Dose-response relationship of locomotor training in patients with spinal cord injury : preliminary results

Background: A large proportion of patients with spinal cord injury (SCI) regain ambulatory function. However, during the first 3 months most patients are unable to walk without support. To enable ambulatory training at such an early stage the body weight is partially relieved and leg movement assisted by two therapists. A more recent approach is the application of robotic-based assistance, which allows for longer training duration. From the science of motor learning and studies including patients with stroke, it is known that training effects depend on the duration of the training. Longer training results in a better walking function. Purpose: The aim of the present study is to evaluate whether prolonged robot-assisted walking training leads to a better walking outcome in patients with incomplete SCI, who are initially unable to walk independently (i.e. B and C according to the International Standards for Neurological Classification of SCI-ISNCSCI), and whether such training is feasible or is associated with undesirable effects. Methods: Patients from three sites with an acute incomplete SCI (within 60 days after injury) were randomized to either standard training (session duration 25 minutes) or intensive training (session duration 50 minutes). After 8 weeks of training walking ability (Walking Index for SCI-WISCI, scale 0-20: 0=not able to walk, 20= able to walk independently), the occurrence of adverse events and the rate of perceived exertion (RPE, scale 1-10: 1=very light, 10= very, very hard), as well as patients’ global impression of change (PGIC, scale 0 -10: 0= much better, 5= no change, 10= much worse) were compared between groups. Results: Seventeen patients with incomplete SCI were randomly assigned either to standard training (ISNCSCI B: n=6; C: n=2) or to intensive training (B: n=3; C: n=6). The average duration of training of the standard group was half the length of the intensive group (24.9±0.6 minutes vs. 48.3±3.2 minutes; p=0.01). Both groups performed an equal number of training sessions within 8 weeks (33.8±6.8 and 34.9±6.0; n.s.). The median WISCI changed from 0 to 4 in the standard group (n.s.) and from 0 to 10.5 (p<0.05) in the intensive group. However, the group difference after training did not reach statistical significance. The median RPE (standard: 6.5, range 1-10 and intensive: 6, range 1-10; n.s.) and the PGIC (standard: 3.5, range 0-5; intensive: 2.5, range 1-4; n.s.) did not differ between the standard and intensive training groups. Conclusions: Longer training using a robotic device is feasible and is not associated with undesirable effects in patients with incomplete SCI. Results show a trend towards a positive dose-response relationship. However, there was a larger proportion of patients with a motor incomplete SCI (i.e. ISNCSCI: C) in the intensive training group. Implications: The duration of a standard training session needs to be re-addressed. Results indicate that more intensive training leads to a better outcome

Elevated Autoantibodies in Subacute Human Spinal Cord Injury Are Naturally Occurring Antibodies

Spinal cord injury (SCI) results in long-term neurological and systemic consequences, including antibody-mediated autoimmunity, which has been related to impaired functional recovery. Here we show that autoantibodies that increase at the subacute phase of human SCI, 1 month after lesion, are already present in healthy subjects and directed against non-native proteins rarely present in the normal spinal cord. The increase of these autoantibodies is a fast phenomenon–their levels are already elevated before 5 days after lesion–characteristic of secondary immune responses, further supporting their origin as natural antibodies. By proteomics studies we have identified that the increased autoantibodies are directed against 16 different nervous system and systemic self-antigens related to changes known to occur after SCI, including alterations in neural cell cytoskeleton, metabolism and bone remodeling. Overall, in the context of previous studies, our results offer an explanation to why autoimmunity develops after SCI and identify novel targets involved in SCI pathology that warrant further investigation

Effectiveness of automated locomotor training in patients with acute incomplete spinal cord injury: A randomized controlled multicenter trial

The aim of this study was to evaluate if the effect of longer training times (50 instead of 25 minutes per day) using a robotic device results in a better outcome of walking ability of subjects with a sub-acute motor complete (AIS B) and incomplete (AIS C) spinal cord injury (SCI). Twenty-one patients were enrolled in the study whereof, 18 completed on average 34 trainings in eight weeks. Longer training times resulted in better locomotor function. The second important result of the study is that a beneficial effect can be achieved by the application of a robotic device for prolonged training sessions without requiring more personal resources. It has to remain open whether even longer training times (more than 50 min) would result in a still better outcome. In any case, the extent of possible recovery in an individual patient is determined by the level and severity of spinal cord damage

Prevalence of Fatigue and Associated Factors in a Spinal Cord Injury Population: Data from an Internet-Based and Face-to-Face Surveys

[Abstract] Fatigue has a profound impact on patients with spinal cord injury (SCI), but only limited treatments are available. The aim of this study was to determine the prevalence of fatigue in SCI and its association with clinical and demographic factors. We used an internet-based survey and a face-to-face interview to estimate the prevalence of fatigue in a SCI population. Fatigue was measured using the Fatigue Severity Scale (FSS). Clinically significant fatigue was defined as FSS scores greater than or equal to four. A total of 253 participants with SCI were included in the study. Clinically significant fatigue was present in one third of our sample. There was no relationship between fatigue and injury level or completeness. We found significant correlations between depression, pain, and level of injury. The relation of fatigue with completeness of injury and spasticity is less clear. Moreover, the online survey and the standard face-to-face interview showed similar results concerning fatigue evaluation. Several factors may contribute to fatigue, however. Future studies should be conducted to clarify which are the most relevant ones and, if possible, to determine which factors are modifiable