Gait quality is improved by locomotor training in individuals with SCI regardless of training approach

<p>Abstract</p> <p>Background</p> <p>While various body weight supported locomotor training (BWSLT) approaches are reported in the literature for individuals with spinal cord injury (SCI), none have evaluated outcomes in terms of gait quality. The purpose of this study was to compare changes in measures of gait quality associated with four different BWSLT approaches in individuals with chronic motor-incomplete SCI, and to identify how gait parameters differed from those of non-disabled (ND) individuals.</p> <p>Methods</p> <p>Data were analyzed from 51 subjects with SCI who had been randomized into one of four BWSLT groups: treadmill with manual assistance (TM), treadmill with electrical stimulation (TS), overground with electrical stimulation (OG), treadmill with locomotor robot (LR). Subjects with SCI performed a 10-meter kinematic walk test before and after 12 weeks of training. Ten ND subjects performed the test under three conditions: walking at preferred speed, at speed comparable to subjects with SCI, and with a walker at comparable speed. Six kinematic gait quality parameters were calculated including: cadence, step length, stride length, symmetry index, intralimb coordination, and timing of knee extension.</p> <p>Results</p> <p>In subjects with SCI, all training approaches were associated with improvements in gait quality. After training, subjects with SCI walked at higher cadence and had longer step and stride lengths. No significant differences were found among training groups, however there was an interaction effect indicating that step and stride length improved least in the LR group. Compared to when walking at preferred speed, gait quality of ND subjects was significantly different when walking at speeds comparable to those of the subjects with SCI (both with and without a walker). Post training, gait quality measures of subjects with SCI were more similar to those of ND subjects.</p> <p>Conclusion</p> <p>BWSLT leads to improvements in gait quality (values closer to ND subjects) regardless of training approach. We hypothesize that the smaller changes in the LR group were due to the passive settings used for the robotic device. Compared to walking at preferred speed, gait quality values of ND individuals walking at a slower speed and while using a walker were more similar to those of individuals with SCI.</p

Upper Limb Capabilities, Self-Care and Fine Motor Activities with and Without Equipment in Persons with Cervical Spinal Cord Injury at Discharge from Rehabilitation and 1 Year Post-Injury

Introduction: There is little information on the impact of assistive technology or devices (AT) on function. The purpose of this project was to explore the impact of AT on self-care (SC) and fine motor (FM) function in persons with cervical SCI, and to examine the functional capabilities of those who benefit from AT. Methods: Persons with acute cervical SCI, all levels and AIS grades, with an upper extremity motor score (UEMS) \u3e 0 were enrolled. At discharge from rehabilitation and 1 year post-injury we collected the Capabilities of Upper Extremity questionnaire (CUE-Q), and the combined SC and FM questions of the SCI Functional Index (SCI-FI) and SCI-FI/AT short forms. The arm with the highest CUE-Q side score was designated the better side. The impact of AT on SC and FM function was evaluated by looking at the difference in SCI-FI and SCI-FI/AT scores, and changes over time. Results: There were 67 participants with data at rehab discharge and 1-year post-injury, 50 male and 17 female, average age 43.3 ± 15.6 years. Median scores by neurologic groupings are shown in the table. All groups demonstrated improvements in CUE-Q and SCI-FI scores from discharge to 1 year post-injury (table and radar charts). By neurologic group, AT was useful for the greatest percentage of persons classified as C4-C5 AB for FM and C6-T1 AB for SC), least useful for C6-T1 CD (charts at right). AT was helpful for the greatest number of items for SC in the C4-C5 CD group at discharge (bolded numbers in table). There tended to be less use of AT for tasks at 1 year compared to rehab discharge. For example, the percentage of persons using AT for brushing teeth at discharge was 48%, while at 1 year it was only 25%. Conclusion: Many persons with tetraplegia are able to perform self-care and fine motor tasks easier using AT, but the benefit depends on the level and severity of injury. There is a decreased reliance on AT over time, which may in part be due to continued recovery after rehabilitation discharge.https://jdc.jefferson.edu/rmposters/1013/thumbnail.jp

Budget impact analysis of robotic exoskeleton use for locomotor training following spinal cord injury in four SCI Model Systems

Background We know little about the budget impact of integrating robotic exoskeleton over-ground training into therapy services for locomotor training. The purpose of this study was to estimate the budget impact of adding robotic exoskeleton over-ground training to existing locomotor training strategies in the rehabilitation of people with spinal cord injury. Methods A Budget Impact Analysis (BIA) was conducted using data provided by four Spinal Cord Injury (SCI) Model Systems rehabilitation hospitals. Hospitals provided estimates of therapy utilization and costs about people with spinal cord injury who participated in locomotor training in the calendar year 2017. Interventions were standard of care walking training including body-weight supported treadmill training, overground training, stationary robotic systems (i.e., treadmill-based robotic gait orthoses), and overground robotic exoskeleton training. The main outcome measures included device costs, training costs for personnel to use the device, human capital costs of locomotor training, device demand, and the number of training sessions per person with SCI. Results Robotic exoskeletons for over-ground training decreased hospital costs associated with delivering locomotor training in the base case analysis. This analysis assumed no difference in intervention effectiveness across locomotor training strategies. Providing robotic exoskeleton overground training for 10% of locomotor training sessions over the course of the year (range 226–397 sessions) results in decreased annual locomotor training costs (i.e., net savings) between $1114 to$4784 per annum. The base case shows small savings that are sensitive to parameters of the BIA model which were tested in one-way sensitivity analyses, scenarios analyses, and probability sensitivity analyses. The base case scenario was more sensitive to clinical utilization parameters (e.g., how often devices sit idle and the substitution of high cost training) than device-specific parameters (e.g., robotic exoskeleton device cost or device life). Probabilistic sensitivity analysis simultaneously considered human capital cost, device cost, and locomotor device substitution. With probabilistic sensitivity analysis, the introduction of a robotic exoskeleton only remained cost saving for one facility. Conclusions Providing robotic exoskeleton for over-ground training was associated with lower costs for the locomotor training of people with SCI in the base case analyses. The analysis was sensitive to parameter assumptions

Sensory Stimulation Augments the Effects of Massed Practice Training in Individuals with Tetraplegia

Objective. To compare functional changes and cortical neuroplasticity associated with upper extremity use following massed practice training and somatosensory stimulation in persons with incomplete tetraplegia. Background. Impaired hand function severely limits the ability of individuals with tetraplegia to perform manual activities of daily living. Massed practice and somatosensory stimulation are two interventions that may be able to maximize transmission of information through the intact connections in the spinal cord. Methods. Twenty-four subjects with chronic incomplete tetraplegia were randomly assigned to one of four groups: massed practice combined with somatosensory stimulation (MP+SS), somatosensory stimulation alone (SS), massed practice alone (MP), and no intervention. Intervention sessions were 2-hours/session, 5-days/week for 3 weeks. Massed practice consisted of repetitive practice of upper extremity functional tasks. Somatosensory stimulation consisted of median nerve stimulation at sub-motor threshold. Outcome measures assessed changes in upper extremity function, pinch grip strength, sensory function, and changes in cortical excitation. Results. Following training, compared to the Control group all groups showed significant improvements in hand function. The MP+SS and SS groups demonstrated significant improvements in upper extremity function and pinch strength compared to the Control group. Only the MP+SS demonstrated a significant change in sensory scores compared to the Control group. The MP+SS and MP groups demonstrated greater change in threshold measures of cortical excitability. Conclusions. Individuals with incomplete tetraplegia obtain functional benefits from massed practice of task-oriented skills. Somatosensory stimulation appear to be a valuable adjunct to training programs designed to improve hand and upper extremity function in these individuals. Grants. This work was supported in part by the Miami Project to Cure Paralysis at the University of Miami Medical School and the Center of Excellence for Functional Recovery in Chronic SCI at the Miami VAMC

Effects of practice combined with somatosensory or motor stimulation on hand function in persons with spinal Cord Injury

Background: Individuals with chronic tetraplegia prioritize recovery of hand function as an important factor in improving their quality of life. Interventions that may improve hand function and increase corticomotor excitability are functional electrical stimulation (FES), somatosensory stimulation (SS), and task-oriented training. Objective: We compared functional and corticomotor outcomes in a control condition to changes associated with FES (triggered via electromygraphic signals) and with SS (constant trains), each combined with either unimanual or bimanual training. Methods: Using a randomized, clinical trial design, comparisons were made to a delayed intervention control group. Participants (n = 24) had chronic tetraplegia, with the ability to activate thenar muscles, and were randomly assigned to either the immediate intervention (intervention) or control/delayed intervention groups. Primary analyses compared intervention (FES or SS) to control/delayed intervention. Secondary analyses compared subgroups of FES versus SS (regardless of uni-or bilateral training) and uni-versus bimanual training (regardless of stimulation type). Outcomes were assessed before and after the control and the intervention period. Results: Compared to control/delayed intervention, the intervention group had greater changes in unimanual function and corticomotor area, regardless of whether practice was combined with FES or with SS. Irrespective of stimulation type, the bimanual subgroups improved to a greater extent than the unimanual subgroups on the bimanual hand function test. Conclusions: Hand training combined with either SS or FES was associated with improved hand use and corticomotor activity in persons with chronic tetraplegia. Both interventions appear to be equally effective. © 2013 Thomas Land Publishers, Inc

Impaired posture-dependent modulation of disynaptic reciprocal Ia inhibition in individuals with incomplete spinal cord injury

Posture influences the strength of spinal reflex circuits in healthy individuals. The purpose of this study was to determine the extent to which sitting and standing posture influences the strength of reciprocal Ia inhibition between ankle flexor and extensor muscles in individuals with incomplete spinal cord injury (SCI). Ten individuals with SCI and 15 healthy individuals participated in the study. Short-latency reciprocal inhibition was measured by conditioning the soleus H-reflex with stimulation of the common peroneal nerve. There was no significant difference in the strength of reciprocal Ia inhibition in sitting and standing positions in individuals with SCI. However, healthy individuals showed increased inhibition in a standing compared to a sitting position. The results suggest an impaired posture-dependent modulation of reciprocal Ia inhibition following SCI

Locomotor Training Approaches for Individuals with Spinal Cord Injury: A Preliminary Report of Walking-related Outcomes

BACKGROUND AND PURPOSEBody weight supported (BWS) locomotor training improves overground walking ability in individuals with motor-incomplete spinal cord injury (SCI). While there are various approaches available for locomotor training, there is no consensus regarding which of these is optimal. The purpose of this ongoing investigation is to compare outcomes associated with these different training approaches. SUBJECTS AND METHODSTwenty-seven subjects with chronic motor-incomplete SCI have completed training and initial and final testing at the time of this preliminary report. Subjects were randomly assigned to 1 of 4 different BWS assisted-stepping groups, including(1) treadmill training with manual assistance (TM), (2) treadmill training with stimulation (TS), (3) overground training with stimulation (OG), or (4) treadmill training with robotic assistance (LR). Prior to and following participation we assessed walking-related outcome measures including overground walking speed, training speed, step length, and step symmetry. RESULTSData pooled across all subject groups showed a significant effect of training on walking speed. While the differences between groups were not statistically significant, there was a trend toward greater improvement in the TS and OG groups. Post hoc subgroup analysis of outcomes from subjects with slower initial walking speed (< 0.1 m/s; n = 15) compared to those with faster initial walking speeds (≥ 0.1 m/s; n = 12) identified meaningful differences in outcomes with walking speed increasing by 85% in the slower group and by only 9% in the faster group. Step length of both stronger and weaker limb increased in all groups with the exception of those in the LR group. Step symmetry was increased in the TM and LR groups. DISCUSSION AND CONCLUSIONThese results represent preliminary findings of changes in walking-related function associated with different forms of BWS locomotor training for individuals with chronic, motor-incomplete SCI. Early data indicates that locomotor outcomes in these individuals appear to be comparable across training approaches. For the individuals in this study sample, those with the greatest deficits in walking function benefitted the most from locomotor training