Development of a rocking chair for use by children with spinal cord injuries

PURPOSE

Activity-based locomotor training improves intrinsic trunk control in children with spinal cord injury (SCI). To reinforce these improvements, there is a need to develop community integration activities to allow a patient to apply the retrained nervous system at home. One activity that has been explored is rocking in a rocking chair. This paper describes the design, fabrication, and evaluation of a rocking chair for children with SCI.

MATERIALS AND METHODS

The Quality Function Deployment (QFD) design process was used. Fundamental needs and features for the rocking chair were defined in a focus group with experienced therapists, and needs were then rated for importance. A House of Quality (HOQ) matrix was developed to correlate needs with design features, and a prototype design was generated. Virtual motion studies and finite element analysis (FEA) were utilized to assess the design. The chair was fabricated and physical testing was performed, including tipping and static and dynamic load assessments.

RESULTS AND CONCLUSIONS

The needs identified through the QFD process were categorized into (1) safety, (2) therapeutic, (3) practical and aesthetic, and (4) data to track chair use. Features selected to meet these needs include safety stops, padding, straps, a stable base, armrests, adjustable footrest, and sensors to capture rocking data. FEA showed a factor of safety (FOS) > 5. Physical testing confirmed physical integrity, load-bearing capacity, and stability of the prototype glider rocking chair. The prototype provides a safe tool for further investigation of rocking for promotion of trunk muscle activation in children with SCI.

Activity based restorative therapy considerations for children: medical and therapeutic perspectives for the pediatric population

Well-established scientific evidence demonstrates that activity is essential for the development and repair of the central nervous system, yet traditional rehabilitation approaches target muscles only above the lesion as a means of compensation. Activity-Based Rehabilitation (ABR) represents an evolving paradigm shift in neurorehabilitation targeting activation of the neuromuscular system below the lesion. Based on activity-dependent plasticity, ABR offers high intensity activation of the nervous system to optimize the capacity for recovery, while working to offset the chronic complications that occur as a result of neurologic injury. Treatment focus shifts from compensatory training to promotion of restoration of function with special emphasis on normalizing sensory cues and movement kinematics. ABR in children carries special considerations for a developing nervous system and the focus is not just restoring functions but advancing functions in line with typical development. Application of activity-based interventions includes traditional rehabilitation strategies at higher intensity and frequency than in traditional models, including locomotor training, functional electrical stimulation, massed practice, and task specific training, applied across the continuum of care from early intervention to the chronic condition.

Functional electrical stimulation therapy controlled by a P300-based brain-computer interface, as a therapeutic alternative for upper limb motor function recovery in chronic post-stroke patients. A non-randomized pilot study

Introduction

Up to 80% of post-stroke patients present upper-limb motor impairment (ULMI), causing functional limitations in daily activities and loss of independence. UMLI is seldom fully recovered after stroke when using conventional therapeutic approaches. Functional Electrical Stimulation Therapy (FEST) controlled by Brain-Computer Interface (BCI) is an alternative that may induce neuroplastic changes, even in chronic post-stroke patients. The purpose of this work was to evaluate the effects of a P300-based BCI-controlled FEST intervention, for ULMI recovery of chronic post-stroke patients.

Methods

A non-randomized pilot study was conducted, including 14 patients divided into 2 groups: BCI-FEST, and Conventional Therapy. Assessments of Upper limb functionality with Action Research Arm Test (ARAT), performance impairment with Fugl-Meyer assessment (FMA), Functional Independence Measure (FIM) and spasticity through Modified Ashworth Scale (MAS) were performed at baseline and after carrying out 20 therapy sessions, and the obtained scores compared using Chi square and Mann-Whitney U statistical tests (𝛼 = 0.05).

Results

After training, we found statistically significant differences between groups for FMA (p = 0.012), ARAT (p < 0.001), and FIM (p = 0.025) scales.

Discussion

It has been shown that FEST controlled by a P300-based BCI, may be more effective than conventional therapy to improve ULMI after stroke, regardless of chronicity.

Conclusion

The results of the proposed BCI-FEST intervention are promising, even for the most chronic post-stroke patients often relegated from novel interventions, whose expected recovery with conventional therapy is very low. It is necessary to carry out a randomized controlled trial in the future with a larger sample of patients.

Combined Transcutaneous Spinal Stimulation and Locomotor Training to Improve Walking Function and Reduce Spasticity in Subacute Spinal Cord Injury: A Randomized Study of Clinical Feasibility and Efficacy

Locomotor training (LT) is intended to improve walking function and can also reduce spasticity in motor-incomplete spinal cord injury (MISCI). Transcutaneous spinal stimulation (TSS) also influences these outcomes. We assessed feasibility and preliminary efficacy of combined LT + TSS during inpatient rehabilitation in a randomized, sham-controlled, pragmatic study. Eighteen individuals with subacute MISCI (2-6 months post-SCI) were enrolled and randomly assigned to the LT + TSS or the LT + TSSsham intervention group. Participants completed a 4-week program consisting of a 2-week wash-in period (LT only) then a 2-week intervention period (LT + TSS or LT + TSSsham). Before and after each 2-week period, walking (10 m walk test, 2-min walk test, step length asymmetry) and spasticity (pendulum test, clonus drop test, modified spinal cord injury-spasticity evaluation tool) were assessed. Sixteen participants completed the study. Both groups improved in walking speed and distance. While there were no significant between-groups differences, the LT + TSS group had significant improvements in walking outcomes following the intervention period; conversely, improvements in the LT + TSSsham group were not significant. Neither group had significant changes in spasticity, and the large amount of variability in spasticity may have obscured ability to observe change in these measures. TSS is a feasible adjunct to LT in the subacute stage of SCI and may have potential to augment training-related improvements in walking outcomes.

Improvements in Function Following Inpatient Activity-Based Therapy for Children With Acute Flaccid Myelitis

BACKGROUND

Acute flaccid myelitis (AFM) is an illness defined by rapid onset of flaccid paralysis in one or more limbs or bulbar muscles, with MRI findings of predominantly spinal cord gray matter abnormalities spanning one or more spinal segments following a viral illness. Individuals with AFM may require rehabilitation to promote recovery. Activity-based restorative therapy (ABRT) has previously been shown to result in positive outcomes in children with neurologic deficits related to AFM.

OBJECTIVES

This study examined functional changes in a group of children with AFM who participated in ABRT in an inpatient setting.

METHODS

Retrospective chart review of children with AFM admitted to a single inpatient rehabilitation unit from 2014 to 2018. Children were assessed using the Functional Independence Measure for Children (WeeFIM), Manual Muscle Testing (MMT), Spinal Cord Independence Measure (SCIM), and the Physical Abilities and Mobility Scale (PAMS) as part of routine clinical care; the Modified Rankin Scale for Neurologic Disability was completed retrospectively.

RESULTS

Children showed significant improvements across all outcome measures, with effect sizes ranging from moderate to large. Significant change was also seen across all muscle groups on MMT, with effect sizes ranging from small to large. Consistent with previous reports, children demonstrated better function in distal than proximal muscle groups at both admission and discharge.

CONCLUSION

Children with AFM who participated in ABRT increased muscle strength and made functional gains across all outcome measures. These results support the utility of rehabilitation in the long-term care of children with AFM and residual neurologic deficit.

Impact of Activity-Based Therapy on Respiratory Outcomes in a Medically Complex Child

Introduction: Activity-based therapies (ABTs) focus on activating the neuromuscular system below the level of spinal cord injury (SCI) promoting neuromuscular capacity. Case description: A 2 year 7 month old with history of prematurity at 29 weeks, neonatal epidural abscess, resultant cervical SCI, respiratory failure, and global developmental delays presented for enrollment in an outpatient activity-based therapy program. Upon presentation to this program, he required nighttime mechanical ventilation via tracheostomy and daytime suctioning. He could not perform any age-appropriate activities and was described by his mother as ‘present’, neither engaged nor attentive. During and after 7 months of participation in ABTs including locomotor training and neuromuscular electrical stimulation, the patient demonstrated unexpected changes in his respiratory status leading to ventilator weaning with concomitant improvements in head and trunk control, participation, development, and quality of life. Discussion: ABT was not only safe for a medically complex child, but also this intervention had a remarkable effect on unresolved respiratory capacity and a more widespread impact on other functions as well as development. A child with a chronic, severe SCI demonstrated positive and impactful improvements in health, functional status, and quality of life during an episode of ABT.

Interdisciplinary, Intensive, Activity-Based Treatment for Intrauterine Spinal Cord Infarct: A Case Report

Intrauterine spinal cord infarcts (IUSCI) with resulting tetraplegia are extremely rare, and there is minimal evidence describing outcomes in this population. This case describes the functional progress of a 3-year-old girl born with IUSCI who participated in activity-based therapies (ABT). Children have developing nervous systems and are particularly suited to benefit from ABT. Over the course of treatment, the child in this case has demonstrated improvements in developmental milestone achievement including fine and gross motor skills and social/cognitive development. Intense, interdisciplinary ABT should be considered for the treatment of children with IUSCI.

Activity-Based Therapy Targeting Neuromuscular Capacity After Pediatric-Onset Spinal Cord Injury

Background: Activity-based therapies aim to improve neuromuscular capacity after spinal cord injury (SCI). Objective: The purpose of this prospective study was to report the impact of Activity-based Locomotor Training (AB-LT) on neuromuscular capacity in pediatric patients with SCI. Methods: Participants were enrolled for their first episode of AB-LT for a minimum of 60 daily, 1.5-hour sessions. The Segmental Assessment of Trunk Control (SATCo) and the Pediatric Neuromuscular Recovery Scale (Pediatric NRS) were assessed initially, every 20 sessions, and post 60 sessions. Results: Twenty-six consecutive patients, mean age 5 years (SD = 3), completed a mean 55 sessions (SD = 4) within 63 weekdays (SD = 9). The Pediatric NRS total score improved significantly, adjusted mean 11.4, from initial to post-60 sessions (p < .05) with an average adjusted evaluation-to-evaluation 3.7 change. SATCo scores improved significantly across 60 sessions, mean change 5.2, an estimated 1.7 change between evaluations (p < .05). Age at enrollment and chronicity had no effect; however, initial neuromuscular capacity scores were negatively correlated with change scores (p < .05). Conclusion: Sixty AB-LT sessions significantly improved trunk and neuromuscular capacity in children with SCI, regardless of age or chronicity at enrollment. Patients with lower initial scores made greater improvements than patients with higher initial neuromuscular capacity. Anecdotal parent reports of their child's functional change in the home and community highlight the synergy between quantitative change in neuromuscular capacity and meaningful, improved quality of life and the need for formal investigation of this relationship.

Activity-based Therapies in Spinal Cord Injury:: Clinical Focus and Empirical Evidence in Three Independent Programs

This article summarizes presentations of a symposium examining the potential impact of activity-based therapies (ABT) in promoting neurological and functional recovery after spinal cord injury (SCI). The symposium addressed 3 key questions concerning activity-based therapy in SCI: (1) What clinical approaches are used? (2) Is there empirical evidence supporting efficacy of ABT in promoting neurological recovery and improving overall function, health, and quality of life? (3) What are the issues related to long-term viability of ABT?

Effectiveness of intense, activity-based physical therapy for individuals with spinal cord injury in promoting motor and sensory recovery: is olfactory mucosa autograft a factor?

BACKGROUND/OBJECTIVES

Rehabilitation for individuals with spinal cord injury (SCI) is expanding to include intense, activity-based, out-patient physical therapy (PT). The study's primary purposes were to (i) examine the effectiveness of intense PT in promoting motor and sensory recovery in individuals with SCI and (ii) compare recovery for individuals who had an olfactory mucosa autograft (OMA) with individuals who did not have the OMA while both groups participated in the intense PT program.

METHODS

Prospective, non-randomized, non-blinded, intervention study. Using the American Spinal Injury Association examination, motor and sensory scores for 23 (7 OMA, 6 matched control and 10 other) participants were recorded.

RESULTS

Mean therapy dosage was 137.3 total hours. The participants' total, upper and lower extremity motor scores improved significantly while sensory scores did not improve during the first 60 days and from initial to discharge examination. Incomplete SCI or paraplegia was associated with greater motor recovery. Five of 14 participants converted from motor-complete to motor-incomplete SCI. Individuals who had the OMA and participated in intense PT did not have greater sensory or greater magnitude or rate of motor recovery as compared with participants who had intense PT alone.

CONCLUSION

This study provides encouraging evidence as to the effectiveness of intense PT for individuals with SCI. Future research is needed to identify the optimal therapy dosage and specific therapeutic activities required to generate clinically meaningful recovery for individuals with SCI including those who elect to undergo a neural recovery/regenerative surgical procedure and those that elect intense therapy alone.

Development of less invasive neuromuscular electrical stimulation model for motor therapy in rodents

BACKGROUND

Combination therapy is essential for functional repairs of the spinal cord. Rehabilitative therapy can be considered as the key for reorganizing the nervous system after spinal cord regeneration therapy. Functional electrical stimulation has been used as a neuroprosthesis in quadriplegia and can be used for providing rehabilitative therapy to tap the capability for central nervous system reorganization after spinal cord regeneration therapy.

OBJECTIVE

To develop a less invasive muscular electrical stimulation model capable of being combined with spinal cord regeneration therapy especially for motor therapy in the acute stage after spinal cord injury.

METHODS

The tibialis anterior and gastrocnemius motor points were identified in intact anesthetized adult female Fischer rats, and stimulation needle electrodes were percutaneously inserted into these points. Threshold currents for visual twitches were obtained upon stimulation using pulses of 75 or 8 kHz for 200 ms. Biphasic pulse widths of 20, 40, 80, 100, 300, and 500 µs per phase were used to determine strength-duration curves. Using these parameters and previously obtained locomotor electromyogram data, stimulations were performed on bilateral joint muscle pairs to produce reciprocal flexion/extension movements of the ankle for 15 minutes while three-dimensional joint kinematics were assessed.

RESULTS

Rhythmic muscular electrical stimulation with needle electrodes was successfully done, but decreased range of motion (ROM) over time. High-frequency and high-amplitude stimulation was also shown to be effective in alleviating decreases in ROM due to muscle fatigue.

CONCLUSIONS

This model will be useful for investigating the ability of rhythmic muscular electrical stimulation therapy to promote motor recovery, in addition to the efficacy of combining treatments with spinal cord regeneration therapy after spinal cord injuries.

Comparison of the effects of body-weight-supported treadmill training and tilt-table standing on spasticity in individuals with chronic spinal cord injury

OBJECTIVE

Determine the effects of body-weight-supported treadmill training (BWSTT) and tilt-table standing (TTS) on clinically assessed and self-reported spasticity, motor neuron excitability, and related constructs in individuals with chronic spinal cord injury (SCI).

DESIGN

Random cross-over.

METHODS

Seven individuals with chronic SCI and spasticity performed thrice-weekly BWSTT for 4 weeks and thrice-weekly TTS for 4 weeks, separated by a 4-week wash-out. Clinical (Modified Ashworth Scale, Spinal Cord Assessment Tool for Spinal reflexes) and self-report (Spinal Cord Injury Spasticity Evaluation Tool, Penn Spasm Frequency Scale) assessments of spasticity, quality of life (Quality of Life Index Spinal Cord Injury Version - III), functional mobility (FIM Motor Subscale), plus soleus H-reflex were measured at baseline, after the first training session and within 2 days of completing each training condition.

RESULTS

In comparison with TTS, a single session of BWSTT had greater beneficial effects for muscle tone (effect size (ES) = 0.69), flexor spasms (ES = 0.57), and the H/M ratio (ES = 0.50). Similarly, flexor spasms (ES = 0.79), clonus (ES = 0.66), and self-reported mobility (ES = 1.27) tended to benefit more from 4 weeks of BWSTT than of TTS. Participation in BWSTT also appeared to be favorable for quality of life (ES = 0.50). In contrast, extensor spasms were reduced to a greater degree with TTS (ES = 0.68 for single session; ES = 1.32 after 4 weeks).

CONCLUSION

While both BWSTT and TTS may provide specific benefits with respect to spasticity characteristics, data from this pilot study suggest that BWSTT may result in a broader range of positive outcomes.

Acute energy cost of multi-modal activity-based therapy in persons with spinal cord injury

OBJECTIVE

To examine acute energy costs of multi-modal activity-based therapy (ABT) in men and women with spinal cord injury (SCI).

STUDY DESIGN

Descriptive case series.

SETTING

An outpatient center in California.

PARTICIPANTS

Seven men and women (age = 28.3 ± 11.6 years; duration of injury = 4.3 ± 2.5 years) with injury levels ranging from C5 to T8.

INTERVENTION

Activity-based therapy.

OUTCOME MEASURES

Oxygen uptake (VO(2)), energy expenditure (kcal/minute), SCI Metabolic Equivalent of Task (MET) (1 MET = 2.7 ml/kg/minute).

RESULTS

Oxygen uptake (VO(2)) during ABT ranged from 5.10 to 8.62 ml/kg/minute, with VO(2) consistently higher during modalities involving load bearing versus non-load bearing (P = 0.08). SCI MET values ranged from 1.89 to 3.24 and were significantly higher in subjects with mid-thoracic injury versus low-cervical injury (P = 0.01).

CONCLUSION

Data reveal that multi-modal ABT increases VO(2) in persons with SCI, but energy expenditure is relatively low. Strategies must be identified to optimize energy expenditure in the SCI to reduce health risks. Modalities involving load bearing seem to be superior to non-load-bearing activities. VO(2) was greater in response to load-bearing modalities than non-load-bearing modalities. It remains to be determined whether chronic ABT enhances cardiovascular fitness and reduces disease risks in this population.