (SD)) and maximum (Mean 143.1% ± 40.6% (SD)) speed conditions as well as the endurance estimated with the six-minute walk test (Mean 166.6% ± 72.1% (SD)). One device-related adverse event (pressure sore on the big toe) occurred in over 800 training sessions.

CONCLUSIONS

Home-based robotic locomotion training with MoreGait is feasible and safe. The magnitude of functional improvements achieved by MoreGait in individuals with iSCI is well within the range of complex locomotion robots used in hospitals. Thus, unsupervised MoreGait training potentially represents an option to prolong effective training aiming at recovery of locomotor function beyond in-patient rehabilitation.

TRIAL REGISTRATION

German Clinical Trials Register (DKRS) DRKS00005587.

Facilitatory effects of anti-spastic medication on robotic locomotor training in people with chronic incomplete spinal cord injury

Background

The objective of this study was to investigate whether an anti-spasticity medication can facilitate the effects of robotic locomotor treadmill training (LTT) to improve gait function in people with incomplete spinal cord injury (SCI).

Methods

Individuals with chronic incomplete SCI were recruited and carried out a 4 week intervention of either locomotor treadmill training (LTT) alone (n = 26) or LTT combined with Tizanidine (TizLTT), an anti-spasticity medication (n = 22). Gait function was evaluated using clinical outcome measures of gait, speed and endurance. To better understand the underlying mechanisms of the therapeutic effects, maximal strength, active range of motion (AROM) and peak velocity (Vp) of ankle dorsi- and planter-flexor muscles were also measured. Differences were assessed using two-way mixed design analysis of variance. The number of subjects that achieved the minimal important difference (MID) for clinical scores was also measured for each group, and the results of those that did attain the MID were compared with those that did not.

Results

Both LTT and TizLTT resulted in significant improvements in walking speed and dorsiflexion maximum strength, with no significant differences between them, using group-averaging analysis. However, using the MID analysis, a higher proportion of subjects in the TizLTT group achieved the MID for walking speed (40%) compared with LTT alone (13%). Those that achieved the MID for walking speed were significantly higher functioning at baseline than those that did not in the TizLTT group, and the change in walking speed was associated with the change in dorsiflexion peak velocity (R² = 0.40; P < 0.05).

Conclusion

Tizanidine appears to facilitate the effects of LTT on gait function in individuals with chronic SCI that are higher functioning at baseline. We speculate that this may be due to restoration of inhibitory mechanisms by Tizanidine, resulting in greater stretch in the planterflexor muscles during the LTT.

Varied Overground Walking Training Versus Body-Weight-Supported Treadmill Training in Adults Within 1 Year of Stroke

Background: Although task-related walking training has been recommended after stroke, the theoretical basis, content, and impact of interventions vary across the literature. There is a need for a comparison of different approaches to task-related walking training after stroke. Objective: To compare the impact of a motor-learning-science–based overground walking training program with body-weight-supported treadmill training (BWSTT) in ambulatory, community-dwelling adults within 1 year of stroke onset. Methods: In this rater-blinded, 1:1 parallel, randomized controlled trial, participants were stratified by baseline gait speed. Participants assigned to the Motor Learning Walking Program (MLWP) practiced various overground walking tasks under the supervision of 1 physiotherapist. Cognitive effort was encouraged through random practice and limited provision of feedback and guidance. The BWSTT program emphasized repetition of the normal gait cycle while supported on a treadmill and assisted by 1 to 3 therapy staff. The primary outcome was comfortable gait speed at postintervention assessment (T2). Results: In total, 71 individuals (mean age = 67.3; standard deviation = 11.6 years) with stroke (mean onset = 20.9 [14.1] weeks) were randomized (MLWP, n = 35; BWSTT, n = 36). There was no significant between-group difference in gait speed at T2 (0.002 m/s; 95% confidence interval [CI] = −0.11, 0.12; P > .05). The MLWP group improved by 0.14 m/s (95% CI = 0.09, 0.19), and the BWSTT group improved by 0.14 m/s (95% CI = 0.08, 0.20). Conclusions: In this sample of community-dwelling adults within 1 year of stroke, a 15-session program of varied overground walking-focused training was not superior to a BWSTT program of equal frequency, duration, and in-session step activity.

Spinal Cord Injury Functional Ambulation Profile: a preliminary look at responsiveness

BACKGROUND

The Spinal Cord Injury Functional Ambulation Profile (SCI-FAP) is a valid, reliable measure of walking skill (eg, walking while negotiating obstacles, doors, and stairs).

OBJECTIVE

The responsiveness of the SCI-FAP was assessed at least 7 months after spinal cord injury (SCI) and compared with that of the 10-Meter Walk Test (10MWT) and the Six-Minute Walk Test (6MWT).

DESIGN

A secondary analysis of data collected during a randomized, single-blind, crossover trial was performed.

METHODS

Participants had incomplete SCI and could walk at least 5 m without manual assistance. After 3 or 4 baseline assessments, participants completed 2 months of precision training (stepping over obstacles and onto targets on the ground) and 2 months of endurance training (treadmill training with body weight support, if needed). Walking function was assessed with the SCI-FAP, 10MWT, and 6MWT. Internal responsiveness was evaluated through change scores and standardized response means (SRMs). External responsiveness was gauged by correlating change scores on the SCI-FAP, 10MWT, and 6MWT. The minimal detectable change was calculated from the standard error of measurement from the baseline assessments.

RESULTS

The SCI-FAP scores improved with both interventions. The magnitude of change was greater for participants whose pretraining self-selected speed was less than 0.5 m/s. The SCI-FAP had moderate SRMs. The 10MWT (fastest speed) and 6MWT had the largest SRMs after precision training and endurance training, respectively. The minimal detectable change in the SCI-FAP was 96 points.

LIMITATIONS

The convenience sample was small and all participants could ambulate independently (with devices); therefore, the generalizability of the findings is limited.

CONCLUSIONS

The SCI-FAP was responsive to changes in walking ability in participants who had incomplete SCI and walked at slow speeds, but overall the 10MWT and 6MWT were more responsive.

Repetitive mass practice or focused precise practice for retraining walking after incomplete spinal cord injury? A pilot randomized clinical trial

BACKGROUND

Retraining walking following spinal cord injury using visually guided tasks may be especially efficacious because it engages the motor cortex, whose input may facilitate improvements in functional walking.

OBJECTIVES

To contrast 2 methods of retraining, one emphasizing precise, visually guided walking over obstacles and on targets (Precision Training), the other emphasizing mass practice of walking on a treadmill (Endurance Training).

METHODS

A randomized, single-blind, crossover design was used. Twenty-two participants, ≥7 months postinjury, were randomly allocated to start with Precision or Endurance Training. Each phase of training was 5 times per week for 2 months, followed by a 2-month rest.

MEASURES

of walking speed, distance, skill, confidence, and depression were obtained before training, then monthly thereafter.

RESULTS

Both forms of training led to significant improvements in walking, with Endurance Training inducing bigger improvements in walking distance than Precision Training, especially for high-functioning walkers who had initial walking speeds >0.5 m/s. The largest improvements in walking speed and distance occurred in the first month of Endurance Training, with minimal changes in the second month of training. In contrast, improvements in walking skill occurred over both months during both types of training. Retention of over ground walking speed, distance, and skill was excellent for both types of training.

CONCLUSIONS

Intensive walking training in the chronic phase after spinal cord injury is effective in improving over ground walking. Visually guided tasks for training individuals with chronic spinal cord injury were not superior to mass practice on a treadmill.

Factors affecting the length of stay of patients with traumatic spinal cord injury in Tianjin, China

PURPOSE

To describe the acute care length of stay (ACLOS) of adult patients with traumatic spinal cord injury (TSCI) in Tianjin, China, and identify the associated demographic and clinical factors.

METHODS

TSCI patients admitted to a general hospital in Tianjin, China from 2004 to 2007 were identified. The predictor variables were demographic and clinical factors, including age, gender, etiology, level of injury, severity, associated injuries, surgery, and complications. The outcome variable was ACLOS. Multivariable linear regression analysis models were used to examine the association between predictor and outcome variables.

RESULTS

This study included 631 TSCI patients. The mean ACLOS was 32.4 ± 37.7 days, with a range of 1-294 days. The median number of hospitalization days was 21 days. Admission to a suburban hospital surgery, urinary infection, poorer functional status, pressure ulcers, and associated injuries were significantly associated with ACLOS.

CONCLUSION

This study examined the effect of epidemiological and clinical factors on ACLOS in Tianjin, China. The factors that influenced the ACLOS were different from factors reported in other studies. More studies are needed in China to determine the effect of these factors on ACLOS in TSCI patients and to propose a predictive model.