Relationship between ASIA examination and functional outcomes in the NeuroRecovery Network Locomotor Training Program. Arch Phys Med Rehabil. 2012;93:1530-1540. [PMID: 22920450 DOI: 10.1016/j.apmr.2012.02.035]

Classifying clinical phenotypes of functional recovery for acute traumatic spinal cord injury. An observational cohort study

PURPOSE

Identify patient subgroups with different functional outcomes after SCI and study the association between functional status and initial ISNCSCI components.

METHODS

Using CART, we performed an observational cohort study on data from 675 patients enrolled in the Rick-Hansen Registry(RHSCIR) between 2014 and 2019. The outcome was the Spinal Cord Independence Measure (SCIM) and predictors included AIS, NLI, UEMS, LEMS, pinprick(PPSS), and light touch(LTSS) scores. A temporal validation was performed on data from 62 patients treated between 2020 and 2021 in one of the RHSCIR participating centers.

RESULTS

The final CART resulted in four subgroups with increasing totSCIM according to PPSS, LEMS, and UEMS: 1)PPSS < 27(totSCIM = 28.4 ± 16.3); 2)PPSS ≥ 27, LEMS < 1.5, UEMS < 45(totSCIM = 39.5 ± 19.0); 3)PPSS ≥ 27, LEMS < 1.5, UEMS ≥ 45(totSCIM = 57.4 ± 13.8); 4)PPSS ≥ 27, LEMS ≥ 1.5(totSCIM = 66.3 ± 21.7). The validation model performed similarly to the original model. The adjusted R-squared and F-test were respectively 0.556 and 62.2(P-value <0.001) in the development cohort and, 0.520 and 31.9(P-value <0.001) in the validation cohort.

CONCLUSION

Acknowledging the presence of four characteristic subgroups of patients with distinct phenotypes of functional recovery based on PPSS, LEMS, and UEMS could be used by clinicians early after tSCI to plan rehabilitation and establish realistic goals. An improved sensory function could be key for potentiating motor gains, as a PPSS ≥ 27 was a predictor of a good function.

Exoskeletal-assisted walking combined with transcutaneous spinal cord stimulation to improve bone health in persons with spinal cord injury: study protocol for a prospective randomised controlled trial

INTRODUCTION

Persons with non-ambulatory spinal cord injury (SCI) undergo immediate unloading of the skeleton and, as a result, have marked loss of bone mineral density below the level of lesion that is directly associated with increased risk of long-bone fractures. There is a paucity of research that has successfully implemented rehabilitation and/or exercise training interventions to mitigate bone loss after acute SCI or reverse bone loss that has already occurred in chronic SCI. This paper describes a research protocol to compare the effect of exoskeletal-assisted walking (EAW) alone versus EAW plus transcutaneous spinal cord stimulation (EAW+tSCS) on bone density, geometry and strength in a cohort of chronic SCI participants.

METHODS AND ANALYSIS

After meeting eligibility criteria and completing baseline testing, sixteen participants will be block randomised into the EAW alone group or the EAW+tSCS combined group (n=8 each group). Each group will receive a total of 108 overground training sessions (60 min sessions, 3 times a week, for 36 weeks) for the 9-month training period. Imaging for bone density and geometry by dual-energy X-ray absorptiometry and peripheral quantitative CT will be performed prior to starting the intervention (baseline), after 72 training sessions, and again after 108 sessions in each of the intervention arms. CT imaging of both lower extremities will be performed at baseline and at the 9-month time point in each of the intervention arms. Finite element models of bone loading will be generated based on three-dimensional (3D) reconstruction of bone architecture from CT imaging prior to and 9 months after the intervention.

ETHICS AND DISSEMINATION

This study is currently approved by the Kessler Foundation and James J. Peters VA Medical Center Institutional Review Board. A member of the research team will review and explain the study consent form and will have all eligible participants sign prior to participation in the study. Results from this study will be disseminated to clinicians and researchers in the SCI community at national and international conferences.

TRIAL REGISTRATION NUMBER

NCT03096197.

Robotic locomotor training in a low-resource setting: a randomized pilot and feasibility trial

PURPOSE

Activity-based Training (ABT) represents the current standard of neurological rehabilitation. Robotic Locomotor Training (RLT), an innovative technique, aims to enhance rehabilitation outcomes. This study aimed to conduct a randomized pilot and feasibility trial of a locomotor training program within South Africa.

MATERIALS AND METHODS

Individuals with chronic traumatic motor incomplete tetraplegia (n = 16). Each intervention involved 60-minute sessions, 3x per week, for 24-weeks. Outcomes included feasibility measures and functional capacity.

RESULTS

17 out of 110 individuals initiated the program (recruitment rate = 15.4%) and 16 completed the program (drop-out rate = 5.8%) and attended sessions (attendance rate = 93.9%). Both groups showed a significant increase in upper extremity motor score (MS) and abdominal strength post intervention. Only the RLT group showed a significant change in lower extremity MS, with a mean increase of 3.00 [0.00; 16.5] points over time. Distance walked in the Functional Ambulatory Inventory (SCI-FAI) increased significantly (p = 0.02) over time only for the RLT group.

CONCLUSIONS

Feasibility rates of the intervention and functional outcomes justify a subsequent powered RCT comparing RLT to ABT as an effective rehabilitation tool for potentially improving functional strength and walking capacity in people with incomplete SCI.

Does Improvement in American Spinal Injury Association Impairment Scale Grade Correlate With Functional Recovery in All Patients With a Traumatic Spinal Cord Injury?

OBJECTIVE

The aim of the study is to determine what improvement on the American Spinal Injury Impairment Scale correlates with functional status after a traumatic spinal cord injury.

DESIGN

We performed an observational cohort study, analyzing prospective data from 168 patients with traumatic spinal cord injury admitted to a single level 1 trauma center. A multivariable analysis was performed to assess the relationship between functional status (from the Spinal Cord Independence Measure) at 1-year follow-up and American Spinal Injury Impairment Scale grade (baseline and 1-yr follow-up), while taking into account covariables describing the sociodemographic status, trauma severity, and level of neurological injury.

RESULTS

Individuals improving to at least American Spinal Injury Impairment Scale grade D had significantly higher Spinal Cord Independence Measure score compared with those not reaching American Spinal Injury Impairment Scale D (89.3 ± 15.2 vs. 52.1 ± 20.4) and were more likely to reach functional independence (68.5% vs. 3.6%), regardless of the baseline American Spinal Injury Impairment Scale grade. Higher final Spinal Cord Independence Measure was more likely with an initial American Spinal Injury Impairment Scale grade D (β = 1.504; 95% confidence interval = 0.46-2.55), and a final American Spinal Injury Impairment Scale grade D (β = 3.716; 95% CI = 2.77-4.66) or E (β = 4.422; 95% CI = 2.91-5.93).

CONCLUSIONS

Our results suggest that reaching American Spinal Injury Impairment Scale grade D or better 1 yr after traumatic spinal cord injury is highly predictive of significant functional recovery, more so than the actual improvement in American Spinal Injury Impairment Scale grade from the injury to the 1-yr follow-up.

Early and intensive motor training to enhance neurological recovery in people with spinal cord injury: trial protocol

STUDY DESIGN

Protocol for a multi-centre randomised controlled trial (the SCI-MT trial).

OBJECTIVES

To determine whether 10 weeks of intensive motor training enhances neurological recovery in people with recent spinal cord injury (SCI).

SETTING

Fifteen spinal injury units in Australia, Scotland, England, Italy, Netherlands, Norway, and Belgium.

METHODS

A pragmatic randomised controlled trial will be undertaken. Two hundred and twenty people with recent SCI (onset in the preceding 10 weeks, American Spinal Injuries Association Impairment Scale (AIS) A lesion with motor function more than three levels below the motor level on one or both sides, or an AIS C or D lesion) will be randomised to receive either usual care plus intensive motor training (12 h of motor training per week for 10 weeks) or usual care alone. The primary outcome is neurological recovery at 10 weeks, measured with the Total Motor Score from the International Standards for Neurological Classification of SCI. Secondary outcomes include global measures of motor function, ability to walk, quality of life, participants' perceptions about ability to perform self-selected goals, length of hospital stay and participants' impressions of therapeutic benefit at 10 weeks and 6 months. A cost-effectiveness study and process evaluation will be run alongside the trial. The first participant was randomised in June 2021 and the trial is due for completion in 2025.

CONCLUSIONS

The findings of the SCI-MT Trial will guide recommendations about the type and dose of inpatient therapy that optimises neurological recovery in people with SCI.

TRIAL REGISTRATION

ACTRN12621000091808 (1.2.2021).

Interventions to Improve Standing Balance in Individuals With Incomplete Spinal Cord Injury: A Systematic Review and Meta-Analysis

Background

Incomplete spinal cord injury (iSCI) often results in impaired balance leading to functional impairments. Recovery of standing balance ability is an important aim of rehabilitative programs. However, limited information is available on effective balance training protocols for individuals with iSCI.

Objectives

To assess the methodological quality and effectiveness of various rehabilitation interventions for improving standing balance in individuals with iSCI.

Methods

A systematic search was performed in SCOPUS, PEDro, PubMed, and Web of Science from inception until March 2021. Two independent reviewers screened articles for inclusion, extracted data, and evaluated methodological quality of the trials. PEDro Scale was used to assess the quality of randomized controlled trials (RCT) and crossover studies while pre-post trials were assessed using the modified Downs and Black tool. A meta-analysis was performed to quantitatively describe the results. The random effects model was applied to present the pooled effect.

Results

Ten RCTs with a total of 222 participants and 15 pre-post trials with 967 participants were analyzed. The mean PEDro score and modified Downs and Black score was 7/10 and 6/9, respectively. The pooled standardized mean difference (SMD) for controlled and uncontrolled trials of body weight-supported training (BWST) interventions was -0.26 (95% CI, -0.70 to 0.18; p = .25) and 0.46 (95% CI, 0.33 to 0.59; p < .001), respectively. The pooled effect size of -0.98 (95% CI, -1.93 to -0.03; p = .04) indicated significant improvements in balance after a combination of BWST and stimulation. Pre-post studies analyzing the effect of virtual reality (VR) training interventions on Berg Balance Scale (BBS) scores in individuals with iSCI reported a mean difference (MD) of 4.22 (95% CI, 1.78 to 6.66; p = .0007). Small effect sizes were seen in pre-post studies of VR+stimulation and aerobic exercise training interventions indicating no significant improvements after training on standing balance measures.

Conclusion

This study demonstrated weak evidence to support the use of BWST interventions for overground training for balance rehabilitation in individuals with iSCI. A combination of BWST with stimulation however showed promising results. There is a need for further RCTs in this field to generalize findings. Virtual reality-based balance training has shown significant improvement in standing balance post iSCI. However, these results are based on single group pre-post trials and lack appropriately powered RCTs involving a larger sample size to support this intervention. Given the importance of balance control underpinning all aspects of daily activities, there is a need for further well-designed and appropriately powered RCTs to evaluate specific features of training interventions to improve standing balance function in iSCI.

Recovery of walking in nonambulatory children with chronic spinal cord injuries: Case series

The immature central nervous system is recognized as having substantial neuroplastic capacity. In this study, we explored the hypothesis that rehabilitation can exploit that potential and elicit reciprocal walking in nonambulatory children with chronic, severe (i.e., lower extremity motor score < 10/50) spinal cord injuries (SCIs). Seven male subjects (3-12 years of age) who were at least 1-year post-SCI and incapable of discrete leg movements believed to be required for walking, enrolled in activity-based locomotor training (ABLT; clinicaltrials.gov NCT00488280). Six children completed the study. Following a minimum of 49 sessions of ABLT, three of the six children achieved walking with reverse rolling walkers. Stepping development, however, was not accompanied by improvement in discrete leg movements as underscored by the persistence of synergistic movements and little change in lower extremity motor scores. Interestingly, acoustic startle responses exhibited by the three responding children suggested preserved reticulospinal inputs to circuitry below the level of injury capable of mediating leg movements. On the other hand, no indication of corticospinal integrity was obtained with transcranial magnetic stimulation evoked responses in the same individuals. These findings suggest some children who are not predicted to improve motor and locomotor function may have a reserve of adaptive plasticity that can emerge in response to rehabilitative strategies such as ABLT. Further studies are warranted to determine whether a critical need exists to re-examine rehabilitation approaches for pediatric SCI with poor prognosis for any ambulatory recovery.

Soleus H and Lower Limb Posterior Root Muscle Reflexes During Stepping After Incomplete SCI

The goal of this study was to examine and compare the step cycle related modulation of the soleus H and posterior root muscle (PRM) reflexes in subjects with and without spinal cord injury. Ten subjects without neurological injury and fifteen subjects with spinal cord injury (SCI) underwent soleus H reflex and lower limb PRM reflex testing while standing and stepping in a robotic gait orthosis. Reflex amplitudes were evaluated during standing, mid stance and mid swing to determine if speed and/or injury altered step cycle related neuromodulation. H and PRM reflexes in the soleus underwent step cycle related modulation in injured and uninjured subjects though the degree of modulation differed between the two reflexes with the H reflex showing more step cycle related modulation. We found in the SCI group that both the soleus H and soleus PRM reflex amplitudes were higher relative to the non-injured group and modulated less during the step cycle. We also found that modulation of the soleus H reflex, but not soleus PRM reflex, correlated to the lower extremity motor scores in individuals with SCI. Our evidence suggests that the inability to provide appropriate step cycle related reflex modulation may be due to decreased supra-spinal regulation of motoneuron and spinal excitability and could be an indicator of the severity of injury as it relates to clinically measured lower extremity motor scores.

Eccentric rehabilitation induces white matter plasticity and sensorimotor recovery in chronic spinal cord injury

Experience-dependent white matter plasticity offers new potential for rehabilitation-induced recovery after neurotrauma. This first-in-human translational experiment combined myelin water imaging in humans and genetic fate-mapping of oligodendrocyte lineage cells in mice to investigate whether downhill locomotor rehabilitation that emphasizes eccentric muscle actions promotes white matter plasticity and recovery in chronic, incomplete spinal cord injury (SCI). In humans, of 20 individuals with SCI that enrolled, four passed the imaging screen and had myelin water imaging before and after a 12-week (3 times/week) downhill locomotor treadmill training program (SCI + DH). One individual was excluded for imaging artifacts. Uninjured control participants (n = 7) had two myelin water imaging sessions within the same day. Changes in myelin water fraction (MWF), a histopathologically-validated myelin biomarker, were analyzed in a priori motor learning and non-motor learning brain regions and the cervical spinal cord using statistical approaches appropriate for small sample sizes. PDGFRα-CreER^T2:mT/mG mice, that express green fluorescent protein on oligodendrocyte precursor cells and subsequent newly-differentiated oligodendrocytes upon tamoxifen-induced recombination, were either naive (n = 6) or received a moderate (75 kilodyne), contusive SCI at T9 and were randomized to downhill training (n = 6) or unexercised groups (n = 6). We initiated recombination 29 days post-injury, seven days prior to downhill training. Mice underwent two weeks of daily downhill training on the same 10% decline grade used in humans. Between-group comparison of functional (motor and sensory) and histological (oligodendrogenesis, oligodendroglial/axon interaction, paranodal structure) outcomes occurred post-training. In humans with SCI, downhill training increased MWF in brain motor learning regions (postcentral, precuneus) and mixed motor and sensory tracts of the ventral cervical spinal cord compared to control participants (P < 0.05). In mice with thoracic SCI, downhill training induced oligodendrogenesis in cervical dorsal and lateral white matter, increased axon-oligodendroglial interactions, and normalized paranodal structure in dorsal column sensory tracts (P < 0.05). Downhill training improved sensorimotor recovery in mice by normalizing hip and knee motor control and reducing hyperalgesia, both of which were associated with new oligodendrocytes in the cervical dorsal columns (P < 0.05). Our findings indicate that eccentric-focused, downhill rehabilitation promotes white matter plasticity and improved function in chronic SCI, likely via oligodendrogenesis in nervous system regions activated by the training paradigm. Together, these data reveal an exciting role for eccentric training in white matter plasticity and sensorimotor recovery after SCI.

Neurophysiological Changes in the First Year After Cell Transplantation in Sub-acute Complete Paraplegia

Neurophysiological testing can provide quantitative information about motor, sensory, and autonomic system connectivity following spinal cord injury (SCI). The clinical examination may be insufficiently sensitive and specific to reveal evolving changes in neural circuits after severe injury. Neurophysiologic data may provide otherwise imperceptible circuit information that has rarely been acquired in biologics clinical trials in SCI. We reported a Phase 1 study of autologous purified Schwann cell suspension transplantation into the injury epicenter of participants with complete subacute thoracic SCI, observing no clinical improvements. Here, we report longitudinal electrophysiological assessments conducted during the trial. Six participants underwent neurophysiology screening pre-transplantation with three post-transplantation neurophysiological assessments, focused on the thoracoabdominal region and lower limbs, including MEPs, SSEPs, voluntarily triggered EMG, and changes in GSR. We found several notable signals not detectable by clinical exam. In all six participants, thoracoabdominal motor connectivity was detected below the clinically assigned neurological level defined by sensory preservation. Additionally, small voluntary activations of leg and foot muscles or positive lower extremity MEPs were detected in all participants. Voluntary EMG was most sensitive to detect leg motor function. The recorded MEP amplitudes and latencies indicated a more caudal thoracic level above which amplitude recovery over time was observed. In contrast, further below, amplitudes showed less improvement, and latencies were increased. Intercostal spasms observed with EMG may also indicate this thoracic “motor level.” Galvanic skin testing revealed autonomic dysfunction in the hands above the injury levels. As an open-label study, we can establish no clear link between these observations and cell transplantation. This neurophysiological characterization may be of value to detect therapeutic effects in future controlled studies.

Treadmill-Based Gait Kinematics in the Yucatan Mini Pig

Yucatan miniature pigs (YMPs) are similar to humans in spinal cord size as well as physiological and neuroanatomical features, making them a useful model for human spinal cord injury. However, little is known regarding pig gait kinematics, especially on a treadmill. In this study, 12 healthy YMPs were assessed during bipedal and/or quadrupedal stepping on a treadmill at six speeds (1.0, 1.5, 2.0, 2.5, 3.0, and 3.5 km/h). Kinematic parameters, including limb coordination and proximal and distal limb angles, were measured. Findings indicate that YMPs use a lateral sequence footfall pattern across all speeds. Stride and stance durations decreased with increasing speed whereas swing duration showed no significant change. Across all speeds assessed, no significant differences were noted between hindlimb stepping parameters for bipedal or quadrupedal gait with the exception of distal limb angular kinematics. Specifically, significant differences were observed between locomotor tasks during maximum flexion (quadrupedal > bipedal), total excursion (bipedal > quadrupedal), and the phase relationship between the timing of maximum extension between the right and left hindlimbs (bipedal > quadrupedal). Speed also impacted maximum flexion and right-left phase relationships given that significant differences were found between the fastest speed (3.5 km/h) relative to each of the other speeds. This study establishes a methodology for bipedal and quadrupedal treadmill-based kinematic testing in healthy YMPs. The treadmill approach used was effective in recruiting primarily the spinal circuitry responsible for the basic stepping patterns as has been shown in cats. We recommend 2.5 km/h (0.7 m/sec) as a target walking gait for pre-clinical studies using YMPs, which is similar to that used in cats.

Effects of Multi-Muscle Electrical Stimulation and Stand Training on Stepping for an Individual With SCI

The objective of this study was to evaluate the biomechanical, neural, and functional outcomes during a 10-min treadmill stepping trial before and after two independent interventions with neuromuscular electrical stimulation (ES) in an individual with spinal cord injury (SCI). In this longitudinal study, a 34-year-old male with sensory- and motor-complete SCI (C5/C6) underwent two consecutive interventions: 61 h of supine lower limb ES (ES-alone) followed by 51 h of ES combined with stand training (ST) using an overhead body-weight support (BWS) system (ST + ES). In post ES-alone (unloaded), compared to baseline, the majority (∼60%) of lower extremity muscles decreased their peak surface electromyography (sEMG) amplitude, while in post ST + ES (loaded), compared to post ES-alone, there was a restoration in muscle activation that endured the continuous 10-min stepping. Temporal α-motor neuron activity patterns were observed for the SCI participant. In post ST + ES, there were increases in spinal activity patterns during mid-stance at spinal levels L5–S2 for the right and left limbs. Moreover, in post ES-alone, trunk stability increased with excursions from the midline of the base-of-support (50%) to the left (44.2%; Baseline: 54.2%) and right (66.4%; baseline: 77.5%). The least amount of trunk excursion observed post ST + ES, from midline to left (43%; AB: 22%) and right (64%; AB: 64%). Overall, in post ES-alone, there were gains in trunk independence with a decrease in lower limb muscle activation, whereas in post ST + ES, there were gains in trunk independence and increased muscle activation in both bilateral trunk muscles as well as lower limb muscles during the treadmill stepping paradigm. The results of the study illustrate the importance of loading during the stimulation for neural and mechanical gains.

International Spinal Cord Injury Physical Therapy-Occupational Therapy Basic Data Set (Version 1.2)

STUDY DESIGN

Expert workgroup consensus, focused literature review, and vetting via feedback from international presentations and spinal cord professional membership groups.

OBJECTIVES

Develop and refine a basic dataset to enable standardized documentation of physical therapy (PT) and occupational therapy (OT) interventions delivered in a controlled clinical trial intended to improve voluntary motor function.

SETTING

International Expert Working Group.

METHODS

An international working group with expertise in spinal cord injury, PT, OT, and measurement developed a draft of the International Spinal Cord Injury (ISCI) Physical Therapy-Occupational Therapy (PT-OT) Basic Data Set (BDS). Emphasis was placed on efficiency and practicality of use. The BDS was iteratively refined based on applicable literature, and feedback collected from presentations at the 2017 and 2019 International Spinal Cord Society meetings.

RESULTS

The ISCI PT-OT BDS contains seven broad categories of interventions: bed/seated mobility, standing activities, walking/stairs, gross motor upper extremity, fine motor upper extremity, strength training, and endurance training. The first five categories are classified as activity-directed and the last two as impairment-directed interventions. Time spent on interventions per category is recorded in 15-min intervals.

CONCLUSIONS

The ISCI PT-OT BDS enables standardized documentation of PT-OT activity-directed or impairment-directed interventions. The ISCI PT-OT BDS is a documentation tool to facilitate evaluation of the influence of rehabilitation therapies on motor function in clinical trials of biologic or pharmacologic agents or rehabilitation technologies that are delivered in the clinical setting.

Mesenchymal stem cells and treadmill training enhance function and promote tissue preservation after spinal cord injury

Spinal cord injury (SCI) is considered a serious neurological disorder that can lead to severe sensory, motor and autonomic deficits. In this work, we investigated whether cell therapy associated with physical activity after mouse SCI could promote morphological and functional outcomes, using a lesion model established by our group. Mesenchymal stem cells (8 × 10⁵ cells/2 µL) or DMEM (2 µL), were injected in the epicenter of the lesion at 7 days after SCI, and the mice started a moderate treadmill training 14 days after injury. Functional assessments were performed weekly up to 8 weeks after injury when the morphological analyses were also performed. Four injured groups were analyzed: DMEM (SCI plus DMEM injection), MSCT (SCI plus MSC injection), DMEM + TMT (SCI plus DMEM injection and treadmill training) and MSCT + TMT (SCI plus MSC injection and treadmill training). The animals that received the combined therapy (MSCT + TMT) were able to recover and maintained the better functional results throughout the analyzed period. The morphometric analysis from MSCT + TMT group evidenced a larger spared white matter area and a higher number of preserved myelinated fibers with the majority of them reaching the ideal G-ratio values, when compared to other groups. Ultrastructural analysis from this group, using transmission electron microscopy, showed better tissue preservation with few microcavitations and degenerating nerve fibers. Also, this group exhibited a significantly higher neurotrophin 4 (NT4) expression as compared to the other groups. The results provided by this study support the conclusion that the association of strategies is a potential therapeutic approach to treat SCI, with the possibility of translation into the clinical practice.

Multi-muscle electrical stimulation and stand training: Effects on standing

OBJECTIVE

To examine the biomechanical and neuromuscular effects of a longitudinal multi-muscle electrical stimulation (submaximal intensities) training of the lower limbs combined with/without activity-based stand training, on the recovery of stability and function for one individual with spinal cord injury (SCI).

DESIGN

Single-subject, longitudinal study.

SETTING

Neuroplasticity laboratory.

PARTICIPANT

A 34-year-old male, with sensory- and motor-complete SCI (C5/C6).

INTERVENTIONS

Two consecutive interventions: 61 hours of supine, lower-limb ES (ES-alone) and 51 hours of ES combined with stand training using an overhead body-weight support system (ST + ES).

OUTCOME MEASURES

Clinical measures, trunk stability, and muscle activity were assessed and compared across time points. Trunk Stability Limit (TSL) determined improvements in trunk independence.

RESULTS

Functional clinical values increased after both interventions, with further increases post ST + ES. Post ES-alone, trunk stability was maintained at 81% body-weight (BW) loading before failure; post ST + ES, BW loading increased to 95%. TSL values decreased post ST + ES (TSL_A/P=54.0 kg.cm, TSL_M/L=14.5 kg.cm), compared to ES-alone (TSL_A/P=8.5 kg.cm, TSL_M/L=3.9 kg.cm). Trunk muscle activity decreased post ST + ES training, compared to ES-alone.

CONCLUSION

Neuromuscular and postural trunk control dramatically improved following the multi-muscle ES of the lower limbs with stand training. Multi-muscle ES training paradigm of the lower limb, using traditional parameters, may contribute to the functional recovery of the trunk.

Effects of Exoskeleton Training Intervention on Net Loading Force in Chronic Spinal Cord Injury

The goal of this study was to understand the rehabilitative effects of longitudinal overground exoskeleton training $( >100$ hours) on gait mechanics, especially foot loading, for gains in walking speed in an individual with chronic motorincomplete SCI. Biomechanical measures included: normalized plantar loading forces, walking speed and bilateral weight transfer ratio during walking in the EksoGT $^{\mathrm{ TM}}$ exoskeleton. Longitudinal training with a robotic exoskeleton yielded improvements in clinical outcomes (AIS classification, ISNCSCI motor scores and 10MWT) and provided functional gains in terms of biomechanical outcomes (plantar forces, weight transfer point) to increase overall walking speed.

Consideration of Dose and Timing When Applying Interventions After Stroke and Spinal Cord Injury

BACKGROUND AND PURPOSE

Nearly 4 decades of investigation into the plasticity of the nervous system suggest that both timing and dose could matter. This article provides a synopsis of our lectures at the IV STEP meeting, which presented a perspective of current data on the issues of timing and dose for adult stroke and spinal cord injury motor rehabilitation.

SUMMARY OF KEY POINTS

For stroke, the prevailing evidence suggests that greater amounts of therapy do not result in better outcomes for upper extremity interventions, regardless of timing. Whether or not greater amounts of therapy result in better outcomes for lower extremity and mobility interventions needs to be explicitly tested. For spinal cord injury, there is a complex interaction of timing postinjury, task-specificity, and the microenvironment of the spinal cord. Inflammation appears to be a key determinant of whether or not an intervention will be beneficial or maladaptive, and specific retraining of eccentric control during gait may be necessary.

RECOMMENDATIONS FOR CLINICAL PRACTICE

To move beyond the limitations of our current interventions and to effectively reach nonresponders, greater precision in task-specific interventions that are well-timed to the cellular environment may hold the key. Neurorehabilitation that ameliorates persistent deficits, attains greater recovery, and reclaims nonresponders will decrease institutionalization, improve quality of life, and prevent multiple secondary complications common after stroke and spinal cord injury.

Current state of balance assessment during transferring, sitting, standing and walking activities for the spinal cord injured population: A systematic review

CONTEXT

Comprehensive balance measures with high clinical utility and sound psychometric properties are needed to inform the rehabilitation of individuals with spinal cord injury (SCI).

OBJECTIVE

To identify the balance measures used in the SCI population, and to evaluate their clinical utility, psychometric properties and comprehensiveness.

METHODS

Medline, PubMed, Embase, Scopus, Web of Science, and the Allied and Complementary Medicine Database were searched from the earliest record to October 19/16. Two researchers independently screened abstracts for articles including a balance measure and adults with SCI. Extracted data included participant characteristics and descriptions of balance measures. Quality was evaluated by considering study design, sampling method and adequacy of description of research participants. Clinical utility of all balance measures was evaluated. Comprehensiveness was evaluated using the modified Systems Framework for Postural Control.

RESULTS

2820 abstracts were returned and 127 articles included. Thirty-one balance measures were identified; 11 evaluated a biomechanical construct and 20 were balance scales. All balance scales had high clinical utility. The Berg Balance Scale and Functional Reach Test were valid and reliable, while the mini-BESTest was the most comprehensive.

CONCLUSION

No single measure had high clinical utility, strong psychometric properties and comprehensiveness. The mini-BESTest and/or Activity-based Balance Level Evaluation may fill this gap with further testing of their psychometric properties.

A systematic review of the effectiveness of task-specific rehabilitation interventions for improving independent sitting and standing function in spinal cord injury

CONTEXT

Impaired balance function after a spinal cord injury (SCI) hinders performance of daily activities.

OBJECTIVE

To assess the evidence on the effectiveness of task-specific training on sitting and standing function in individuals with SCI across the continuum of care.

METHODS

A systematic search was conducted on literature published to June 2016 using people (acute or chronic SCI), task-specific interventions compared to conventional physical therapy, and outcome (sitting or standing balance function). The PEDro scale was used to investigate the susceptibility to bias and trial quality of the randomized controlled trials (RCTs). A standardized mean difference (SMD) was conducted to investigate the effect size for interventions with sitting or standing balance outcomes.

RESULTS

Nineteen articles were identified; three RCTs, two prospective controlled trials, one cross-over study, nine pre-post studies and four prospective cohort studies. RCT and cross-over studies were rated from 6 to 8 indicating good quality on the PEDro scale. The SMD of task-specific interventions in sitting compared to active and inactive (no training) control groups was -0.09 (95% CI: -0.663 to 0.488) and 0.39 (95% CI: -0.165 to 0.937) respectively, indicating that the addition of task-specific exercises did not affect sit and reach test performance significantly. Similarly, the addition of BWS training did not significantly affect BBS compared to conventional physical therapy -0.36 (95% CI: -0.840 to 0.113). Task-specific interventions reported in uncontrolled trials revealed positive effects on sitting and standing balance function.

CONCLUSION

Few RCT studies provided balance outcomes, and those that were evaluated indicate negligible effect sizes. Given the importance of balance control underpinning all aspects of daily activities, there is a need for further research to evaluate specific features of training interventions to improve both sitting and standing balance function in SCI.

Life after personalized adaptive locomotor training: a qualitative follow-up study

STUDY DESIGN

Qualitative follow-up study.

OBJECTIVES

Intensive locomotor training can improve physical and psychological functioning for individuals with spinal cord injury. Few studies have examined long-term effects of locomotor training. Specifically, there is a lack of qualitative follow-up that provide insight into participants' perceptions of the effects of locomotor training on level of function and daily life. This study aimed to gain insight into participants' perceptions of intensive locomotor training and whether participation influenced the level of function and community living 1-2 years after training.

SETTING

Tertiary rehabilitation facility in Ontario, Canada.

METHODS

Participants were six individuals who had lived with spinal cord injury between 1.9 and 2.7 years at the time of the interviews and had completed locomotor training during the subacute phase of injury. Semi-structured interviews explored participants' daily experiences and level of function after locomotor training. Interviews were analyzed using thematic analysis.

RESULTS

Three themes were identified. (1) Outcomes: Personalized Adapted Locomotor Training led to transferable gains from the program to daily functioning and eased transitions out of the rehabilitation hospital. (2) Continuing the rehabilitation journey: following disappointment after training ended, recovery was perceived incomplete regardless of current functional status. Endeavors were now directed to maintaining gains achieved during the program. (3) Challenges: since discharge from Personalized Adapted Locomotor Training, participants identified changes in their psychological well-being and the risk of falls as challenges.

CONCLUSIONS

Personalized Adapted Locomotor Training was a positive experience. The identified challenges present future opportunities for the improved delivery of intensive locomotor training programs.

Intramedullary Lesion Length on Postoperative Magnetic Resonance Imaging is a Strong Predictor of ASIA Impairment Scale Grade Conversion Following Decompressive Surgery in Cervical Spinal Cord Injury

BACKGROUND

Evidence indicates that, over time, patients with spinal cord injury (SCI) improve neurologically in various degrees. We sought to further investigate indicators of grade conversion in cervical SCI.

OBJECTIVE

To detect predictors of ASIA impairment scale (AIS) grade conversion in SCI following surgical decompression.

METHODS

In a retrospective study, demographics, clinical, imaging, and surgical data from 100 consecutive patients were assessed for predictors of AIS grade conversion.

RESULTS

American Spinal Injury Association motor score was 17.1. AIS grade was A in 52%, B in 29%, and C in 19% of patients. Surgical decompression took place on an average of 17.6 h following trauma (≤12 h in 51 and >12 h in 49). Complete decompression was verified by magnetic resonance imaging (MRI) in 73 patients. Intramedullary lesion length (IMLL) on postoperative MRI measured 72.8 mm, and hemorrhage at the injury epicenter was noted in 71 patients. Grade conversion took place in 26.9% of AIS grade A patients, 65.5% of AIS grade B, and 78.9% of AIS grade C. AIS grade conversion had statistical relationship with injury severity score, admission AIS grade, extent of decompression, presence of intramedullary hemorrhage, American Spinal Injury Association motor score, and IMLL. A stepwise multiple logistic regression analysis indicated IMLL was the sole and strongest indicator of AIS grade conversion (odds ratio 0.950, 95% CI 0.931-0.969). For 1- and 10-mm increases in IMLL, the model indicates 4% and 40% decreases, respectively, in the odds of AIS grade conversion.

CONCLUSION

Compared with other surrogates, IMLL remained as the only predictor of AIS grade conversion.

Longitudinal Recovery and Reduced Costs After 120 Sessions of Locomotor Training for Motor Incomplete Spinal Cord Injury

OBJECTIVE

To determine the impact of long-term, body weight-supported locomotor training after chronic, incomplete spinal cord injury (SCI), and to estimate the health care costs related to lost recovery potential and preventable secondary complications that may have occurred because of visit limits imposed by insurers.

DESIGN

Prospective observational cohort with longitudinal follow-up.

SETTING

Eight outpatient rehabilitation centers that participate in the Christopher & Dana Reeve Foundation NeuroRecovery Network (NRN).

PARTICIPANTS

Individuals with motor incomplete chronic SCI (American Spinal Injury Association Impairment Scale C or D; N=69; 0.1-45y after SCI) who completed at least 120 NRN physical therapy sessions.

INTERVENTIONS

Manually assisted locomotor training (LT) in a body weight-supported treadmill environment, overground standing and stepping activities, and community integration tasks.

MAIN OUTCOME MEASURES

International Standards for Neurological Classification of Spinal Cord Injury motor and sensory scores, orthostatic hypotension, bowel/bladder/sexual function, Spinal Cord Injury Functional Ambulation Inventory (SCI-FAI), Berg Balance Scale, Modified Functional Reach, 10-m walk test, and 6-minute walk test. Longitudinal outcome measure collection occurred every 20 treatments and at 6- to 12-month follow-up after discharge from therapy.

RESULTS

Significant improvement occurred for upper and lower motor strength, functional activities, psychological arousal, sensation of bowel movement, and SCI-FAI community ambulation. Extended training enabled minimal detectable changes at 60, 80, 100, and 120 sessions. After detectable change occurred, it was sustained through 120 sessions and continued 6 to 12 months after treatment.

CONCLUSIONS

Delivering at least 120 sessions of LT improves recovery from incomplete chronic SCI. Because walking reduces rehospitalization, LT delivered beyond the average 20-session insurance limit can reduce rehospitalizations and long-term health costs.

Development and validation of a bowel-routine-based self-report questionnaire for sacral sparing after spinal cord injury

STUDY DESIGN

An observational study.

OBJECTIVE

To develop a self-administered tool for assessment of sacral sparing after spinal cord injury (SCI) and to test its validity in individuals with SCI.

SETTING

Peking University Third Hospital, Beijing, China.

METHODS

A 5-item SCI sacral sparing self-report questionnaire was developed based on several events that most patients might experience during bowel routine. 102 participants who sustained SCI within 12 months were asked to complete the questionnaire followed by an anorectal examination. Agreements of answers to the questionnaire and the physical examination were analyzed. Sensitivity, specificity and Youden's index of each item was calculated.

RESULTS

The first four questions regarding the S4-5 sensation including deep anal pressure showed high agreement with the results of the physical examination (κ: 0.79-0.93). Sensitivity, specificity and Youden's index were also high (all above 80%). For the fifth question related to the voluntary anal contraction, the agreement was almost perfect with good sensitivity and specificity among patients without increased anal sphincter tone (AST). In patients with increased AST, the agreement was fair.

CONCLUSION

The validity of this questionnaire for the assessment of sacral sparing in up to 12 months post injury is good except for the motor function when there was increased AST. In some situations it could be considered as an alternative tool for digital rectal examination, especially when repeated examinations are not feasible. It is suggested that change of sacral sparing may be detected by the questionnaire.

Nutech functional score: A novel scoring system to assess spinal cord injury patients

AIM

To develop a new scoring system, nutech functional scores (NFS) for assessing the patients with spinal cord injury (SCI).

METHODS

The conventional scale, American Spinal Injury Association’s (ASIA) impairment scale is a measure which precisely describes the severity of the SCI. However, it has various limitations which lead to incomplete assessment of SCI patients. We have developed a 63 point scoring system, i.e., NFS for patients suffering with SCI. A list of symptoms either common or rare that were found to be associated with SCI was recorded for each patient. On the basis of these lists, we have developed NFS.

RESULTS

These lists served as a base to prepare NFS, a 63 point positional (each symptom is sub-graded and get points based on position) and directional (moves in direction BAD → GOOD) scoring system. For non-progressive diseases, 1, 2, 3, 4, 5 denote worst, bad, moderate, good and best (normal), respectively. NFS for SCI has been divided into different groups based on the affected part of the body being assessed, i.e., motor assessment (shoulders, elbow, wrist, fingers-grasp, fingers-release, hip, knee, ankle and toe), sensory assessment, autonomic assessment, bed sore assessment and general assessment. As probability based studies required a range of (-1, 1) or at least the range of (0, 1) to be useful for real world analysis, the grades were converted to respective numeric values.

CONCLUSION

NFS can be considered as a unique tool to assess the improvement in patients with SCI as it overcomes the limitations of ASIA impairment scale.

What Is Being Trained? How Divergent Forms of Plasticity Compete To Shape Locomotor Recovery after Spinal Cord Injury

Spinal cord injury (SCI) is a devastating syndrome that produces dysfunction in motor and sensory systems, manifesting as chronic paralysis, sensory changes, and pain disorders. The multi-faceted and heterogeneous nature of SCI has made effective rehabilitative strategies challenging. Work over the last 40 years has aimed to overcome these obstacles by harnessing the intrinsic plasticity of the spinal cord to improve functional locomotor recovery. Intensive training after SCI facilitates lower extremity function and has shown promise as a tool for retraining the spinal cord by engaging innate locomotor circuitry in the lumbar cord. As new training paradigms evolve, the importance of appropriate afferent input has emerged as a requirement for adaptive plasticity. The integration of kinematic, sensory, and loading force information must be closely monitored and carefully manipulated to optimize training outcomes. Inappropriate peripheral input may produce lasting maladaptive sensory and motor effects, such as central pain and spasticity. Thus, it is important to closely consider the type of afferent input the injured spinal cord receives. Here we review preclinical and clinical input parameters fostering adaptive plasticity, as well as those producing maladaptive plasticity that may undermine neurorehabilitative efforts. We differentiate between passive (hindlimb unloading [HU], limb immobilization) and active (peripheral nociception) forms of aberrant input. Furthermore, we discuss the timing of initiating exposure to afferent input after SCI for promoting functional locomotor recovery. We conclude by presenting a candidate rapid synaptic mechanism for maladaptive plasticity after SCI, offering a pharmacological target for restoring the capacity for adaptive spinal plasticity in real time.

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.

Supraspinal Control Predicts Locomotor Function and Forecasts Responsiveness to Training after Spinal Cord Injury

Restoration of walking ability is an area of great interest in the rehabilitation of persons with spinal cord injury. Because many cortical, subcortical, and spinal neural centers contribute to locomotor function, it is important that intervention strategies be designed to target neural elements at all levels of the neuraxis that are important for walking ability. While to date most strategies have focused on activation of spinal circuits, more recent studies are investigating the value of engaging supraspinal circuits. Despite the apparent potential of pharmacological, biological, and genetic approaches, as yet none has proved more effective than physical therapeutic rehabilitation strategies. By making optimal use of the potential of the nervous system to respond to training, strategies can be developed that meet the unique needs of each person. To complement the development of optimal training interventions, it is valuable to have the ability to predict future walking function based on early clinical presentation, and to forecast responsiveness to training. A number of clinical prediction rules and association models based on common clinical measures have been developed with the intent, respectively, to predict future walking function based on early clinical presentation, and to delineate characteristics associated with responsiveness to training. Further, a number of variables that are correlated with walking function have been identified. Not surprisingly, most of these prediction rules, association models, and correlated variables incorporate measures of volitional lower extremity strength, illustrating the important influence of supraspinal centers in the production of walking behavior in humans.

Assessment of Functional Improvement without Compensation for Human Spinal Cord Injury: Extending the Neuromuscular Recovery Scale to the Upper Extremities

The Neuromuscular Recovery Scale (NRS) is a tool for measuring functional recovery in spinal cord injured (SCI) persons based on tasks that test pre-injury functional capability. The NRS has been shown to be a valid, reliable, and responsive instrument for measuring functional recovery. The NRS has been updated to include three items measuring upper extremity function, and a new scoring mechanism has been defined. The purpose of this prospective, observational study was to explore the properties of the expanded NRS, introduce and evaluate the new scoring method, and to examine the score's relationship with other SCI outcome measures. The NRS and seven other SCI outcome measures were assessed at enrollment and after every 20 locomotor training sessions in 64 participants of the NeuroRecovery Network (NRN) of the Christopher and Dana Reeve Foundation (CDRF). The NRS exhibited a dominant first principal component that correlated strongly with the new NRS score, as well as a potential secondary component discriminating upper extremity function. The new NRS score and its empirical subscales were generally well-correlated with International Standards for the Neurological Classification of Spinal Cord Injury (ISNCSCI) motor scores and other established SCI functional measures, but exhibited substantial variability at their boundary values. The NRS score was more strongly correlated with other SCI functional measures than ISNCSCI motor scores were. The new NRS score was most responsive to change brought on by locomotor training. The expanded NRS appears to be a valuable tool in measuring functional recovery from SCI; further evaluation of its psychometric properties is warranted.

Promoting Gait Recovery and Limiting Neuropathic Pain After Spinal Cord Injury

Most persons living with a spinal cord injury experience neuropathic pain in the months following their lesion, at the moment where they receive intensive gait rehabilitation. Based on studies using animal models, it has been proposed that central sensitization in nociceptive pathways (maladaptive plasticity) and plasticity related to motor learning (adaptive plasticity) share common neural mechanisms and compete with each other. This article aims to address the discrepancy between the growing body of basic science literature supporting this hypothesis and the general belief in rehabilitation research that pain and gait rehabilitation represent two independent problems. First, the main findings from basic research showing interactions between nociception and learning in the spinal cord will be summarized, focusing both on evidence demonstrating the impact of nociception on motor learning and of motor learning on central sensitization. Then, the generalizability of these findings in animal models to humans will be discussed. Finally, the way potential interactions between nociception and motor learning are currently taken into account in clinical research in patients with spinal cord injury will be presented. To conclude, recommendations will be proposed to better integrate findings from basic research into future clinical research in persons with spinal cord injury.

Rehabilitation Strategies after Spinal Cord Injury: Inquiry into the Mechanisms of Success and Failure

Body-weight supported locomotor training (BWST) promotes recovery of load-bearing stepping in lower mammals, but its efficacy in individuals with a spinal cord injury (SCI) is limited and highly dependent on injury severity. While animal models with complete spinal transections recover stepping with step-training, motor complete SCI individuals do not, despite similarly intensive training. In this review, we examine the significant differences between humans and animal models that may explain this discrepancy in the results obtained with BWST. We also summarize the known effects of SCI and locomotor training on the muscular, motoneuronal, interneuronal, and supraspinal systems in human and non-human models of SCI and address the potential causes for failure to translate to the clinic. The evidence points to a deficiency in neuronal activation as the mechanism of failure, rather than muscular insufficiency. While motoneuronal and interneuronal systems cannot be directly probed in humans, the changes brought upon by step-training in SCI animal models suggest a beneficial re-organization of the systems' responsiveness to descending and afferent feedback that support locomotor recovery. The literature on partial lesions in humans and animal models clearly demonstrate a greater dependency on supraspinal input to the lumbar cord in humans than in non-human mammals for locomotion. Recent results with epidural stimulation that activates the lumbar interneuronal networks and/or increases the overall excitability of the locomotor centers suggest that these centers are much more dependent on the supraspinal tonic drive in humans. Sensory feedback shapes the locomotor output in animal models but does not appear to be sufficient to drive it in humans.

Intermittent Hypoxia and Locomotor Training Enhances Dynamic but Not Standing Balance in Patients With Incomplete Spinal Cord Injury

OBJECTIVE

To test the effect of combined intermittent hypoxia (IH) and body weight-supported treadmill training (BWSTT) on standing and dynamic balance in persons with incomplete spinal cord injury (iSCI).

DESIGN

Randomized, triple-blind, placebo-controlled study.

SETTING

Rehabilitation medical centers.

PARTICIPANTS

Study participants (N=35) with chronic iSCI with American Spinal Injury Association grades C and D (>1y postinjury) were randomly assigned to either IH plus BWSTT (n=18) or continued normoxia (placebo) plus BWSTT protocol (n=17).

INTERVENTIONS

Participants received either IH (alternating 1.5min 9% inspired O₂ with 1.5min 21% inspired O₂, 15 cycles per day) or continued normoxia (21% O₂) combined with 45 minutes of BWSTT for 5 consecutive days, followed by 3 times per week IH or normoxia plus BWSTT, for 3 additional weeks.

MAIN OUTCOME MEASURES

Standing balance (normalized jerk and root-mean-square [RMS]) and dynamic balance (turning duration, cadence in a turn, and turn-to-sit duration) were assessed before and after IH and normoxia protocol by means of instrumented sway and instrumented timed Up and Go test.

RESULTS

There was no significant difference in standing balance between interventions for both normalized jerk and RMS instrumented sway components (both P>.05). There was a significantly faster cadence (P<.001), turning duration (P<.001), and turn-to-sit duration (P=.001) in subjects receiving IH plus BWSTT, compared with placebo.

CONCLUSIONS

A 4-week protocol of IH combined with locomotor training improves dynamic, but not standing, balance in persons with iSCI.

A Systematic Review of Experimental Strategies Aimed at Improving Motor Function after Acute and Chronic Spinal Cord Injury

While various approaches have been proposed in clinical trials aimed at improving motor function after spinal cord injury in humans, there is still limited information regarding the scope, methodological quality, and evidence associated with single-intervention and multi-intervention approaches. A systematic review performed using the PubMed search engine and the key words "spinal cord injury motor recovery" identified 1973 records, of which 39 were selected (18 from the search records and 21 from reference list inspection). Study phase ( clinicaltrials.org criteria) and methodological quality (Cochrane criteria) were assessed. Studies included proposed a broad range of single-intervention (encompassing cell therapies, pharmacology, electrical stimulation, rehabilitation) (encompassing cell therapies, pharmacology, electrical stimulation, rehabilitation) and multi-intervention approaches (that combined more than one strategy). The highest evidence level was for Phase III studies supporting the role of multi-intervention approaches that contained a rehabilitation component. Quality appraisal revealed that the percentage of selected studies classified with high risk of bias by Cochrane criteria was as follows: random sequence generation = 64%; allocation concealment = 77%; blinding of participants and personnel = 69%; blinding of outcome assessment = 64%; attrition = 44%; selective reporting = 44%. The current literature contains a high proportion of studies with a limited ability to measure efficacy in a valid manner because of low methodological strength in all items of the Cochrane risk of bias assessment. Recommendations to decrease bias are discussed and include increased methodological rigor in the study design and recruitment of study participants, and the use of electrophysiological and imaging measures that can assess functional integrity of the spinal cord (and may be sufficiently sensitive to detect changes that occur in response to therapeutic interventions).

Yoga therapy in an individual with spinal cord injury: A case report

No known research addresses the effects of yoga in those with spinal cord injury (SCI), yet yoga has the potential to improve many impairments commonly associated with SCI. This case report documents the outcomes of a yoga program in an individual with an SCI. The participant was a 59-year-old male who sustained an incomplete C3-C6 SCI. He practiced Hatha yoga for 60-min sessions, twice per week for 12 weeks and despite neurological injury, was able to complete a yoga program with modifications. Improvements were noted in balance; endurance; flexibility; posture; muscle strength of the hip extensors, hip abductors and knee extensors; and in performance of functional goals. No changes were noted in gait velocity, satisfaction in performance of goals or in overall quality of life. The participant was able to practice yoga even though he used an assistive device to walk.

Responsiveness of the Neuromuscular Recovery Scale During Outpatient Activity-Dependent Rehabilitation for Spinal Cord Injury

BACKGROUND

The Neuromuscular Recovery Scale (NRS) was developed by researchers and clinicians to functionally classify people with spinal cord injury (SCI) by measuring functionally relevant motor tasks without compensation. Previous studies established strong interrater and test-retest reliability and validity of the scale.

OBJECTIVE

To determine responsiveness of the NRS, a version including newly added upper-extremity items, in an outpatient rehabilitation setting.

METHODS

Assessments using the NRS and 6 other instruments were conducted at enrollment and discharge from a locomotor training program for 72 outpatients with SCI classified as American Spinal Injury Association Impairment Scale grades A to D (International Standards for Neurological Classification of Spinal Cord Injury). Mixed-model t statistics for instruments were calculated and adjusted for confounding factors (eg, sample size, demographic variables) for all patients and subgroups stratified by injury level and/or severity. The resulting adjusted response means (ARMs) and 95% confidence intervals (CIs) were used to determine responsiveness, and significant differences between instruments were identified with pairwise comparisons.

RESULTS

The NRS was significantly responsive for SCI outpatients (ARM = 1.05; CI = 0.75-1.35). Changes in motor function were detected across heterogeneous groups. Regardless of injury level or severity, the responsiveness of the NRS was equal to, and often significantly exceeded, the responsiveness of other instruments.

CONCLUSIONS

The NRS is a responsive measure that detects change in motor function during outpatient neurorehabilitation for SCI. There is potential utility for its application in randomized controlled trials and as a measure of clinical recovery across diverse SCI populations.

Quantification of Lower Extremity Kinesthesia Deficits Using a Robotic Exoskeleton in People With a Spinal Cord Injury

BACKGROUND

Our ability to sense movement is essential for motor control; however, the impact of kinesthesia deficits on functional recovery is not well monitored in the spinal cord injury (SCI) population. One problem is the lack of accurate and reliable tools to measure kinesthesia.

OBJECTIVE

The purpose of this study was to establish the validity and reliability of a quantitative robotic assessment tool to measure lower limb kinesthesia in people with SCI.

METHODS

Seventeen individuals with an incomplete SCI and 17 age-matched controls completed 2 robotic-based assessments of lower limb kinesthesia sense, separated by at least 1 week. The Lokomat, a lower limb robotic exoskeleton, was used to quantify the movement detection score bilaterally for the hip and knee joints. Four passive movement speeds (0.5, 1.0, 2.0, and 4.0 deg/s) were applied in both flexion and extension directions. Participants responded via pressing a joystick button when movement was felt.

RESULTS

The movement detection score was significantly greater in people with SCI compared with the control group, particularly at the slowest movement speed. The difference between groups was more pronounced among those classified as ASIA (American Spinal Injury Association) Impairment Scale B. Our measure showed high test-retest reliability and good internal consistency for the hip and knee joints.

CONCLUSIONS

Our findings demonstrated that lower limb kinesthesia deficits are common in the SCI population and highlighted the importance of valid and reliable tools to monitor sensory function. Future studies need to examine changes in sensory function in response to therapy.

Comprehensive assessment of walking function after human spinal cord injury

Regaining any locomotor function after spinal cord injury is not only of immediate importance for affected patients but also for clinical research as it allows to investigate mechanisms underlying motor impairment and locomotor recovery. Clinical scores inform on functional outcomes that are clinically meaningful to value effects of therapy while they all lack the ability to explain underlying mechanisms of recovery. For this purpose, more elaborate recordings of walking kinematics combined with assessments of spinal cord conductivity and muscle activation patterns are required. A comprehensive assessment framework comprising of multiple complementary modalities is necessary. This will not only allow for capturing even subtle changes induced by interventions that are likely missed by standard clinical outcome measures. It will be fundamental to attribute observed changes to naturally occurring spontaneous recovery in contrast to specific changes induced by novel therapeutic interventions beyond the improvements achieved by conventional therapy.

Training conditions that best reproduce the joint powers of unsupported walking

OBJECTIVE

To identify the clinically relevant combinations of body weight support and speed that best reproduce the joint powers of unsupported walking.

METHODS

Timing and magnitude of lower extremity joint powers were calculated for 8 neurologically intact volunteers (4M/4F) walking with 0%, 30% and 50% body weight support at three speeds (slow, comfortable, and fast). Lower extremity joint power absorption was analyzed during weight acceptance and forward propulsion. In addition, power generation was analyzed during forward propulsion. Timings and magnitudes of joint powers per condition were evaluated to identify the training combinations of body weight support and speed that best preserved the powers of unsupported walking at slow, comfortable and fast speeds.

RESULTS

For all speeds examined, increasing body weight support to 30% without changing speed provided the best match. In general, changes in speed disrupted the joint power magnitudes and timings more than application of body weight support. Increasing body weight support when faster training speeds were used proved a viable method for reproducing the joint powers of slow, unsupported walking.

CONCLUSIONS

These data provide a reference for understanding the effect of potential training conditions on power absorption and generation within the lower extremity joints during walking. It is possible to reproduce the joint powers of unsupported walking with certain combinations of body weight support and speed. We recommend applying adequate levels of BWS when training speeds are faster than the overground speed goal, as occurs during treadmill-based locomotor rehabilitation of individuals with incomplete spinal cord injury.

Exercise preconditioning protects against spinal cord injury in rats by upregulating neuronal and astroglial heat shock protein 72

The heat shock protein 72 (HSP 72) is a universal marker of stress protein whose expression can be induced by physical exercise. Here we report that, in a localized model of spinal cord injury (SCI), exercised rats (given pre-SCI exercise) had significantly higher levels of neuronal and astroglial HSP 72, a lower functional deficit, fewer spinal cord contusions, and fewer apoptotic cells than did non-exercised rats. pSUPER plasmid expressing HSP 72 small interfering RNA (SiRNA-HSP 72) was injected into the injured spinal cords. In addition to reducing neuronal and astroglial HSP 72, the (SiRNA-HSP 72) significantly attenuated the beneficial effects of exercise preconditioning in reducing functional deficits as well as spinal cord contusion and apoptosis. Because exercise preconditioning induces increased neuronal and astroglial levels of HSP 72 in the gray matter of normal spinal cord tissue, exercise preconditioning promoted functional recovery in rats after SCI by upregulating neuronal and astroglial HSP 72 in the gray matter of the injured spinal cord. We reveal an important function of neuronal and astroglial HSP 72 in protecting neuronal and astroglial apoptosis in the injured spinal cord. We conclude that HSP 72-mediated exercise preconditioning is a promising strategy for facilitating functional recovery from SCI.

Activity-based therapy for recovery of walking in individuals with chronic spinal cord injury: results from a randomized clinical trial

OBJECTIVE

To examine the effects of activity-based therapy (ABT) on neurologic function, walking ability, functional independence, metabolic health, and community participation.

DESIGN

Randomized controlled trial with delayed treatment design.

SETTING

Outpatient program in a private, nonprofit rehabilitation hospital.

PARTICIPANTS

Volunteer sample of adults (N=48; 37 men and 11 women; age, 18-66y) with chronic (≥12mo postinjury), motor-incomplete (ASIA Impairment Scale grade C or D) spinal cord injury (SCI).

INTERVENTIONS

A total of 9h/wk of ABT for 24 weeks including developmental sequencing; resistance training; repetitive, patterned motor activity; and task-specific locomotor training. Algorithms were used to guide group allocation, functional electrical stimulation utilization, and locomotor training progression.

MAIN OUTCOME MEASURES

Neurologic function (International Standards for Neurological Classification of Spinal Cord Injury); walking speed and endurance (10-meter walk test, 6-minute walk test, and Timed Up and Go test); community participation (Spinal Cord Independence Measure, version III, and Reintegration to Normal Living Index); and metabolic function (weight, body mass index, and Quantitative Insulin Sensitivity Check).

RESULTS

Significant improvements in neurologic function were noted for experimental versus control groups (International Standards for Neurological Classification of Spinal Cord Injury total motor score [5.1±6.3 vs 0.9±5.0; P=.024] and lower extremity motor score [4.2±5.2 vs -0.6±4.2; P=.004]). Significant differences between experimental and control groups were observed for 10-meter walk test speed (0.096±0.14m/s vs 0.027±0.10m/s; P=.036) and 6-minute walk test total distance (35.97±48.2m vs 3.0±25.5m; P=.002).

CONCLUSIONS

ABT has the potential to promote neurologic recovery and enhance walking ability in individuals with chronic, motor-incomplete SCI. However, further analysis is needed to determine for whom ABT is going to lead to meaningful clinical benefits.

Activity-based therapy for recovery of walking in chronic spinal cord injury: results from a secondary analysis to determine responsiveness to therapy

OBJECTIVE

To gain insight into who is likely to benefit from activity-based therapy (ABT), as assessed by secondary analysis of data obtained from a clinical trial.

DESIGN

Secondary analysis of results from a randomized controlled trial with delayed treatment design.

SETTING

Outpatient program in a private, nonprofit rehabilitation hospital.

PARTICIPANTS

Volunteer sample of adults (N=38; 27 men; 11 women; age, 22-63y) with chronic (≥12mo postinjury), motor-incomplete (American Spinal Injury Association [ASIA] Impairment Scale [AIS] grade C or D) spinal cord injury (SCI).

INTERVENTIONS

A total of 9h/wk of ABT for 24 weeks including developmental sequencing; resistance training; repetitive, patterned motor activity; and task-specific locomotor training. Algorithms were used to guide group allocation, functional electrical stimulation utilization, and locomotor training progression.

MAIN OUTCOME MEASURES

Walking speed and endurance (10-meter walk test and 6-minute walk test) and functional ambulation (timed Up and Go test).

RESULTS

This secondary analysis identified likely responders to ABT on the basis of injury characteristics: AIS classification, time since injury, and initial walking ability. Training effects were the most clinically significant in AIS grade D participants with injuries <3 years in duration. This information, along with information about preliminary responsiveness to therapy (gains after 12wk), can help predict the degree of recovery likely from participation in an ABT program.

CONCLUSIONS

ABT has the potential to promote neurologic recovery and enhance walking ability in individuals with chronic, motor-incomplete SCI. However, not everyone with goals of walking recovery will benefit. Individuals with SCI should be advised of the time, effort, and resources required to undertake ABT. Practitioners are encouraged to use the findings from this trial to assist prospective participants in establishing realistic expectations for recovery.

Treadmill training after surgical removal of a spinal tumor in infancy

BACKGROUND AND PURPOSE

Step training on a treadmill is a common intervention for adult and pediatric patients with spinal cord injuries (SCI). Treadmill training has not been used as an intervention for infants and toddlers with SCI before walking onset. This case report describes the intervention and stepping behaviors on a treadmill and overground of a toddler after the surgical removal of a rare spinal tumor resulting in SCI.

CASE DESCRIPTION

The toddler presented with an inability to step on the left, rare stepping on the right, and an apparent lack of sensation in the lower extremities. After spinal tumor excision at 5.5 weeks of age, step training on a treadmill and overground occurred once per week from 15 to 35 months of age in addition to traditional physical therapy.

OUTCOMES

Independent symmetrical stepping emerged both on and off the treadmill over 20 months. Improvements in the number and pattern of steps occurred with training. Walking speed increased, and milestones important to overground walking developed.

DISCUSSION

Independent steps developed during the intervention with little motor development of the lower extremities during the first year of life. Furthermore, improvements in stepping alternation, standing, and walking occurred despite no evidence of sensation in the lower extremities.

Can spinal cord injury patients show a worsening in ASIA impairment scale classification despite actually having neurological improvement? The limitation of ASIA Impairment Scale Classification

BACKGROUND

In our clinical training program, which includes probable American Spinal Injury Association impairment scale (AIS) grade changes in the event of recovery, we have noticed some confounding results regarding the AIS grading in spinal cord injury (SCI) patient case examples who are expected to recover. We also observed an individual case that showed a conflict between AIS grade conversion and neurological changes in European Multicenter Study on Human Spinal Cord Injury study.

STUDY DESIGN

The analysis of SCI case examples for the probable AIS grade changes in the event of recovery.

OBJECTIVES

To demonstrate the possible problems with AIS classification in SCI cases involving presumed motor and sensory changes, and to clarify the possible causes of the inverse relationship between the motor/sensory changes and AIS conversion in certain conditions.

SETTING

Ankara, Turkey.

METHODS

We studied the case examples of reference from the 2011 revision of International Standards for the Neurological Classification of Spinal Cord Injury.

RESULTS

We encountered the same unique problem of deteriorating AIS grades within the critical zones of conversion when presumed neurological improvement took place, and vice versa.

CONCLUSION

When recovery occurs without observing any motor or sensory changes while taking only the AIS into account, it would be possible to make an incorrect conclusion. This is most likely an indication of a limitation of the AIS. To enlighten this paradox, the large amount of data in SCI databases should be reanalyzed.

Are the 10 meter and 6 minute walk tests redundant in patients with spinal cord injury?

Objective

To evaluate the relationship and redundancy between gait speeds measured by the 10 Meter Walk Test (10MWT) and 6 Minute Walk Test (6MWT) after motor incomplete spinal cord injury (iSCI). To identify gait speed thresholds supporting functional ambulation as measured with the Spinal Cord Injury Functional Ambulation Inventory (SCI-FAI).

Design

Prospective observational cohort.

Setting

Seven outpatient rehabilitation centers from the Christopher and Dana Reeve Foundation NeuroRecovery Network (NRN).

Participants

249 NRN patients with American Spinal Injury Association Impairment Scale (AIS) level C (n = 20), D (n = 179) and (n = 50) iSCI not AIS evaluated, from February 2008 through April 2011.

Interventions

Locomotor training using body weight support and walking on a treadmill, overground and home/community practice.

Main Outcome Measure(s)

10MWT and 6MWT collected at enrollment, approximately every 20 sessions, and upon discharge.

Results

The 10MWT and 6MWT speeds were highly correlated and the 10MWT speeds were generally faster. However, the predicted 6MWT gait speed from the 10MWT, revealed increasing error with increased gait speed. Regression lines remained significantly different from lines of agreement, when the group was divided into fast (≥0.44 m/s) and slow walkers (<0.44 m/s). Significant differences between 6MWT and 10MWT gait speeds were observed across SCI-FAI walking mobility categories (Wilcoxon sign rank test p<.001), and mean speed thresholds for limited community ambulation differed for each measure. The smallest real difference for the 6MWT and 10MWT, as well as the minimally clinically important difference (MCID) values, were also distinct for the two tests.

Conclusions

While the speeds were correlated between the 6MWT and 10MWT, redundancy in the tests using predictive modeling was not observed. Different speed thresholds and separate MCIDs were defined for community ambulation for each test.

Early rehabilitation improves neurofunctional outcome after surgery in children with spinal tumors

To investigate the effect of early rehabilitation on neurofunctional outcome after surgery in children with spinal tumors, this study reviewed the medical charts and radiographic records of 70 pediatric patients (1–17 years old) who received spinal tumor surgical removal. The peddiatric patients received rahabilitation treatment at 4 (range, 2–7) days after surgery for 10 (range, 7–23) days. Results from the Modified McCormick Scale, Functional Independence Measure for Children, American Spinal Injury Association Impairment Scale and Karnofsky Performance Status Scale demonstrated that the sensory function, motor function and activity of daily living of pediatric children who received early rehabilitation were significantly improved. Results also showed that tumor setting and level localization as well as patients's clinical symptoms have no influences on neurofunctional outcomes.

Elevated MMP-9 in the lumbar cord early after thoracic spinal cord injury impedes motor relearning in mice

Spinal cord injury results in distant pathology around putative locomotor networks that may jeopardize the recovery of locomotion. We previously showed that activated microglia and increased cytokine expression extend at least 10 segments below the injury to influence sensory function. Matrix metalloproteinase-9 (MMP-9) is a potent regulator of acute neuroinflammation. Whether MMP-9 is produced remote to the injury or influences locomotor plasticity remains unexamined. Therefore, we characterized the lumbar enlargement after a T9 spinal cord injury in C57BL/6 (wild-type [WT]) and MMP-9-null (knock-out [KO]) mice. Within 24 h, resident microglia displayed an activated phenotype alongside increased expression of progelatinase MMP-3 in WT mice. By 7 d, increases in active MMP-9 around lumbar vasculature and production of proinflammatory TNF-α were evident. Deletion of MMP-9 attenuated remote microglial activation and restored TNF-α expression to homeostatic levels. To determine whether MMP-9 impedes locomotor plasticity, we delivered lumbar-focused treadmill training in WT and KO mice during early (2-9 d) or late (35-42 d) phases of recovery. Robust behavioral improvements were observed by 7 d, when only trained KO mice stepped in the open field. Locomotor improvements were retained for 4 weeks as identified using state of the art mouse kinematics. Neither training nor MMP-9 depletion alone promoted recovery. The same intervention delivered late was ineffective, suggesting that lesion site sparing is insufficient to facilitate activity-based training and recovery. Our work suggests that by attenuating remote mechanisms of inflammation, acute treadmill training can harness endogenous spinal plasticity to promote robust recovery.

Locomotor training: as a treatment of spinal cord injury and in the progression of neurologic rehabilitation

Scientists, clinicians, administrators, individuals with spinal cord injury (SCI), and caregivers seek a common goal: to improve the outlook and general expectations of the adults and children living with neurologic injury. Important strides have already been accomplished; in fact, some have labeled the changes in neurologic rehabilitation a "paradigm shift." Not only do we recognize the potential of the damaged nervous system, but we also see that "recovery" can and should be valued and defined broadly. Quality-of-life measures and the individual's sense of accomplishment and well-being are now considered important factors. The ongoing challenge from research to clinical translation is the fine line between scientific uncertainty (ie, the tenet that nothing is ever proven) and the necessary burden of proof required by the clinical community. We review the current state of a specific SCI rehabilitation intervention (locomotor training), which has been shown to be efficacious although thoroughly debated, and summarize the findings from a multicenter collaboration, the Christopher and Dana Reeve Foundation's NeuroRecovery Network.