Validity of the walking scale for spinal cord injury and other domains of function in a multicenter clinical trial

Exploring the potential of routine serological markers in predicting neurological outcomes in spinal cord injury

Spinal cord injury (SCI) is a rare condition with a heterogeneous presentation, making the prediction of recovery challenging. However, serological markers have been shown to be associated with severity and long-term recovery following SCI. Therefore, our investigation aimed to assess the feasibility of translating this association into a prediction of the lower extremity motor scores (LEMS) at chronic stage (52 weeks after initial injury) in patients with SCI using routine serological markers. Serological markers, assessed within the initial seven days post-injury in the observational cohort study from the Trauma Hospital Murnau underwent diverse feature engineering approaches. These involved arithmetic measurements such as mean, median, minimum, maximum, and range, as well as considerations of the frequency of marker testing and whether values fell within the normal range. To predict LEMS scores at the chronic stage, eight different regression models (including linear, tree-based, and ensemble models) were used to quantify the predictive value of serological markers relative to a baseline model that relied on the very acute LEMS score and patient age alone. The inclusion of serological markers did not improve the performance of the prediction model. The best-performing approach including serological markers achieved a mean absolute error (MAE) of 6.59 (2.14), which was equivalent to the performance of the baseline model. As an alternative approach, we trained separate models based on the LEMS observed at the very acute stage after injury. Specifically, we considered individuals with an LEMS of 0 or an LEMS exceeding zero separately. This strategy led to a mean improvement in MAE across all cohorts and models, of 1.20 (2.13). We conclude that, in our study, routine serological markers hold limited power for prediction of LEMS. However, the implementation of model stratification by the very acute LEMS markedly enhanced prediction performance. This observation supports the inclusion of clinical knowledge in the modeling of prediction tasks for SCI recovery. Additionally, it lays the path for future research to consider stratified analyses when investigating the predictive power of potential biomarkers.

Amplify Gait to Improve Locomotor Engagement in Spinal Cord Injury (AGILE SCI) trial: study protocol for an assessor blinded randomized controlled trial

BACKGROUND

Among ambulatory people with incomplete spinal cord injury (iSCI), balance deficits are a primary factor limiting participation in walking activities. There is broad recognition that effective interventions are needed to enhance walking balance following iSCI. Interventions that amplify self-generated movements (e.g., error augmentation) can accelerate motor learning by intensifying sensorimotor feedback and facilitating exploration of motor control strategies. These features may be beneficial for retraining walking balance after iSCI. We have developed a cable-driven robot that creates a movement amplification environment during treadmill walking. The robot applies a continuous, laterally-directed, force to the pelvis that is proportional in magnitude to real-time lateral velocity. Our purpose is to investigate the effects of locomotor training in this movement amplification environment on walking balance. We hypothesize that for ambulatory people with iSCI, locomotor training in a movement amplification environment will be more effective for improving walking balance and participation in walking activities than locomotor training in a natural environment (no applied external forces).

METHODS

We are conducting a two-arm parallel-assignment intervention. We will enroll 36 ambulatory participants with chronic iSCI. Participants will be randomized into either a control or experimental group. Each group will receive 20 locomotor training sessions. Training will be performed in either a traditional treadmill environment (control) or in a movement amplification environment (experimental). We will assess changes using measures that span the International Classification of Functioning, Disability and Health (ICF) framework including 1) clinical outcome measures of gait, balance, and quality of life, 2) biomechanical assessments of walking balance, and 3) participation in walking activities quantified by number of steps taken per day.

DISCUSSION

Training walking balance in people with iSCI by amplifying the individual's own movement during walking is a radical departure from current practice and may result in new strategies for addressing balance impairments. Knowledge gained from this study will expand our understanding of how people with iSCI improve walking balance and how an intervention targeting walking balance affects participation in walking activities. Successful outcomes could motivate development of clinically feasible tools to replicate the movement amplification environment within clinical settings.

TRIAL REGISTRATION

NCT04340063.

Relationship of serial muscle ultrasound of rectus femoris and ambulatory recovery in patients with acute incomplete spinal cord injury: A prospective observational study

CONTEXT/OBJECTIVE

To investigate the change in serial muscle ultrasound of rectus femoris of patients with incomplete spinal cord injury (SCI) performed within 2 months after SCI during acute rehabilitation, and the relationship with functional outcomes at 1 year post-injury.

DESIGN

Prospective observational study.

SETTING

Inpatient multi-speciality tertiary rehabilitation center in Singapore.

PARTICIPANTS

Fifty-four patients with incomplete SCI, defined as American Spinal Injury Association Impairment Scale B-D, with SCI above L2, were recruited from March 2020 to June 2021. Serial muscle ultrasound of the rectus femoris thickness and echo intensity were obtained at 1 week post-injury and after 2 months via standardized protocols.

OUTCOME MEASURES

Functional Independence Measure (FIM) motor score, Lower Extremity Motor Score (LEMS), Spinal Cord Independence Measure III (SCIM III) indoor mobility component and Walking Index for Spinal Cord Injury II (WISCI II) were assessed in the first week post-admission and at 1 year.

RESULTS

There was a significant positive correlation between change in rectus femoris muscle thickness over 2 months and FIM motor score (P < 0.001), LEMS (P < 0.001), SCIM III indoor mobility component (P < 0.001) and WISCI II (P < 0.001) at 1 year. For the change in echo intensity over 2 months, there was a significantly negative correlation with FIM motor score (P = 0.002), LEMS (P = 0.002), SCIM III indoor mobility component (P = 0.001) and WISCI II (P = 0.001) at 1 year.

CONCLUSION

The findings suggest that ultrasonographic serial assessment of rectus femoris muscle thickness and echo intensity during rehabilitation may be useful for determining the long-term functional outcomes in patients with incomplete SCI.

The relationship between balance control and thigh muscle strength and muscle activity in persons with incomplete spinal cord injury

STUDY DESIGN

Cross-sectional study.

OBJECTIVES

A spinal cord injury (SCI) can compromise the ability to maintain sufficient balance control during activities in an upraised position. The objective of the study was to explore the relationship between balance control and muscle strength and muscle activation in the lower extremities in persons with incomplete SCI (iSCI).

SETTING

Sunnaas Rehabilitation Hospital, Norway.

METHODS

Thirteen men and two women with iSCI and 15 healthy, matched controls were included. Performance of the Berg Balance Scale (BBS) short version (7 items) was used to indicate balance control. Maximal voluntary contraction (MVC) was performed to measure isometric muscle strength in thigh muscles (knee extension/flexion), while surface electromyography (EMG) was measured from M. Vastus Lateralis and M. Biceps Femoris. The relative activation of each muscle during each of the BBS tasks was reported as the percentage of the maximal activation during the MVC (%EMGmax).

RESULTS

The iSCI participants had a significantly lower BBS sum score and up to 40% lower muscle strength in knee- flexion and extension compared to the matched healthy controls. They also exhibited a significantly higher %EMGmax, i.e. a higher muscle activation, during most of the balance tests. Univariate regression analysis revealed a significant association between balance control and mean values of %EMGmax in Biceps Femoris, averaged over the seven BBS tests.

CONCLUSIONS

The participants with iSCI had poorer balance control, reduced thigh muscle strength and a higher relative muscle activation in their thigh muscles, during balance-demanding activities.

Construct Validity of the Gait Deviation Index for People With Incomplete Spinal Cord Injury (GDI-SCI)

BACKGROUND

The Gait Deviation Index for Spinal Cord Injury (SCI-GDI) was recently proposed as a dimensionless multivariate kinematic measure based on 21 gait features derived from 3-dimensional kinematic data which quantifies gait impairment of adult population with incomplete spinal cord injury (iSCI) relative to the normative gait of a healthy group. Nevertheless, no validity studies of the SCI-GDI have been published to date.

OBJECTIVE

To assess the construct validity of the SCI-GDI in adult population following iSCI. Methods. SCI-GDI data were obtained from a sample of 50 healthy volunteers and 35 adults with iSCI. iSCI group was also assessed with the following measures: 10-Meter Walk Test (10MWT) at both self-selected (SS) and maximum speeds, Timed Up and Go Test (TUGT), SS and maximum levels of the Walking Index for Spinal Cord Injury (WISCI) II, mobility items of the Spinal Cord Independence Measure III (SCIM IIIIOMob), Lower Extremity Motor Score (LEMS), and Modified Ashworth Scale (MAS). Spearman's correlation coefficient was used to investigate the relationship with the SCI-GDI.

RESULTS

SCI-GDI shows strong correlation with the 10MWT (r ≥ -.716) and good correlation with LEMS (r = .638), TUGT (r = -.582), SS WISCI II levels (r = .521), and SCIM IIIIOMob (r = .501). No significant correlations were found with maximum WISCI II levels and MAS (P > .006).

CONCLUSIONS

Construct validity of the SCI-GDI was demonstrated with the 10MWT, TUGT, LEMS, SCIM IIIIOMob, and SS WISCI II levels for independently walking adults with iSCI. Future work will include assessing the psychometric characteristics with a more heterogeneous sample, also considering the pediatric population.

The effect of high-frequency repetitive transcranial magnetic stimulation on motor recovery and gait parameters in chronic incomplete spinal cord injury: A randomized-controlled study

Objectives

This study aims to examine the effect of high-frequency repetitive transcranial magnetic stimulation (rTMS) on gait parameters and lower extremity motor recovery in a more specific sample of individuals with chronic and traumatic incomplete spinal cord injury (iSCI).

Patients and methods

This double-blind, sham-controlled, randomized study included a total of 28 individuals (20 males, 8 females; mean age: 35.7±12.1 years; range, 18 to 45 years) with chronic (>1 year) traumatic iSCI. The participants were randomly allocated to either sham rTMS group (n=14) or real rTMS group (n=14). We compared the groups based on the lower extremity motor scores (LEMS), the temporal-spatial gait measurements using three-dimensional gait analysis, the Walking Index for SCI-II (WISCI-II), and 10-m walking test at baseline, three weeks (post-treatment) and five weeks (follow-up) after the treatment.

Results

The real rTMS group revealed a significant improvement in walking speed, LEMS score, and 10-m walking test after the treatment compared to baseline (p=0.001, p=0.002, and p=0.023, respectively). Changes in the LEMS score were significantly increased in the real rTMS group compared to the sham group at both three and five weeks (p=0.001 and p=0.001, respectively). No significant difference was observed in the other variables between the groups (p>0.05).

Conclusion

Our study findings support the therapeutic effectiveness of rTMS on motor recovery in chronic iSCI. The rTMS can be used as an adjuvant therapy to conventional physiotherapy in the rehabilitation of patients with iSCI.

A 50-step walking test for analysis of recovery after decompressive surgery for thoracolumbar disc herniation in dogs

BACKGROUND

Despite its importance, there is no agreed definition of recovery of ambulation in dogs with spinal cord injury.

OBJECTIVES

To validate a new walking test in dogs recovering from thoracolumbar spinal cord injury.

ANIMALS

Two hundred twenty-four dogs weighing <20 kg: 120 normally ambulatory dogs, plus 104 dogs undergoing decompressive surgery for acute thoracolumbar intervertebral disc herniation.

METHODS

Prospective cohort studies. The distance each freely-ambulatory dog walked during 50 step cycles was regressed on ulna length. For each postsurgical dog, we recorded when the calculated 50-step distance was completed without falling, or their inability to complete this distance by 4 months or more after surgery. Bayesian analysis compared outcomes for presurgical neurologic categories; association of recovery with several preoperative variables was explored using logistic and time-to-event regression.

RESULTS

For control dogs, 50-step distance (m) = 1.384 × ulnar length (cm) + 2.773. In postsurgical dogs, the 50-step test provided decisive evidence that deep pain-negative dogs were less likely to recover ambulation than dogs with intact pain perception (12/29 recovered vs 71/75; Bayes factor [BF] = 5.9 × 106 ) and, if they did recover, it took much longer (median 91 days vs median 14 days; BF = 1.5 × 103 ). Exploratory analysis suggested that presurgical neurologic status (subhazard ratio [SHR] = 0.022; P < .001) and duration of presurgical anesthesia (SHR = 0.740; P = .04) were associated with rapidity of recovery.

CONCLUSIONS AND CLINICAL IMPORTANCE

This straightforward 50-step walking test provides robust data on ambulatory recovery well-suited to large scale pragmatic trials on treatment of thoracolumbar spinal cord injury in dogs.

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

Introduction

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

Methods

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

Results

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

Conclusions

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

Application of the Gait Deviation Index to Study Gait Impairment in Adult Population With Spinal Cord Injury: Comparison With the Walking Index for Spinal Cord Injury Levels

The Gait Deviation Index (GDI) is a multivariate measure of overall gait pathology based on 15 gait features derived from three-dimensional (3D) kinematic data. GDI aims at providing a comprehensive, easy to interpret, and clinically meaningful metric of overall gait function. It has been used as an outcome measure to study gait in several conditions: cerebral palsy (CP), post-stroke hemiparetic gait, Duchenne muscular dystrophy, and Parkinson’s disease, among others. Nevertheless, its use in population with Spinal Cord Injury (SCI) has not been studied yet. The aim of the present study was to investigate the applicability of the GDI to SCI through the assessment of the relationship of the GDI with the Walking Index for Spinal Cord Injury (WISCI) II. 3D gait kinematics of 34 patients with incomplete SCI (iSCI) was obtained. Besides, 3D gait kinematics of a sample of 50 healthy volunteers (HV) was also gathered with Codamotion motion capture system. A total of 302 (iSCI) and 446 (HV) strides were collected. GDI was calculated for each stride and grouped for each WISCI II level. HV data were analyzed as an additional set. Normal distribution for each group was assessed with Kolmogorov-Smirnov tests. Afterward, ANOVA tests were performed between each pair of WISCI II levels to identify differences among groups (p < 0.05). The results showed that the GDI was normally distributed across all WISCI II levels in both iSCI and HV groups. Furthermore, our results showed an increasing relationship between the GDI values and WISCI II levels in subjects with iSCI, but only discriminative in WISCI II levels 13, 19, and 20. The index successfully distinguished HV group from all the individuals with iSCI. Findings of this study indicated that the GDI is not an appropriate multivariate walking metric to represent the deviation of gait pattern in adult population with iSCI from a normal gait profile when it is compared with the levels of walking impairment described by the WISCI II. Future work should aim at defining and validating an overall gait index derived from 3D kinematic gait variables appropriate for SCI, additionally taking into account other walking ability outcome measures.

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

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

Early Clinical Prediction of Independent Outdoor Functional Walking Capacity in a Prospective Cohort of Traumatic Spinal Cord Injury Patients

OBJECTIVE

The first objective was to identify a method for early prediction of independent outdoor functional walking 1 yr after a traumatic spinal cord injury using the motor and sensory function derived from the International Standards for Neurological Classification of Spinal Cord Injury assessment during acute care. Then, the second objective was to develop a clinically relevant prediction rule that would be accurate, easy to use, and quickly calculated in clinical setting.

DESIGN

A prospective cohort of 159 traumatic spinal cord injury patients was analyzed. Bivariate correlations were used to determine the assessment method of motor strength and sensory function as well as the specific dermatomes and myotomes best associated with independent outdoor functional walking 1 yr after injury. An easy-to-use clinical prediction rule was produced using a multivariable linear regression model.

RESULTS

The highest motor strength for a given myotome (L3 and L5) and preserved light touch sensation (dermatome S1) were the best predictors of the outcome. The proposed prediction rule displayed a sensitivity of 84.21%, a specificity of 85.54%, and a global accuracy of 84.91% for classification.

CONCLUSIONS

After an acute traumatic spinal cord injury, accurately predicting the ability to walk is challenging. The proposed clinical prediction rule aims to enhance previous work by identifying traumatic spinal cord injury patients who will reach a mobility level that fosters social participation and quality of life in the chronic period after the injury.

TO CLAIM CME CREDITS

Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME.

CME OBJECTIVES

Upon completion of this article, the reader should be able to: (1) Revise the different motor and sensory function assessment methods used for prognostication of walking after an acute traumatic spinal cord injury; (2) Identify clinical factors that are significantly associated with functional walking 1 yr after a traumatic spinal cord injury; and (3) Accurately estimate the likelihood of reaching independent outdoor functional walking in the chronic phase after an acute traumatic spinal cord injury.

LEVEL

Advanced.

ACCREDITATION

The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Walking Ability Outcome Measures in Individuals with Spinal Cord Injury: A Systematic Review

Walking function recovery in spinal cord injury (SCI) is tackled through several therapeutic approaches in which precise evaluation is essential. A systematic review was performed to provide an updated qualitative review of walking ability outcome measures in SCI and to analyze their psychometric properties. PubMed, Cochrane, and PEDro databases were consulted until 1 April 2020. Seventeen articles written in English were included. Five of them studied the walking index for SCI, four studied the 10 meter walk test, and two studied the six-minute walk test, the timed Up and go test, and the Berg balance scale. The rest of the articles studied the following metrics: gait profile score, spinal cord injury functional ambulation profile, five times sit-to-stand test, spinal cord injury functional ambulation inventory, spinal cord independence measure (indoors and outdoors mobility items), locomotor stages in spinal cord injury, community balance and mobility scale, and activity-based balance level evaluation scale. The choice of a single or a set of metrics should be determined by the clinician. Based on the results obtained in this review, a combination of outcome measures is proposed to assess walking ability. Future work is required to integrate a more realistic environment for walking assessment.

Toward Improving the Prediction of Functional Ambulation After Spinal Cord Injury Though the Inclusion of Limb Accelerations During Sleep and Personal Factors

OBJECTIVE

To determine if functional measures of ambulation can be accurately classified using clinical measures; demographics; personal, psychosocial, and environmental factors; and limb accelerations (LAs) obtained during sleep among individuals with chronic, motor incomplete spinal cord injury (SCI) in an effort to guide future, longitudinal predictions models.

DESIGN

Cross-sectional, 1-5 days of data collection.

SETTING

Community-based data collection.

PARTICIPANTS

Adults with chronic (>1 year), motor incomplete SCI (N=27).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Ambulatory ability based on the 10-m walk test (10MWT) or 6-minute walk test (6MWT) categorized as nonambulatory, household ambulator (0.01-0.44 m/s, 1-204 m), or community ambulator (>0.44 m/s, >204 m). A random forest model classified ambulatory ability using input features including clinical measures of strength, sensation, and spasticity; demographics; personal, psychosocial, and environmental factors including pain, environmental factors, health, social support, self-efficacy, resilience, and sleep quality; and LAs measured during sleep. Machine learning methods were used explicitly to avoid overfitting and minimize the possibility of biased results.

RESULTS

The combination of LA, clinical, and demographic features resulted in the highest classification accuracies for both functional ambulation outcomes (10MWT=70.4%, 6MWT=81.5%). Adding LAs, personal, psychosocial, and environmental factors, or both increased the accuracy of classification compared with the clinical/demographic features alone. Clinical measures of strength and sensation (especially knee flexion strength), LA measures of movement smoothness, and presence of pain and comorbidities were among the most important features selected for the models.

CONCLUSIONS

The addition of LA and personal, psychosocial, and environmental features increased functional ambulation classification accuracy in a population with incomplete SCI for whom improved prognosis for mobility outcomes is needed. These findings provide support for future longitudinal studies that use LA; personal, psychosocial, and environmental factors; and advanced analyses to improve clinical prediction rules for functional mobility outcomes.

Validation of the Spinal Cord Injury Functional Index for Use in Community-Dwelling Individuals With SCI

OBJECTIVE

To evaluate the psychometric properties of the Spinal Cord Injury Functional Index (SCI-FI) instruments in a community-dwelling sample.

DESIGN

Cross-sectional study.

SETTING

Community setting.

PARTICIPANTS

Individuals (N=269) recruited from 6 SCI Model Systems sites.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Participants completed computer adaptive test and short form versions of 4 SCI-FI/Capacity (C) banks (ie, Ambulation, Basic Mobility, Fine Motor, Self-Care) and 1 SCI-FI/Assistive Technology (AT) bank (Wheelchair Mobility) at baseline and after 2 weeks. The Self-Report Functional Measure (SRFM) and the clinician-rated motor FIM were used to evaluate evidence of convergent validity.

RESULTS

Pearson correlations, intraclass correlation coefficients, minimal detectable change, and Bland-Altman plots supported the test-retest reliability of the SCI-FI instruments. Correlations were large with the SRFM (.69-.89) and moderate-to-large for the FIM instrument (.44-.64), supporting convergent validity. Known-groups validity was demonstrated by a significant main effect of injury level on all instruments and a main effect of injury completeness on the SCI-FI/C instruments. A ceiling effect was detected for individuals with incomplete paraplegia on the Fine Motor/C and Self-Care/C Short Forms.

CONCLUSION

Findings support the test-retest reliability, convergent validity, and known-groups validity of the SCI-FI/C instruments and the SCI-FI/AT Wheelchair Mobility instruments for use by community-dwelling individuals.

Effects of Performance-Based Training on Gait and Balance in Individuals With Incomplete Spinal Cord Injury

OBJECTIVE

To determine changes in balance and gait following a task-specific, performance-based training protocol for overground locomotor training (OLT) in individuals with motor-incomplete spinal cord injury (iSCI).

DESIGN

Convenience sample, prepilot and postpilot study.

SETTING

Human performance research laboratory.

PARTICIPANTS

Adults (N=15; 12 men and 3 women; mean age [y] ± SD, 41.5±16.9), American Spinal Injury Association Impairment Scale C or D, >6 months post-spinal cord injury.

INTERVENTIONS

Two 90-minute OLT sessions per week over 12 to 15 weeks. OLT sessions were built on 3 principles of motor learning: practice variability, task specificity, and progressive overload (movement complexity, resistance, velocity, volume). Training used only voluntary movements without body-weight support, robotics, electrical stimulation, or bracing. Subjects used ambulatory assistive devices as necessary.

MAIN OUTCOME MEASURES

Berg Balance Scale (BBS), Spinal Cord Injury Functional Ambulation Inventory (SCI-FAI) gait parameters, spatiotemporal measures of gait (step length, step width, percent stance, stance:swing ratio) from 7 participants who walked across a pressure-sensitive walkway.

RESULTS

Fourteen participants completed the OLT protocol and 1 participant completed 15 sessions due to scheduled surgery. The BBS scores showed a mean improvement of 4.53±4.09 (P<.001). SCI-FAI scores showed a mean increase of 2.47±3.44 (P=.01). Spatiotemporal measures of gait showed no significant changes.

CONCLUSION

This pilot demonstrated improvements in balance and selected gait characteristics using a task-specific, performance-based OLT for chronic iSCI.

Short-term results of intrathecal injection of low-dose bupivacaine in outpatients with chronic low back and lower extremity pain

PURPOSE

To investigate the safety and efficacy of intrathecal injection as an alternative to epidural injection for analgesia.

METHODS

Seventy consecutive outpatients with chronic low back and lower extremity pain received lumbar intrathecal injection of low-dose isobaric bupivacaine using a 25-gauge pencil-point needle. The patients received 0.5, 1.0, and 1.5 mg of bupivacaine at 1-week intervals to determine the optimal dose. Thereafter, they received two more weekly injections with the optimal dose. The safety and efficacy of the treatment were assessed over a 1-year period.

RESULTS

No serious adverse events were encountered. The optimal dose of bupivacaine (1.0 mg in 60% of patients) alleviated pain and disability (both, p < 0.0001) and provided anesthesia below L1 (L5-T6). Motor block was negligible, and balance impairment improved relative to baseline (p < 0.0001).

CONCLUSION

Intrathecal injection of low-dose bupivacaine offers a safe and effective treatment for chronic low back and lower extremity pain.

TRIAL REGISTRATION

The study was approved by the Kitasato University Hospital Ethics Committee, and written informed consent was obtained from all individual participants included in the study. This trial was registered with the University Hospital Medical Information Network (UMIN000008670). These slides can be retrieved under electronic supplementary material.

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.

Phase I-II Clinical Trial Assessing Safety and Efficacy of Umbilical Cord Blood Mononuclear Cell Transplant Therapy of Chronic Complete Spinal Cord Injury

Umbilical cord blood-derived mononuclear cell (UCB-MNC) transplants improve recovery in animal spinal cord injury (SCI) models. We transplanted UCB-MNCs into 28 patients with chronic complete SCI in Hong Kong (HK) and Kunming (KM). Stemcyte Inc. donated UCB-MNCs isolated from human leukocyte antigen (HLA ≥4:6)-matched UCB units. In HK, four patients received four 4-μl injections (1.6 million cells) into dorsal entry zones above and below the injury site, and another four received 8-μl injections (3.2 million cells). The eight patients were an average of 13 years after C5-T10 SCI. Magnetic resonance diffusion tensor imaging of five patients showed white matter gaps at the injury site before treatment. Two patients had fiber bundles growing across the injury site by 12 months, and the rest had narrower white matter gaps. Motor, walking index of SCI (WISCI), and spinal cord independence measure (SCIM) scores did not change. In KM, five groups of four patients received four 4-μl (1.6 million cells), 8-μl (3.2 million cells), 16-μl injections (6.4 million cells), 6.4 million cells plus 30 mg/kg methylprednisolone (MP), or 6.4 million cells plus MP and a 6-week course of oral lithium carbonate (750 mg/day). KM patients averaged 7 years after C3-T11 SCI and received 3-6 months of intensive locomotor training. Before surgery, only two patients walked 10 m with assistance and did not need assistance for bladder or bowel management before surgery. The rest could not walk or do their bladder and bowel management without assistance. At about a year (41-87 weeks), WISCI and SCIM scores improved: 15/20 patients walked 10 m ( p = 0.001) and 12/20 did not need assistance for bladder management ( p = 0.001) or bowel management ( p = 0.002). Five patients converted from complete to incomplete (two sensory, three motor; p = 0.038) SCI. We conclude that UCB-MNC transplants and locomotor training improved WISCI and SCIM scores. We propose further clinical trials.

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.

Differences in health, participation and life satisfaction outcomes in adults following paediatric- versus adult-sustained spinal cord injury

STUDY DESIGN

Cross-sectional.

OBJECTIVES

To compare differences in self-reported health status, participation and life satisfaction outcomes between adults with a spinal cord injury (SCI) sustained during paediatric (P) versus adulthood (A) years.

SETTING

Ontario, Canada.

METHODS

Secondary analysis of data from the Study of Health and Activity in People with SCI. Eighty-seven participants who sustained an SCI prior to age 19 (M±s.e.=25±1.5 years postinjury (YPI)) were matched for lesion level (C2-L5), severity (complete/incomplete), gender, age, education and ethnicity with 87 participants who sustained an SCI at ⩾age 19 years (M_YPI=12.8±1.1).

RESULTS

Those with a paediatric SCI reported significantly less pain, fewer visits to the physician in the past year, greater functional independence, social participation, occupational participation and minutes per day of moderate-to-vigorous physical activity than those who sustained an SCI in adulthood. No significant differences were found for the measures of depression, perceived health status or life satisfaction (P>0.05). With the exception of moderate-to-vigorous physical activity and visits to the physician in the past year, between-group differences were independent of YPI.

CONCLUSIONS

Regardless of time since injury, people who sustained a paediatric SCI reported better health and greater participation than those injured in adulthood. Nevertheless, both groups scored well below able-bodied normative values for all measures. The results highlight the importance of a comprehensive life-course approach to SCI rehabilitation, irrespective of age at the time of injury.

The energy expenditure of people with spinal cord injury whilst walking compared to an able-bodied population

BACKGROUND

In the field of spinal cord injury (SCI) research there is an emphasis on the ability to ambulate.

PURPOSE

To determine the ambulation energy expenditure (EE) and factors that affect ambulation EE in SCI participants compared to able-bodied participants.

METHODS

This was a cross-sectional study. Participants were recruited from seven SCI rehabilitation units within the Johannesburg area. The following were used: demographic questionnaire to capture participants' characteristics, modified Ashworth scale for spasticity; goniometer for range of movement (ROM); American Spinal Injury Association (ASIA) scale for patient classification; accelerometer for EE and the six-minute walk test (6MWT) for endurance. Characteristics of the study participants were summarised using descriptive statistics. Data were analysed as follows: two-sample t-test for comparison between the able-bodied and SCI sample and Pearson product moment correlations for relationship between identified factors and EE.

RESULTS

Participants comprised 45 in the SCI group and 21 in the able-bodied group. The mean energy expenditure per metre (EE/m) for the SCI participants was 0.33 (± 0.29) calories compared to 0.08 (± 0.02) calories for the able-bodied participants. A decrease in walking velocity resulted in an increase in EE. For SCI participants, every decrease in degree of hip flexion ROM resulted in a 0.003 increase in EE/m walked. A unit decrease in velocity resulted in an increase of 0.41 in EE/m walked. Energy expenditure per metre decreased from ASIA A to ASIA D. Crutch walking utilised 0.34 calories per metre less energy than walking frames (p = 0.03).

CONCLUSION

Based on this study's findings, factors to consider in order to maximise energy efficiency whilst walking are maintaining hip flexion ROM and optimising velocity of walking.

Framework for Assessment of the Usability of Lower-Extremity Robotic Exoskeletal Orthoses

Persons with neurologic conditions such as spinal cord injury, stroke, and multiple sclerosis often lose the ability to stand and walk. Robotic hip-knee-ankle-foot exoskeletal orthoses have become commercially available and may allow some of these people to stand and walk again. These devices may also have applications beyond mobility, such as exercise, amelioration of secondary complications related to lack of ambulation, and the promotion of neuroplasticity. The authors present a framework for assessment of the usability of robotic exoskeletal orthoses available now or in the near future. The framework contains six modules: Functional applications, Personal factors, Device factors, External factors, Activities, and Health outcomes. Metrics and measures are suggested for each framework factor.

Cross-cultural validation of the Persian version of the Functional Independence Measure for patients with stroke

PURPOSE

To translate and cross-culturally adapt the Functional Independence Measure (FIM) into the Persian language and to test the reliability and validity of the Persian FIM (PFIM) in patients with stroke.

METHOD

In this cross-sectional study carried out in an outpatient stroke rehabilitation center, 40 patients with stroke (mean age 60 years) were participated. A standard forward-backward translation method and expert panel validation was followed to develop the PFIM. Two experienced occupational therapists (OTs) assessed the patients independently in all items of the PFIM in a single session for inter-rater reliability. One of the OTs reassessed the patients after 1 week for intra-rater reliability.

RESULTS

There were no floor or ceiling effects for the PFIM. Excellent inter-rater and intra-rater reliability was noted for the PFIM total score, motor and cognitive subscales (ICC(agreement)0.88-0.98). According to the Bland-Altman agreement analysis, there was no systematic bias between raters and within raters. The internal consistency of the PFIM was with Cronbach's alpha from 0.70 to 0.96. The principal component analysis with varimax rotation indicated a three-factor structure: (1) self-care and mobility; (2) sphincter control and (3) cognitive that jointly accounted for 74.8% of the total variance. Construct validity was supported by a significant Pearson correlation between the PFIM and the Persian Barthel Index (r = 0.95; p < 0.001).

CONCLUSIONS

The PFIM is a highly reliable and valid instrument for measuring functional status of Persian patients with stroke.

IMPLICATIONS FOR REHABILITATION

The Functional Independence Measure (FIM) is an outcome measure for disability based on the International Classification of Functioning, Disability and Health (ICF). The FIM was cross-culturally adapted and validated into Persian language. The Persian version of the FIM (PFIM) is reliable and valid for assessing functional status of patients with stroke. The PFIM can be used in Persian speaking countries to assess the limitations in activities of daily living of patients with stroke.

The effects of the Nintendo™ Wii Fit on gait, balance, and quality of life in individuals with incomplete spinal cord injury

PURPOSE

To assess the effects of virtual reality using the NintendoTM Wii Fit on balance, gait, and quality of life in ambulatory individuals with incomplete spinal cord injury (iSCI).

RELEVANCE

There is a need for continued research to support effective treatment techniques in individuals with iSCI to maximize each individual's potential functional performance.

SUBJECTS

Five males with a mean age of 58.6 years who had an iSCI and were greater than one-year post injury.

METHODS

An interrupted time series design with three pre-tests over three weeks, a post-test within one week of the intervention, and a four-week follow up. Outcome measures: gait speed, timed up and go (TUG), forward functional reach test (FFRT) and lateral functional reach test (LFRT), RAND SF-36. Intervention consisted of one-hour sessions with varied games using the Nintendo Wii Fit twice per week for seven weeks. Survey data was also collected at post-test. Results There were statistically significant changes found in gait speed and functional reach. The changes were also maintained at the four-week follow up post-test. Survey reports suggested improvements in balance, endurance, and mobility with daily tasks at home.

CONCLUSION

All subjects who participated in training with the NintendoTM Wii Fit demonstrated statistically significant improvements in gait speed and functional reach after seven weeks of training. Given the potential positive impact that the NintendoTM Wii Fit has on functional reach and gait speed in patients with iSCI, physical therapists may want to incorporate these activities as part of a rehabilitation program.

Influence of Spinal Cord Integrity on Gait Control in Human Spinal Cord Injury

Background Clinical trials in spinal cord injury (SCI) primarily rely on simplified outcome metrics (ie, speed, distance) to obtain a global surrogate for the complex alterations of gait control. However, these assessments lack sufficient sensitivity to identify specific patterns of underlying impairment and to target more specific treatment interventions. Objective To disentangle the differential control of gait patterns following SCI beyond measures of time and distance. Methods The gait of 22 individuals with motor-incomplete SCI and 21 healthy controls was assessed using a high-resolution 3-dimensional motion tracking system and complemented by clinical and electrophysiological evaluations applying unbiased multivariate analysis. Results Motor-incomplete SCI patients showed varying degrees of spinal cord integrity (spinal conductivity) with severe limitations in walking speed and altered gait patterns. Principal component (PC) analysis applied on all the collected data uncovered robust coherence between parameters related to walking speed, distortion of intralimb coordination, and spinal cord integrity, explaining 45% of outcome variance (PC 1). Distinct from the first PC, the modulation of gait-cycle variables (step length, gait-cycle phases, cadence; PC 2) remained normal with respect to regained walking speed, whereas hip and knee ranges of motion were distinctly altered with respect to walking speed (PC 3). Conclusions In motor-incomplete SCI, distinct clusters of discretely controlled gait parameters can be discerned that refine the evaluation of gait impairment beyond outcomes of walking speed and distance. These findings are specifically different from that in other neurological disorders (stroke, Parkinson) and are more discrete at targeting and disentangling the complex effects of interventions to improve walking outcome following motor-incomplete SCI.

Is the relationship among outcome variables shown in randomized trials?

BACKGROUND

Randomized controlled trials (RCTs) often have more than one primary outcome and frequently have secondary and harm outcomes. Comparison of outcomes between study arms is the primary focus of RCTs, but there are times when the relation between outcomes is important, such as determining whether an intermediate outcome and a clinical outcome have a strong association. We sought to determine how often reports of RCTs depict the relations among outcomes at the individual patient level and, for those studies that use composite outcomes, how often the relations between component elements are depicted.

METHODS

We selected 20 general, specialty and subspecialty medical journals with high impact factors that publish original clinical research. We identified every RCT in the 2011 and 2012 issues and randomly selected 10 articles per journal. For each article we recorded the number of outcomes, the number of composite outcomes and how often the relations between outcomes or elements of composite outcomes were portrayed.

RESULTS

All but 16 of the 200 RCTs had more than one outcome. Thus, outcomes could have been related in 92% of studies, but such relations were only reported in 2 (1%). A total of 33 (17%) investigations measured a composite outcome, 32 of which showed data for each component. None, however, showed cross-tabulation of the components.

CONCLUSIONS

Readers are rarely shown the relation between outcomes. Mandatory posting of datasets or requirements for detailed appendices would allow readers to see these cross-tabulations, helping future investigators know which outcomes are redundant, which provide unique information and which are most responsive to changes in the independent variables. While not every relationship between outcomes requires depiction, at present such information is seldom portrayed.

Effects of underwater treadmill training on leg strength, balance, and walking performance in adults with incomplete spinal cord injury

OBJECTIVE

To document the effects of underwater treadmill training (UTT) on leg strength, balance, and walking performance in adults with incomplete spinal cord injury (iSCI).

DESIGN

Pre-test and post-test design.

SETTING

Exercise physiology laboratory.

PARTICIPANTS

Adult volunteers with iSCI (n = 11).

INTERVENTION

Participants completed 8 weeks (3 × /week) of UTT. Each training session consisted of three walks performed at a personalized speed, with adequate rest between walks. Body weight support remained constant for each participant and ranged from 29 to 47% of land body weight. Increases in walking speed and duration were staggered and imposed in a gradual and systematic fashion.

OUTCOME MEASURES

Lower-extremity strength (LS), balance (BL), preferred and rapid walking speeds (PWS and RWS), 6-minute walk distance (6MWD), and daily step activity (DSA).

RESULTS

Significant (P < 0.05) increases were observed in LS (13.1 ± 3.1 to 20.6 ± 5.1 N·kg(-1)), BL (23 ± 11 to 32 ± 13), PWS (0.41 ± 0.27 to 0.55 ± 0.28 m·s(-1)), RWS (0.44 ± 0.31 to 0.71 ± 0.40 m·s(-1)), 6MWD (97 ± 80 to 177 ± 122 m), and DSA (593 ± 782 to 1310 ± 1258 steps) following UTT.

CONCLUSION

Physical function and walking ability were improved in adults with iSCI following a structured program of UTT featuring individualized levels of body weight support and carefully staged increases in speed and duration. From a clinical perspective, these findings highlight the potential of UTT in persons with physical disabilities and diseases that would benefit from weight-supported exercise.

Development of a database for translational spinal cord injury research

Efforts to understand spinal cord injury (SCI) and other complex neurotrauma disorders at the pre-clinical level have shown progress in recent years. However, successful translation of basic research into clinical practice has been slow, partly because of the large, heterogeneous data sets involved. In this sense, translational neurological research represents a "big data" problem. In an effort to expedite translation of pre-clinical knowledge into standards of patient care for SCI, we describe the development of a novel database for translational neurotrauma research known as Visualized Syndromic Information and Outcomes for Neurotrauma-SCI (VISION-SCI). We present demographics, descriptive statistics, and translational syndromic outcomes derived from our ongoing efforts to build a multi-center, multi-species pre-clinical database for SCI models. We leveraged archived surgical records, postoperative care logs, behavioral outcome measures, and histopathology from approximately 3000 mice, rats, and monkeys from pre-clinical SCI studies published between 1993 and 2013. The majority of animals in the database have measures collected for health monitoring, such as weight loss/gain, heart rate, blood pressure, postoperative monitoring of bladder function and drug/fluid administration, behavioral outcome measures of locomotion, and tissue sparing postmortem. Attempts to align these variables with currently accepted common data elements highlighted the need for more translational outcomes to be identified as clinical endpoints for therapeutic testing. Last, we use syndromic analysis to identify conserved biological mechanisms of recovery after cervical SCI between rats and monkeys that will allow for more-efficient testing of therapeutics that will need to be translated toward future clinical trials.

The Irvine, Beatties, and Bresnahan (IBB) Forelimb Recovery Scale: An Assessment of Reliability and Validity

The IBB scale is a recently developed forelimb scale for the assessment of fine control of the forelimb and digits after cervical spinal cord injury [SCI; (1)]. The present paper describes the assessment of inter-rater reliability and face, concurrent and construct validity of this scale following SCI. It demonstrates that the IBB is a reliable and valid scale that is sensitive to severity of SCI and to recovery over time. In addition, the IBB correlates with other outcome measures and is highly predictive of biological measures of tissue pathology. Multivariate analysis using principal component analysis (PCA) demonstrates that the IBB is highly predictive of the syndromic outcome after SCI (2), and is among the best predictors of bio-behavioral function, based on strong construct validity. Altogether, the data suggest that the IBB, especially in concert with other measures, is a reliable and valid tool for assessing neurological deficits in fine motor control of the distal forelimb, and represents a powerful addition to multivariate outcome batteries aimed at documenting recovery of function after cervical SCI in rats.

Feasibility of sensory tongue stimulation combined with task-specific therapy in people with spinal cord injury: a case study

Background

Previous evidence suggests the effects of task-specific therapy can be further enhanced when sensory stimulation is combined with motor practice. Sensory tongue stimulation is thought to facilitate activation of regions in the brain that are important for balance and gait. Improvements in balance and gait have significant implications for functional mobility for people with incomplete spinal cord injury (iSCI). The aim of this case study was to evaluate the feasibility of a lab- and home-based program combining sensory tongue stimulation with balance and gait training on functional outcomes in people with iSCI.

Methods

Two male participants (S1 and S2) with chronic motor iSCI completed 12 weeks of balance and gait training (3 lab and 2 home based sessions per week) combined with sensory tongue stimulation using the Portable Neuromodulation Stimulator (PoNS). Laboratory based training involved 20 minutes of standing balance with eyes closed and 30 minutes of body-weight support treadmill walking. Home based sessions consisted of balancing with eyes open and walking with parallel bars or a walker for up to 20 minutes each. Subjects continued daily at-home training for an additional 12 weeks as follow-up.

Results

Both subjects were able to complete a minimum of 83% of the training sessions. Standing balance with eyes closed increased from 0.2 to 4.0 minutes and 0.0 to 0.2 minutes for S1 and S2, respectively. Balance confidence also improved at follow-up after the home-based program. Over ground walking speed improved by 0.14 m/s for S1 and 0.07 m/s for S2, and skilled walking function improved by 60% and 21% for S1 and S2, respectively.

Conclusions

Sensory tongue stimulation combined with task-specific training may be a feasible method for improving balance and gait in people with iSCI. Our findings warrant further controlled studies to determine the added benefits of sensory tongue stimulation to rehabilitation training.

Induction of central nervous system plasticity by repetitive transcranial magnetic stimulation to promote sensorimotor recovery in incomplete spinal cord injury

Cortical and spinal cord plasticity may be induced with non-invasive transcranial magnetic stimulation to encourage long term potentiation or depression of neuronal circuits. Such plasticity inducing stimulation provides an attractive approach to promote changes in sensorimotor circuits that have been degraded by spinal cord injury (SCI). If residual corticospinal circuits can be conditioned appropriately there should be the possibility that the changes are accompanied by functional recovery. This article reviews the attempts that have been made to restore sensorimotor function and to obtain functional benefits from the application of repetitive transcranial magnetic stimulation (rTMS) of the cortex following incomplete spinal cord injury. The confounding issues that arise with the application of rTMS, specifically in SCI, are enumerated. Finally, consideration is given to the potential for rTMS to be used in the restoration of bladder and bowel sphincter function and consequent functional recovery of the guarding reflex.

Reliability, validity, and effectiveness of center of pressure parameters in assessing stabilometric platform in subjects with incomplete spinal cord injury: a serial cross-sectional study

Background

Spinal cord injury (SCI) can damage long tracts, affecting postural stability. Impairments in balance have recently been proposed to be highly predictive of functional recovery in patients with SCI and thus merit evaluation. In addition to common observational clinical scales, more objective evaluation methods of balance can be implemented by analyzing center of pressure (COP) parameters using stabilometric platforms (SPs). COP analysis has been used in various pathologies, but the COP parameters with regard to measurement vary, depending on the features of the target population, and have only been assessed in healthy subjects. Specifically, concerning subjects with SCI, few studies have reported COP parameters, and none has addressed the reliability, validity, or responsiveness of this measure. The objective of this serial cross-sectional study was to analyze the reliability, validity, and responsiveness of COP parameters under various conditions in incomplete SCI subjects to assess balance.

Methods

Twenty-three patients with incomplete SCI were examined 111 times for 1 year. Each session comprised administration of the Berg Balance scale, Tinetti scale, and WISCI scale and evaluation of stabilometric platform use. Stabilometry was performed under various sensory conditions (OF: open feet; CF: closed feet; OE: open eyes; CE: closed eyes), wherein several COP parameters were analyzed (L: COP path length; V: mean COP velocity, V_AP: anteroposterior COP velocity; V_LL: laterolateral COP velocity, A: COP ellipse area, SA1: x-axis of COP ellipse area; SA2: y-axis of COP ellipse area). The reliability, validity, and responsiveness of COP parameters that were associated with visual/support area conditions were analyzed.

Results

Of the COP parameters, V and arithmetically related measures had the highest reliability, validity, and effectiveness scores. Of all test conditions, OE-OF was the most valid, whereas CE-OF was the most responsive.

Conclusion

The assessment of balance in SCI subjects can be reliable, valid, and effective in acquiring V data, based on OF-OE and OF-CE conditions and heel distance values.

The effect of impedance-controlled robotic gait training on walking ability and quality in individuals with chronic incomplete spinal cord injury: an explorative study

Background

There is increasing interest in the use of robotic gait-training devices in walking rehabilitation of incomplete spinal cord injured (iSCI) individuals. These devices provide promising opportunities to increase the intensity of training and reduce physical demands on therapists. Despite these potential benefits, robotic gait-training devices have not yet demonstrated clear advantages over conventional gait-training approaches, in terms of functional outcomes. This might be due to the reduced active participation and step-to-step variability in most robotic gait-training strategies, when compared to manually assisted therapy. Impedance-controlled devices can increase active participation and step-to-step variability. The aim of this study was to assess the effect of impedance-controlled robotic gait training on walking ability and quality in chronic iSCI individuals.

Methods

A group of 10 individuals with chronic iSCI participated in an explorative clinical trial. Participants trained three times a week for eight weeks using an impedance-controlled robotic gait trainer (LOPES: LOwer extremity Powered ExoSkeleton). Primary outcomes were the 10-meter walking test (10MWT), the Walking Index for Spinal Cord Injury (WISCI II), the six-meter walking test (6MWT), the Timed Up and Go test (TUG) and the Lower Extremity Motor Scores (LEMS). Secondary outcomes were spatiotemporal and kinematics measures. All participants were tested before, during, and after training and at 8 weeks follow-up.

Results

Participants experienced significant improvements in walking speed (0.06 m/s, p = 0.008), distance (29 m, p = 0.005), TUG (3.4 s, p = 0.012), LEMS (3.4, p = 0.017) and WISCI after eight weeks of training with LOPES. At the eight-week follow-up, participants retained the improvements measured at the end of the training period. Significant improvements were also found in spatiotemporal measures and hip range of motion.

Conclusion

Robotic gait training using an impedance-controlled robot is feasible in gait rehabilitation of chronic iSCI individuals. It leads to improvements in walking ability, muscle strength, and quality of walking. Improvements observed at the end of the training period persisted at the eight-week follow-up. Slower walkers benefit the most from the training protocol and achieve the greatest relative improvement in speed and walking distance.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

MEASURES

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

RESULTS

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

CONCLUSIONS

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

Quality of residual neuromuscular control and functional deficits in patients with spinal cord injury

Study Design: Prospective cohort study.

Objective: This study examined the relationship between motor control and clinical function outcomes after spinal cord injury (SCI).

Setting: University of Louisville, Louisville, KY, USA.

Materials: Eleven persons with SCI and 5 non-injured subjects were included in this study.

Methods: The ASIA Impairment Scale (AIS) was used to categorize injury level and severity. Multi-muscle, surface EMG (sEMG) recording, was carried out using a protocol of reflex and volitional motor tasks and was analyzed using a vector-based tool that calculates index values that relate a distribution of multi-muscle activation pattern of each SCI subject to the prototype obtained from non-injured subject group and presents overall magnitude as a separate value. Functional Independence Measure motor sub-scale, Spinal Cord Injury Independence Measure (SCIM-III), and Walking Index for Spinal Cord Injury (WISCI) scale scores were compared to neurophysiological parameters.

Results: AIS category and injury level correlated significantly with the WISCI and SCIM mobility sub-scales. sEMG-derived parameters were significantly correlated with SCIM and WISCI scores but only for examinations carried out 48 or more days post-injury.

Conclusion: These results supported the hypothesis that clinically relevant function after SCI is related to the degree to which functional organization within the central nervous system is disrupted. Further, due likely to the constraints placed on the expression of functional ability by early post-injury immobilization and hospitalization, neurophysiological assessment of motor function may provide better sensitivity and reliability than can be obtained using the clinical function scales examined here within the early period after injury.

Motor and gait improvement in patients with incomplete spinal cord injury induced by high-frequency repetitive transcranial magnetic stimulation

OBJECTIVE

To assess the effect of high-frequency repetitive transcranial magnetic stimulation (rTMS) on lower extremities motor score (LEMS) and gait in patients with motor incomplete spinal cord injury (SCI).

METHOD

The prospective longitudinal randomized, double-blind study assessed 17 SCI patients ASIA D. We assessed LEMS, modified Ashworth Scale (MAS), 10-m walking test (10MWT), Walking Index for SCI (WISCI II) scale, step length, cadence, and Timed Up and Go (TUG) test at baseline, after the last of 15 daily sessions of rTMS and 2 weeks later. Patients were randomized to active rTMS or sham stimulation. Three patients from the initial group of 10 randomized to sham stimulation entered the active rTMS group after a 3-week washout period. Therefore a total of 10 patients completed each study condition. Both groups were homogeneous for age, gender, time since injury, etiology, and ASIA scale. Active rTMS consisted of 15 days of daily sessions of 20 trains of 40 pulses at 20 Hz and an intensity of 90% of resting motor threshold. rTMS was applied with a double cone coil to the leg motor area.

RESULTS

There was a significant improvement in LEMS in the active group (28.4 at baseline and 33.2 after stimulation; P = .004) but not in the sham group (29.6 at baseline, and 30.9 after stimulation; P = .6). The active group also showed significant improvements in the MAS, 10MWT, cadence, step length, and TUG, and these improvements were maintained 2 weeks later. Following sham stimulation, significant improvement was found only for step length and TUG. No significant changes were observed in the WISCI II scale in either group.

CONCLUSION

High-frequency rTMS over the leg motor area can improve LEMS, spasticity, and gait in patients with motor incomplete SCI.

Validity and reliability of the Berg Balance Scale for community-dwelling persons with lower-limb amputation

OBJECTIVE

To evaluate the validity and reliability of the Berg Balance Scale (BBS) for use in people with lower-limb amputation.

DESIGN

Cross-sectional study.

SETTING

Research laboratory.

PARTICIPANTS

Individuals (N=30; age, 54±12y; 20 men) with unilateral transtibial (n=13), unilateral transfemoral (n=14), or bilateral (n=3) lower-limb amputation of dysvascular (n=7), traumatic (n=14), infectious (n=6), or congenital (n=3) origin.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

BBS, 2-minute walk test, L test, Prosthesis Evaluation Questionnaire-Mobility Subscale, Activities-specific Balance Confidence Scale, and Frenchay Activities Index; self-reported descriptors were also collected, including frequency of prosthesis use, number of falls in 12 months before the visit, fear of falling, and daily mobility aid use.

RESULTS

The BBS had high interrater reliability (intraclass correlation coefficient =.945) and internal consistency (α=.827). Relations between the BBS scores and those of other outcome measures were all statistically significant (P≤.001). Significant group differences in BBS scores were observed for fear of falling (P=.008) and mobility aid use (P<.001), but not for multiple (≥2) falls in the previous 12 months (P=.381). BBS items involving reaching forward, turning 360°, tandem standing, and standing on 1 leg had relatively greater frequencies of lower scores across participants.

CONCLUSIONS

The BBS appears to be a valid and reliable clinical instrument for assessing balance in individuals with lower-limb amputation, but it may not be able to discriminate between individuals with greater or lesser fall risk. Limitations in prosthetic motion and control may be responsible for the challenges experienced on items of lower performance. Future studies would be useful to assess the responsiveness of the BBS to interventions aimed at improving balance in individuals with lower-limb amputation.

Correlation between time to diagnosis and rehabilitation outcomes in patients with spinal dural arteriovenous fistula

BACKGROUND

Spinal dural arteriovenous fistulas (SDAVFs) are the most common spinal vascular malformations and can be a significant cause of myelopathy although they are under diagnosed. Surgical or embolization treatment of SDAVFs improved significantly in the last decade. However, a high percentage of patients are still left with severe disability.

OBJECTIVE

To describe the correlation between time to diagnosis and the rehabilitation outcomes of eight patients with SDAVFs.

DESIGN

Retrospective chart study of all SDAVF patients in 20 years.

SETTING

A tertiary university rehabilitation center.

MAIN OUTCOME MEASURES

The lower extremities motor score (LEMS), Functional Independence Measure (FIM), Spinal Cord Independence Measure (SCIM) and Walking Scale for Spinal Cord Injury (WISC II). Overall prognosis was evaluated using the Aminoff-Logue scale (ALS).

RESULTS

There were seven men and one woman with mean age of 61.3 ± 15 (30-72) and mean time until the diagnosis of SDAVF of 265.5 ± 245 days (4-730). At the end of rehabilitation period, five of the eight patients remained wheelchair dependent. Strong correlation was found between LEMS, FIM, SCIM, and WISC II scores and the functional level according to the ALS scale. A significant correlation was found between time to diagnosis and the height of the SDAVF, the clinical and rehabilitation outcomes. Patients with high SDAVF which were diagnosed late had the poorest prognosis.

CONCLUSIONS

The potential for functional ambulation in patients with SDAVF is related to the time of intervention. This finding emphasizes the important of early diagnosis and early intervention in SDAVF.