Effect of Locomotor Training on Motor Recovery and Walking Ability in Patients with Incomplete Spinal Cord Injury: A Case Series

[Purpose] The aim of this study was to describe the effect of locomotor training on a treadmill for three individuals who have an incomplete spinal cord injury (SCI). [Subjects and Methods] Three indivduals (2 males, 1 female) with incomplete paraplegia participated in this prospective case series. All subjects participated in locomotor training for a maximum of 20 minutes on a motorized treadmill without elevation at a comfortable walking speed three days a week for four weeks as an adjunct to a conventional physiotherapy program. The lower extremity strength and walking capabilities were used as the outcome measures of this study. Lower extremity strength was measured by lower extremity motor score (LEMS). Walking capability was assessed using the Walking Index for Spinal Cord Injury (WISCI II). [Results] An increase in lower extremity motor score and walking capabilities at the end of training program was found. [Conclusion] Gait training on a treadmill can enhance motor recovery and walking capabilities in subjects with incomplete SCI. Further research is needed to generalize these findings and to identify which patients might benefit from locomotor training.Key words: Locomotor training, Spinal cord injury, Paraplegia     

Locomotor training progression and outcomes after incomplete spinal cord injury

BACKGROUND AND PURPOSE: The use of locomotor training with a body-weight-support system and treadmill (BWST) and manual assistance has increased in rehabilitation. The purpose of this case report is to describe the process for retraining walking in a person with an incomplete spinal cord injury (SCI) using the BWST and transferring skills from the BWST to overground assessment and community ambulation. CASE DESCRIPTION: Following discharge from rehabilitation, a man with an incomplete SCI at C5-6 and an American Spinal Injury Association (ASIA) Impairment Scale classification of D participated in 45 sessions of locomotor training. OUTCOMES: Walking speed and independence improved from 0.19 m/s as a home ambulator using a rolling walker and a right ankle-foot orthosis to 1.01 m/s as a full-time ambulator using a cane only for community mobility. Walking activity (mean+/-SD) per 24 hours increased from 1,054+/-543 steps to 3,924+/-1,629 steps. DISCUSSION: In a person with an incomplete SCI, walking ability improved after locomotor training that used a decision-making algorithm and progression across training environments.     

Efficacy of rehabilitation robotics for walking training in neurological disorders: a review

Robotic technologies are becoming more prevalent for treating neurological conditions in clinical settings. We conducted a literature search of original articles to identify all studies that examined the use of robotic devices for restoring walking function in adults with neurological disorders. We evaluated and rated each study using either the Physiotherapy Evidence Database scale for randomized controlled trials (RCTs) or the Downs and Black scale for non-RCTs. We reviewed 30 articles (14 RCTs, 16 non-RCTs) that examined the effects of locomotor training with robotic assistance in patients following stroke, spinal cord injury (SCI), multiple sclerosis (MS), traumatic brain injury (TBI), and Parkinson disease (PD). This review supports that locomotor training with robotic assistance is beneficial for improving walking function in individuals following a stroke and SCI. Gait speed and endurance were not found to be significantly different among patients with motor incomplete SCI after a variety of locomotor training approaches. Limited evidence demonstrates that locomotor training with robotic assistance is beneficial in populations of patients with MS, TBI, or PD. We discuss clinical implications and decision making in the area of gait rehabilitation for neurological dysfunction.     

Medical and rehabilitation issues in the care of children with spinal cord injury

Rehabilitation of the child with SCI involves setting and changing goals appropriate to the child's age, development, and family expectations. Unlike adults with SCI, who may be very close to expected levels of independence at discharge from inpatient rehabilitation, children often require years of outpatient therapy to achieve optimal outcomes. Children with SCI also are at risk for unique complications, which can alter their function. The rehabilitation community extends beyond the usual hospital based practice to include school and transitional services. The focus of rehabilitation changes across stages of development to initially enhance independence in mobility and self-care skills, and later to promote academic achievement, independent living, and employment.     

Functional outcomes and disability after nontraumatic spinal cord injury rehabilitation: Results from a retrospective study

OBJECTIVE: To describe, in a group of patients undergoing initial inpatient rehabilitation after nontraumatic spinal cord injury (SCI), the demographic characteristics, clinical features, and outcomes, with a focus on the functional status and disability. DESIGN: Retrospective data analysis, 3-year case series. SETTING: Tertiary medical unit specializing in nontraumatic SCI rehabilitation. PARTICIPANTS: Consecutive sample of 70 adult inpatient referrals with nontraumatic SCI undergoing initial inpatient rehabilitation. INTERVENTION: Chart review. MAIN OUTCOME MEASURES: Primary outcomes were demographic characteristics, clinical features, mortality, length of stay (LOS), neurologic classification, accommodation setting, support services, mobility, bladder and bowel continence, and FIM instrument scores. RESULTS: Forty-one patients (58.6%) were paraplegic incomplete, 23 (32.9%) were tetraplegic incomplete, and 6 (8.6%) were paraplegic complete. Eight patients (11.4%) died before hospital discharge. Of those who survived, 47 (75.8%) were discharged home, 11 (17.7%) were transferred to a nursing home, and 4 (6.4%) went elsewhere in the community. The geometric mean LOS was 55.8 days. Nine patients (14.5%) were discharged walking unaided, 27 (43.5%) were walking at least 10 m with a gait aid, and 26 (41.9%) were wheelchair dependent for mobility. Thirty patients (48.4%) were voiding on sensation, 7 (11.1%) used intermittent catheterization, 23 (37.2%) had an indwelling catheter, and 2 (2.8%) used reflex voiding. Eleven patients (17.7%) were fecally continent on sensation and 47 (75.8%) were fecally continent with a bowel program, 1 patient (1.6%) had a colostomy, and 3 patients (4.8%) were discharged fecally incontinent. The mean Rasch FIM motor score was 39.6 on admission and 58.7 at discharge (paired t test, t=-11.2; P<.000). CONCLUSIONS: Most nontraumatic SCI patients returned home with a good level of functioning regarding mobility, bladder, and bowel status, in comparison to other studies of patients with SCI. Patients' disability was usually significantly reduced during rehabilitation.     

Balance and ambulation improvements in individuals with chronic incomplete spinal cord injury using locomotor training-based rehabilitation

Harkema SJ, Schmidt-Read M, Lorenz DJ, Edgerton VR, Behrman AL. Balance and ambulation improvements in individuals with chronic incomplete spinal cord injury using locomotor training–based rehabilitation.ObjectiveTo evaluate the effects of intensive locomotor training on balance and ambulatory function at enrollment and discharge during outpatient rehabilitation after incomplete SCI.DesignProspective observational cohort.SettingSeven outpatient rehabilitation centers from the Christopher and Dana Reeve Foundation NeuroRecovery Network (NRN).ParticipantsPatients (N=196) with American Spinal Injury Association Impairment Scale (AIS) grade C or D SCI who received at least 20 locomotor training treatment sessions in the NRN.InterventionsIntensive locomotor training, including step training using body-weight support and manual facilitation on a treadmill followed by overground assessment and community integration.Main Outcome MeasuresBerg Balance Scale; Six-Minute Walk Test; 10-Meter Walk Test.ResultsOutcome measures at enrollment showed high variability between patients with AIS grades C and D. Significant improvement from enrollment to final evaluation was observed in balance and walking measures for patients with AIS grades C and D. The magnitude of improvement significantly differed between AIS groups for all measures. Time since SCI was not associated significantly with outcome measures at enrollment, but was related inversely to levels of improvement.ConclusionsSignificant variability in baseline values of functional outcome measures is evident after SCI in individuals with AIS grades C and D and significant functional recovery can continue to occur even years after injury when provided with locomotor training. These results indicate that rehabilitation, which provides intensive activity-based therapy, can result in functional improvements in individuals with chronic incomplete SCI.     

Relationship Between ASIA Examination and Functional Outcomes in the NeuroRecovery Network Locomotor Training Program

Buehner JJ, Forrest GF, Schmidt-Read M, White S, Tansey K, Basso DM. Relationship between ASIA examination and functional outcomes in the NeuroRecovery Network Locomotor Training Program.ObjectiveTo determine the effects of locomotor training on: (1) the International Standards for Neurological Classification of Spinal Cord Injury examination; (2) locomotion (gait speed, distance); (3) balance; and (4) functional gait speed stratifications after chronic incomplete spinal cord injury (SCI).DesignProspective observational cohort.SettingOutpatient rehabilitation centers in the NeuroRecovery Network (NRN).ParticipantsIndividuals (n=225) with American Spinal Injury Association Impairment Scale (AIS) grade C or D chronic motor incomplete SCI having completed locomotor training in the NRN.InterventionThe NRN Locomotor Training Program consists of manual-facilitated body weight–supported standing and stepping on a treadmill and overground.Main Outcome MeasuresAIS classification, lower extremity pin prick, light touch and motor scores, ten-meter walk and six-minute walk tests, and the Berg Balance Scale.ResultsSignificant gains occurred in lower extremity motor scores but not in sensory scores, and these were only weakly related to gait speed and distance. Final Berg Balance Scale scores and initial lower extremity motor scores were positively related. Although 70% of subjects showed significantly improved gait speed after locomotor training, only 8% showed AIS category conversion.ConclusionsLocomotor training improves gait speed to levels sufficient for independent in-home or community ambulation after chronic motor incomplete SCI. Changes in lower extremity motor and sensory scores do not capture the full extent of functional recovery, nor predict responsiveness to locomotor training. Functional classification based on gait speed may provide an effective measure of treatment efficacy or functional improvement after incomplete SCI.     

Locomotor training after human spinal cord injury: a series of case studies

Many individuals with spinal cord injury (SCI) do not regain their ability to walk, even though it is a primary goal of rehabilitation. Mammals with thoracic spinal cord transection can relearn to step with their hind limbs on a treadmill when trained with sensory input associated with stepping. If humans have similar neural mechanisms for locomotion, then providing comparable training may promote locomotor recovery after SCI. We used locomotor training designed to provide sensory information associated with locomotion to improve stepping and walking in adults after SCI. Four adults with SCIs, with a mean postinjury time of 6 months, received locomotor training. Based on the American Spinal Injury Association (ASIA) Impairment Scale and neurological classification standards, subject 1 had a T5 injury classified as ASIA A, subject 2 had a T5 injury classified as ASIA C, subject 3 had a C6 injury classified as ASIA D, and subject 4 had a T9 injury classified as ASIA D. All subjects improved their stepping on a treadmill. One subject achieved overground walking, and 2 subjects improved their overground walking. Locomotor training using the response of the human spinal cord to sensory information related to locomotion may improve the potential recovery of walking after SCI.     

A Comparison of Robotic Walking Therapy and Conventional Walking Therapy in Individuals With Upper Versus Lower Motor Neuron Lesions: A Randomized Controlled Trial

Objective

To compare a walking reeducation program with robotic locomotor training plus overground therapy (LKOGT) to conventional overground training (OGT) in individuals with incomplete upper motor neuron (UMN) or lower motor neuron (LMN) injuries having either traumatic or nontraumatic nonprogressive etiology.

Design

Randomized open controlled trial with blind evaluation by an independent observer.

Setting

An inpatient spinal cord injury rehabilitation center.

Participants

A total of 88 adults within 6 months of spinal cord injury onset (group A, 44 with UMN injury, and group B, 44 with LMN injury) were graded on the American Spinal Injury Association Impairment Scale as C or D. Each of these groups was then randomly allocated to conditions 1 or 2.

Interventions

Condition 1: Subgroups A1 and B1 were treated with LKOGT for 60 minutes. Condition 2: Subgroups A2 and B2 received 60 minutes of conventional OGT 5 days per week for 8 weeks. Subjects with UMN and LMN were randomized into 2 training groups.

Main Outcome Measures

Ten-meter walk test and 6-minute walk test (6MWT). Walking Index for Spinal Cord Injury II, lower extremity motor score (LEMS), and the FIM-Locomotor were secondary outcome measures.

Results

By using the LKOGT program compared with OGT, we found significant differences in the 6MWT for groups A1 and B1. LKOGT also provided higher scores than did OGT in secondary outcomes such as the LEMS and the FIM-Locomotor.

Conclusions

Robotic-assisted step training yielded better results in the 6MWT and the LEMS in patients with UMN and LMN.     

Gait training in human spinal cord injury using electromechanical systems: effect of device type and patient characteristics

Benito-Penalva J, Edwards DJ, Opisso E, Cortes M, Lopez-Blazquez R, Murillo N, Costa U, Tormos JM, Vidal-Samsó J, Valls-Solé J, European Multicenter Study about Human Spinal Cord Injury Study Group, Medina J. Gait training in human spinal cord injury using electromechanical systems: effect of device type and patient characteristics.ObjectiveTo report the clinical improvements in spinal cord injury (SCI) patients associated with intensive gait training using electromechanical systems according to patient characteristics.DesignProspective longitudinal study.SettingInpatient SCI rehabilitation center.ParticipantsAdults with SCI (n=130).InterventionPatients received locomotor training with 2 different electromechanical devices, 5 days per week for 8 weeks.Main Outcome MeasuresLower-extremity motor score, Walking Index for Spinal Cord Injury, and 10-meter walking test data were collected at the baseline, midpoint, and end of the program. Patients were stratified according to the American Spinal Injury Association (ASIA) category, time since injury, and injury etiology. A subgroup of traumatic ASIA grade C and D patients were compared with data obtained from the European Multicenter Study about Human Spinal Cord Injury (EM-SCI).ResultsOne hundred and five patients completed the program. Significant gains in lower-limb motor function and gait were observed for both types of electromechanical device systems, to a similar degree. The greatest rate of improvement was shown in the motor incomplete SCI patients, and for patients <6 months postinjury. The positive response associated with training was not affected by injury etiology, age, sex, or lesion level. The trajectory of improvement was significantly enhanced relative to patients receiving the conventional standard of care without electromechanical systems (EM-SCI).ConclusionsThe use of electromechanical systems for intensive gait training in SCI is associated with a marked improvement in lower-limb motor function and gait across a diverse range of patients and is most evident in motor incomplete patients, and for patients who begin the regimen early in the recovery process.     

水中平板步行训练对脊髓损伤患者康复疗效的初步观察

目的观察水中平板步行训练对脊髓损伤患者的康复疗效。方法对11例外伤性不完全性脊髓损伤患者进行水中平板步行训练等康复治疗，记录水中平板步行训练前后的ASIA运动评分、ASIA感觉评分。以及训练时的行走距离、最大步速和训练前后的日常生活活动能力（ADL）评分变化。结果经水中平板步行训练后，患者的ASIA感觉评分提高（P〈0．05），ASIA运动评分、行走距离、最大步速及ADL评分明显提高（P〈0．01）。结论在常规康复治疗基础上进行水中平板步行训练可改善不完全性脊髓损伤患者的运动、感觉功能及生活自理能力。     

Effectiveness of automated locomotor training in patients with chronic incomplete spinal cord injury: a multicenter trial

OBJECTIVE: To determine whether automated locomotor training with a driven-gait orthosis (DGO) can increase functional mobility in people with chronic, motor incomplete spinal cord injury (SCI). DESIGN: Repeated assessment of the same patients or single-case experimental A-B design. SETTING: Research units of rehabilitation hospitals in Chicago; Heidelberg, Germany; and Basel and Zurich, Switzerland. PARTICIPANTS: Twenty patients with a chronic (>2 y postinjury), motor incomplete SCI, classified by the American Spinal Injury Association (ASIA) Impairment Scale with ASIA grades C (n=9) and D (n=11) injury. Most patients (n=16) were ambulatory before locomotor training. INTERVENTION: Locomotor training was provided using robotic-assisted, body-weight-supported treadmill training 3 to 5 times a week over 8 weeks. Single training sessions lasted up to 45 minutes of total walking time, with gait speed between .42 and .69 m/s and body-weight unloading as low as possible (mean +/- standard deviation, 37%+/-17%). MAIN OUTCOME MEASURES: Primary outcome measures included the 10-meter walk test, the 6-minute walk test, the Timed Up & Go test, and the Walking Index for Spinal Cord Injury-II tests. Secondary measures included lower-extremity motor scores and spastic motor behaviors to assess their potential contribution to changes in locomotor function. All subjects were tested before, during, and after training. RESULTS: Locomotor training using the DGO resulted in significant improvements in the subjects' gait velocity, endurance, and performance of functional tasks. There were no significant changes in the requirement of walking aids, orthoses, or external physical assistance. There was no correlation between improvements in walking speed or changes in muscle strength or spastic motor behaviors. CONCLUSIONS: Intensive locomotor training on a treadmill with the assistance of a DGO results in improved overground walking.     

脊髓步行中枢模式发生器

一般认为，哺乳动物（包括人在内）都是通过脊髓步行中枢模式发生器（CPG）控制步行运动，而CPG网络的边界是灵活的，脊髓损伤后脊髓步行CPG可实现网络重组。研究显示，减重步行平板训练（BWSTT）可使脊髓横断猫完全恢复后肢步行能力；临床也发现，脊髓损伤患者可通过BWSTT提高步行能力，表明脊髓可能具有运动学习的能力。因此，如何利用脊髓步行CPG的神经可塑性，为脊髓损伤患者制定最佳的步行训练方案，是令人关注的问题。     

Description of a multifaceted rehabilitation program including overground gait training for a child with cerebral palsy: A case report

ABSTRACT

This case describes the outcomes of a multifaceted rehabilitation program including body weight-supported overground gait training (BWSOGT) in a nonambulatory child with cerebral palsy (CP) and the impact of this treatment on the child's functional mobility. The patient is a nonambulatory 10-year-old female with CP who during an inpatient rehabilitation stay participated in direct, physical therapy 6 days per week for 5 weeks. Physical therapy interventions included stretching of her bilateral lower extremities, transfer training, bed mobility training, balance training, kinesiotaping, supported standing in a prone stander, two trials of partial weight-supported treadmill training, and for 4 weeks, three to five times per week, engaged in 30 minutes of BWSOGT using the Up n' go® gait trainer, Lite Gait Walkable^TM, and Rifton Pacer gait trainer. Following the multifaceted rehabilitation program, the patient demonstrated increased step initiation, increased weight bearing through bilateral lower extremities, improved bed mobility, and increased participation in transfers. The child's Gross Motor Functional Measure (GMFM) scores increased across four dimensions and her Physical Abilities and Mobility Scale (PAMS) increased significantly. This case report illustrates that a multifaceted rehabilitation program including BWSOGT was an effective intervention strategy to improve functional mobility in this nonambulatory child with CP.     

Unexpected recovery after robotic locomotor training at physiologic stepping speed: a single-case design

Spiess MR, Jaramillo JP, Behrman AL, Teraoka JK, Patten C. Unexpected recovery after robotic locomotor training at physiologic stepping speed: a single-case design.ObjectivesTo investigate the effect of walking speed on the emergence of locomotor electromyogram (EMG) patterns in an individual with chronic incomplete spinal cord injury (SCI), and to determine whether central pattern generator activity during robotic locomotor training (RLT) transfers to volitional EMG activity during overground walking.DesignSingle-case (B-A-B; experimental treatment–withdrawal–experimental treatment) design.SettingFreestanding rehabilitation research center.ParticipantA 50-year-old man who was nonambulatory for 16 months after incomplete SCI (sub-T11).InterventionsThe participant completed two 6-week blocks of RLT, training 4 times per week for 30 minutes per session at walking speeds up to 5km/h (1.4m/s) over continuous bouts lasting up to 17 minutes.Main Outcome MeasuresSurface EMG was recorded weekly during RLT and overground walking. The Walking Index for Spinal Cord Injury (WISCI-II) was assessed daily during training blocks.ResultsDuring week 4, reciprocal, patterned EMG emerged during RLT. EMG amplitude modulation revealed a curvilinear relationship over the range of walking speeds from 1.5 to 5km/h (1.4m/s). Functionally, the participant improved from being nonambulatory (WISCI-II 1/20), to walking overground with reciprocal stepping using knee-ankle-foot orthoses and a walker (WISCI-II 9/20). EMG was also observed during overground walking. These functional gains were maintained greater than 4 years after locomotor training (LT).ConclusionsHere we report an unexpected course of locomotor recovery in an individual with chronic incomplete SCI. Through RLT at physiologic walking speeds, it was possible to activate the central pattern generator even 16 months postinjury. Further, to a certain degree, improvements from RLT transferred to overground walking. Our results suggest that LT-induced changes affect the central pattern generator and allow supraspinal inputs to engage residual spinal pathways.     

Robotic resistance treadmill training improves locomotor function in human spinal cord injury: a pilot study

Wu M, Landry JM, Schmit BD, Hornby TG, Yen S-C. Robotic resistance treadmill training improves locomotor function in human spinal cord injury: a pilot study.ObjectiveTo determine whether cable-driven robotic resistance treadmill training can improve locomotor function in humans with incomplete spinal cord injury (SCI).DesignRepeated assessment of the same patients with crossover design.SettingResearch units of rehabilitation hospitals in Chicago.ParticipantsPatients with chronic incomplete SCI (N=10) were recruited to participate in this study.InterventionsSubjects were randomly assigned to 1 of 2 groups. One group received 4 weeks of assistance training followed by 4 weeks of resistance training, while the other group received 4 weeks of resistance training followed by 4 weeks of assistance training. Locomotor training was provided by using a cable-driven robotic locomotor training system, which is highly backdrivable and compliant, allowing patients the freedom to voluntarily move their legs in a natural gait pattern during body weight supported treadmill training (BWSTT), while providing controlled assistance/resistance forces to the leg during the swing phase of gait.Main Outcome MeasuresPrimary outcome measures were evaluated for each participant before training and after 4 and 8 weeks of training. Primary measures were self-selected and fast overground walking velocity and 6-minute walking distance. Secondary measures included clinical assessments of balance, muscle tone, and strength.ResultsA significant improvement in walking speed and balance in humans with SCI was observed after robotic treadmill training using the cable-driven robotic locomotor trainer. There was no significant difference in walking functional gains after resistance versus assistance training, although resistance training was more effective for higher functioning patients.ConclusionsCable-driven robotic resistance training may be used as an adjunct to BWSTT for improving overground walking function in humans with incomplete SCI, particularly for those patients with relatively high function.     

Asymmetric lower-limb bone loss after spinal cord injury: case report

Osteoporosis is a significant secondary condition that occurs acutely after spinal cord injury (SCI). This article reports on a patient with motor incomplete SCI and asymmetric lower-limb bone loss as it correlates with lower-limb motor function and gait characteristics. A 32-year-old Caucasian male completed a comprehensive inpatient rehabilitation program, including 3 months of robotic body-weight-supported treadmill training three times a week. Bone mineral density (BMD) was monitored up to 1.5 years post-SCI by dual-energy X-ray absorptiometry. Ground reaction forces were measured through an instrumented treadmill for bilateral weight-bearing comparison. At 1.5 years postinjury, neurological examination revealed thoracic 4 American Spinal Injury Association Impairment Scale D SCI with less strength, reduced weight bearing, and lower BMD in the more neurologically impaired leg. These results suggest that osteoporosis may vary according to severity of impairment within individuals and that monitoring lower-limb BMD is especially important for patients who ambulate.     

Robotic orthoses for body weight-supported treadmill training

BWSTT has become an accepted standard of care in gait rehabilitation methods. This type of locomotor training has many functional benefits, but the physical labor costs are considerable. To reduce therapist effort and improve the repeatability of locomotor training, three groups have developed commercially available robotic devices for assisted stepping. The purpose of these robotic devices is to augment locomotor rehabilitation by decreasing therapist manual assistance, increasing the amount of stepping practice, while decreasing therapist effort. Current clinical studies have yielded positive and promising results in locomotor rehabilitation inpatients with neurologic impairments of stroke or SCI. The potential benefits from robotic technology are significant for clinical use and research. As further research is conducted, rehabilitation therapists and patient outcomes will be able to contribute to the development of current and future technologies.     

Obesity and inpatient rehabilitation outcomes for patients with a traumatic spinal cord injury

Stenson KW, Deutsch A, Heinemann AW, Chen D. Obesity and inpatient rehabilitation outcomes for patients with a traumatic spinal cord injury.

Objective

To examine the effect of obesity on change in FIM self-care and mobility ratings and community discharge for patients with traumatic spinal cord injury (SCI).

Design

Retrospective cohort study analyzing National Model Systems SCI Database data.

Setting

Fourteen Model Systems SCI programs.

Participants

Patients (N=1524) with a new traumatic SCI discharged from Model Systems rehabilitation centers between October 2006 and October 2009.

Interventions

None.

Main Outcome Measures

Change in FIM self-care and mobility ratings, discharge destination. Separate analyses were conducted by neurologic category: paraplegia incomplete, paraplegia complete, tetraplegia incomplete, and tetraplegia complete.

Results

Of all patients with traumatic SCI, approximately 25% were obese at admission. Patients who were obese were more likely to be married and slightly older than nonobese patients. In patients with paraplegia incomplete, obese patients had lower FIM self-care (−1.9; 95% confidence interval [CI], −3.4 to −.4) and mobility score gains (−1.5; 95% CI, −2.9 to −.1) than normal-weight patients. For patients with paraplegia complete, obese patients had significantly lower self-care (−2.2; 95% CI, −3.5 to −.8) and mobility score gains (−2.7; 95% CI, −3.9 to −1.5). For patients with tetraplegia incomplete and tetraplegia complete, FIM self-care and mobility ratings for obese patients were not significantly different from ratings for normal-weight patients. Within each neurologic category, the percentage of patients discharged to the community was not significantly different for nonobese and obese patients.

Conclusions

Obesity appears to be a barrier to meeting self-care and mobility functional goals for patients with paraplegia in inpatient SCI rehabilitation.     

Ambulation and balance outcomes measure different aspects of recovery in individuals with chronic, incomplete spinal cord injury

Forrest GF, Lorenz DJ, Hutchinson K, VanHiel LR, Basso DM, Datta S, Sisto SA, Harkema SJ. Ambulation and balance outcomes measure different aspects of recovery in individuals with chronic, incomplete spinal cord injury.ObjectiveTo evaluate relationships among ambulation and balance outcome measures over time for incomplete spinal cord injury (SCI) after locomotor training, in order to facilitate the selection of effective and sensitive rehabilitation outcomes.DesignProspective observational cohort.SettingOutpatient rehabilitation centers (N=7) from the Christopher and Dana Reeve Foundation NeuroRecovery Network.ParticipantsPatients with incomplete SCI (N=182) American Spinal Injury Association Impairment Scale level C (n=61) and D (n=121).InterventionsIntensive locomotor training, including step training using body weight support and manual facilitation on a treadmill followed by overground assessment and community integration.Main Outcome MeasuresSix-minute and 10-meter walk tests, Berg Balance Scale, Modified Functional Reach, and Neuromuscular Recovery Scale collected at enrollment, approximately every 20 sessions, and on discharge.ResultsWalking and standing balance measures for all participants were strongly correlated (r≥.83 for all pairwise outcome correlations), standing and sitting balance measures were not highly correlated (r≤.48 for all pairwise outcome correlations), and walking measures were weakly related to sitting balance. The strength of relationships among outcome measures varied with functional status. Correlations among evaluation-to-evaluation changes were markedly reduced from performance correlations. Walk tests, when conducted with different assistive devices, were strongly correlated but had substantial variability in performance.ConclusionsThese results cumulatively suggest that changes in walking and balance measures reflect different aspects of recovery and are highly influenced by functional status and the utilization of assistive devices. These factors should be carefully considered when assessing clinical progress and designing clinical trials for rehabilitation.