Voluntary driven exoskeleton as a new tool for rehabilitation in chronic spinal cord injury: a pilot study

Background contextTreadmill training after traumatic spinal cord injury (SCI) has become an established therapy to improve walking capabilities. The hybrid assistive limb (HAL) exoskeleton has been developed to support motor function and is tailored to the patients' voluntary drive.PurposeTo determine whether locomotor training with the exoskeleton HAL is safe and can increase functional mobility in chronic paraplegic patients after SCI.DesignA single case experimental A-B (pre-post) design study by repeated assessments of the same patients. The subjects performed 90 days (five times per week) of HAL exoskeleton body weight supported treadmill training with variable gait speed and body weight support.Patient sampleEight patients with chronic SCI classified by the American Spinal Injury Association (ASIA) Impairment Scale (AIS) consisting of ASIA A (zones of partial preservation [ZPP] L3–S1), n=4; ASIA B (with motor ZPP L3–S1), n=1; and ASIA C/D, n=3, who received full rehabilitation in the acute and subacute phases of SCI.Outcome measuresFunctional measures included treadmill-associated walking distance, speed, and time, with additional analysis of functional improvements using the 10-m walk test (10MWT), timed-up and go test (TUG test), 6-minute walk test (6MWT), and the walking index for SCI II (WISCI II) score. Secondary physiologic measures including the AIS with the lower extremity motor score (LEMS), the spinal spasticity (Ashworth scale), and the lower extremity circumferences.MethodsSubjects performed standardized functional testing before and after the 90 days of intervention.ResultsHighly significant improvements of HAL-associated walking time, distance, and speed were noticed. Furthermore, significant improvements have been especially shown in the functional abilities without the exoskeleton for over-ground walking obtained in the 6MWT, TUG test, and the 10MWT, including an increase in the WISCI II score of three patients. Muscle strength (LEMS) increased in all patients accompanied by a gain of the lower limb circumferences. A conversion in the AIS was ascertained in one patient (ASIA B to ASIA C). One patient reported a decrease of spinal spasticity.ConclusionsHybrid assistive limb exoskeleton training results in improved over-ground walking and leads to the assumption of a beneficial effect on ambulatory mobility. However, evaluation in larger clinical trials is required.     

Neuromechanical adaptations during a robotic powered exoskeleton assisted walking session

Objective: To evaluate gait parameters and neuromuscular profiles of exoskeleton-assisted walking under Max Assist condition during a single-session for; (i) able bodied (AB) individuals walking assisted with (EXO) and without (non-EXO) a powered exoskeleton, (ii) non-ambulatory SCI individuals walking assisted with a powered exoskeleton.

Design: Single-session.

Setting: Motion analysis laboratory.

Participants: Four AB individuals and four individuals with SCI.

Interventions: Powered lower extremity exoskeleton.

Outcome Measures: Temporal-spatial parameters, kinematics, walking velocity and electromyography data.

Results: AB individuals in exoskeleton showed greater stance time and a significant reduction in walking velocity (P < 0.05) compared to non-EXO walking. Interestingly, when the AB individuals voluntarily assisted the exoskeleton movements, they walked with an increased velocity and lowered stance time to resemble that of slow walking. For SCI individuals, mean percent stance time was higher and walking velocity was lower compared to all AB walking conditions (P < 0.05). There was muscle activation in several lower limb muscles for SCI group. For AB individuals, there were similarities among EXO and non-EXO walking conditions however there were differences in several lower limb EMGs for phasing of muscle activation.

Conclusion: The data suggests that our AB individuals experienced reduction in walking velocity and muscle activation amplitudes while walking in the exoskeleton and moreover with voluntary control there is a greater temporal-spatial response of the lower limbs. Also, there are neuromuscular phasic adaptions for both AB and SCI groups while walking in the exoskeleton that are inconsistent to non-EXO gait muscle activation.     

The Effect of Body Weight-Supported Treadmill Training on Muscle Morphology in an Individual With Chronic,Motor- Complete Spinal Cord Injury: A Case Study

Abstract

Objective: The purpose of this pilot study was to examine the effects of 4 months of thrice-weekly body weight-supported treadmill training (BWSTT) on skeletal muscle morphology in a woman (age 27 y) with chronic, motor-complete (ASIA B) spinal cord injury (SCI).

Methods: The participant performed passive thrice-weekly BWSTT for 4 months (48 total sessions) with manual assistance from therapists. Muscle biopsies of the vastus lateralis were taken prior to the beginning of the training program as well as following the completion of 4 months of training. Histochemical analysis was utilized to evaluate changes in muscle fiber size and type following training.

Results: At baseline, vastus lateralis muscle biopsies showed evidence of fiber atrophy and fiber type redistribution typical of persons with SCI, with mean fiber areas (and % distributions) of type I, type I la and type llx fibers being 3474nm2 (1.3%), 3146nm2 (30.8%) and 1284^im2 (68.0%), respectively. Following training, there were increases in treadmill walking speed (pre: 1.0km/h; post: 2.5km/h) and distance walked/session (pre: 500m; post: 1875m). Vastus lateralis mean fiber area increased by 27.1% and type I fiber % distribution increased to 24.6%, whereas type I la and type llx fiber % distributions both decreased following training.

Conclusion: These data indicate that 4 months of thrice-weekly BWSTT improved muscle morphology in an individual with chronic, motor-complete SCI.     

Neuromotor and Musculoskeletal Responses to Locomotor Training for an Individual With Chronic Motor Complete AIS-B Spinal Cord Injury

Background/objective: To determine the effects of locomotor training (LT)using body weight support(BWS), treadmill, and manual assistance on muscle activation, bone mineral density (BMD), and body composition changes for an individual with motor complete spinal cord injury (AIS B), 1 year after injury.

Methods: A man with chronic C6 AIS B (motor complete and sensory incomplete) spinal cord injury (SCI),1 year after injury, completed 2 blocks of LT over a 9-monthtraining period (35-session block followed by8.6 weeks of no training and then a 62-session block).

Results: Before training, muscle activation was minimal for any muscle examined, whereas after the 2 blocksof LT (97 sessions), hip and knee muscle activation patterns for the bilateral rectus femoris, biceps femoris,and gastrocnemius were in phase with the kinematics. Mean EMG amplitude increased for all bilateral muscles and burst duration increased for rectus femoris and gastrocnemius muscles, whereas burst duration decreased for the biceps femoris after 62 LT sessions. Before LT, left biceps femoris had a pattern that reflected muscle stretch, whereas after training, muscle stretch of the left biceps femoris could not totally account for mean EMG amplitude or burst duration. After the62 training sessions, total BMD decreased (1.54%), and regional BMD decreased (legs: 6.72%). Total weight increased, lean mass decreased (6.6%), and fat mass increased (7.4%) in the arms, whereas fat mass decreased (3.5%) and lean mass increased (4%) in the legs.

Conclusions: LT can induce positive neural and body composition changes in a nonambulatory personwith chronic SCI, indicating that neuromuscular plasticity can beinduced by repetitive locomotor trainingafter a motor complete SCI.     

Metabolic and Cardiac Responses To Robotic–Assisted Locomotion In Motor–Complete Tetraplegia: A Case Report

Abstract

Background/Objective: To examine acute metabolic responses to treadmill locomotion in a participant with motor—complete tetraplegia.

Methods: The participant—a woman with a chronic ASIA B C3–C4 spinal cor injury—walked on a treadmill with 40% body weight support (BWS) and robotic assistance. Oxygen consumption (VO₂), minute ventilation (V_E),and heart rate (HR) were measured during seated resting, supported standing, and 40 minutes of walking with stepping assistance from a Lokomat-driven gait orthosis.

Results: A resting VO₂ equal to 50 milliliters perminutewas predictably low, and did not change after the participant assumed an upright posture. Both VO₂ and V2_E increased immediately upon onset of locomotion, suggesting a neuragenie rather than a humoral regulatory response to movement. VO₂ averaged 2.4 metabolic units (METS) during locomotion at an average expenditure of 2.98 kilocalories per minute. HR was unaltered by standing, but du ring locomotion averaged 1 7 beats higherthan du ring resting.lncreases in V E but not vo2 upon standing, and decreases in vo2 but not V E immediately after walking, rule out changes in V2_E alone as the source for increased vo2 du ring walking.

Conclusion: The data collected on this single participant show that treadmilllocomotion with BWS and robotic assistance elicits a metabolic response to treadmill gaiting characterized by increased VO₂ , V_E HR, and caloric expenditure     

Impact of an implanted neuroprosthesis on community ambulation in incomplete SCI

Objective: Test the effect of a multi-joint control with implanted electrical stimulation on walking after spinal cord injury (SCI).

Design: Single subject research design with repeated measures.

Setting: Hospital-based biomechanics laboratory and user assessment of community use.

Participants: Female with C6 AIS C SCI 30 years post injury.

Interventions: Lower extremity muscle activation with an implanted pulse generator and gait training.

Outcome Measures: Walking speed, maximum distance, oxygen consumption, upper extremity (UE) forces, kinematics and self-assessment of technology.

Results: Short distance walking speed at one-year follow up with or without stimulation was not significantly different from baseline. However, average walking speed was significantly faster (0.22?m/s) with stimulation over longer distances than volitional walking (0.12?m/s). In addition, there was a 413% increase in walking distance from 95?m volitionally to 488?m with stimulation while oxygen consumption and maximum upper extremity forces decreased by 22 and 16%, respectively. Stimulation also produced significant (P?≤?0.001) improvements in peak hip and knee flexion, ankle angle at foot off and at mid-swing.

Conclusion: An implanted neuroprosthesis enabled a subject with incomplete SCI to walk longer distances with improved hip and knee flexion and ankle dorsiflexion resulting in decreased oxygen consumption and UE support. Further research is required to determine the robustness, generalizability and functional implications of implanted neuroprostheses for community ambulation after incomplete SCI.     

The effects of robot assisted gait training on temporal-spatial characteristics of people with spinal cord injuries: A systematic review

Context: Robotic assisted gait training (RAGT) technology can be used as a rehabilitation tool or as an assistive device for spinal cord injured (SCI) individuals. Its impact on upright stepping characteristics of SCI individuals using treadmill or overground robotic exoskeleton systems has yet to be established.

Objective: To systematically review the literature and identify if overground or treadmill based RAGT use in SCI individuals elicited differences in temporal-spatial characteristics and functional outcome measures.

Methods: A systematic search of the literature investigating overground and treadmill RAGT in SCIs was undertaken excluding case-studies and case-series. Studies were included if the primary outcomes were temporal-spatial gait parameters. Study inclusion and methodological quality were assessed and determined independently by two reviewers. Methodological quality was assessed using a validated scoring system for randomized and non-randomized trials.

Results: Twelve studies met all inclusion criteria. Participant numbers ranged from 5-130 with injury levels from C2 to T12, American Spinal Injuries Association A-D. Three studies used overground RAGT systems and the remaining nine focused on treadmill based RAGT systems. Primary outcome measures were walking speed and walking distance. The use of treadmill or overground based RAGT did not result in an increase in walking speed beyond that of conventional gait training and no studies reviewed enabled a large enough improvement to facilitate community ambulation.

Conclusion: The use of RAGT in SCI individuals has the potential to benefit upright locomotion of SCI individuals. Its use should not replace other therapies but be incorporated into a multi-modality rehabilitation approach.     

Factors Related to Obstacle Crossing in Independent Ambulatory Patients With Spinal Cord Injury

Abstract

Background/Objectives: To evaluate factors related to the ability of ambulatory patients with spinal cord injury (SCI) to walk over small obstacles.

Study Design: Cross-sectional study.

Methods: Thirty-four patients with SCI (ASIA impairment scale [AIS] D) who were able to walk independently at least 10 m with or without walking devices were recruited for the study. Participants were required to walk over small obstacles (1,4, and 8 cm in height or width; total of 6 conditions). A “fail” was recorded when either the lower limbs or the walking device contacted the obstacle. Multiple logistic regression models were applied to determine the effects of walking devices (presence or absence), SCI levels (tetraparesis or paraparesis), and SCI stages (acute or chronic) on the ability of obstacle crossing.

Results: Fifteen participants (44%) failed to adequately clear the foot or walking device over obstacles in at least one condition (range 1–3 conditions). After adjusting for covariates, the chance of failure on obstacle crossing was greatly increased with the use of walking devices (odds ratio = 8.50; 95% CI = 0.85?75.03)

Conclusions: Gait safety in independent ambulatory participants with SCI remains threatened. Participants who walked with walking devices encountered a greater chance of failing to walk over obstacles as a result of inefficiently moving the foot or walking device over small obstacles. Thus, instead of training in an empty/ quiet room, rehabilitation procedures should incorporate contextual conditions that patients encounter at home and in the community in order to minimize risk of injury and prepare patients to be more independent after discharge.     

Safety and feasibility of exoskeleton-assisted walking during acute/sub-acute SCI in an inpatient rehabilitation facility: A single-group preliminary study

Abstract

Context/objective: Information on the safety and feasibility of lower extremity powered exoskeletons for persons with acute/sub-acute spinal cord injury (SCI) is limited. Understanding the safety and feasibility of employing powered exoskeletons in acute/sub-acute (<6 months post injury) at a SCI acute inpatient rehabilitation (SCI-AIR) facility could guide clinical practice and provide a basis for larger clinical trials on efficacy and effectiveness.

Design: Single group observational study.

Setting: SCI-AIR.

Participants: Participants (n?=?12; age: 28–71 years; 58% AIS D; 58% male) with neurological levels of injuries ranging from C2 to L3.

Interventions: Up to 90?min of exoskeleton-assisted locomotor training was provided up to three times per week during SCI-AIR.

Outcome measures: Safety of device use during inpatient locomotor training was quantified as the number of adverse events (AE) per device exposure hour. Feasibility of device use was defined in terms of protocol compliance, intensity, and proficiency.

Results: Concerning safety, symptomatic hypotension was the most common AE reported at 111-events/exoskeleton-hours. Protocol compliance had a mean (SD) of 54% (30%). For intensity, 77% of participants incorporated variable assistance into at least 1 walking session; 70% of participants' sessions were completed with a higher RPE than the physical therapist. In proficiency, 58% achieved at least minimal assistance when walking with the device.

Conclusion: Exoskeleton training in SCI-AIR can be safe and feasible for newly injured individuals with SCI who have clinically defined ambulatory goals. Nonetheless, sufficient controls to minimize risks for AEs, such as hypotensive events, are required.     

Prognostic validity of a clinical trunk control test for independence and walking in individuals with spinal cord injury

Objective: The objective of the present work was to determine the prognostic validity of the trunk control test for walking and independence in individuals with SCI.

Design: A cohort, prospective study was carried out in all individuals with sub-acute SCI.

Setting: All inpatients at the Mexico City based National Rehabilitation Institute (INR).

Participants: Ninety individuals with a clinical diagnosis of sub-acute SCI, American Spinal Injury Association Impairment Scale (AIS) A-D, and that have not participated in a rehabilitation program were included. Thirty-five individuals had good initial trunk control and the remaining 55 had poor trunk control. All individuals participated in a standard rehabilitation program subsequently.

Interventions: N/A

Outcome Measures: The trunk control test was performed at baseline. At 1, 3, 6, 9 and 12 months after the first evaluation, walking and independence were assessed.

Results: Survival Analysis revealed that 62.5% and 100% individuals with good trunk control at baseline assessment were respectively walking and independent in ADL at 12 months and 14% and 48% individuals with poor trunk control were walking and independent in ADL. Cox regression analysis revealed that individuals with good trunk control were 4.6 times more likely to walk independently at 12 months and 2.9 times more likely to be independent in activities of daily living.

Conclusion: The present study revealed that the trunk control test is useful for providing a prognosis of independence and walking at 1 year in individuals with SCI, independently of the neurologic level and the severity of the injury.     

Acute Effects Of Locomotor Training on Overground Walking Speed and H-Reflex Modulation in Individuals with Incomplete Spinal Cord Injury

Abstract

Objective: The purpose of this study was to assess the effect of a single bout of a locomotor-training paradigm on overground walking speed and H-reflex modulation of individuals with incomplete spinal cord injury (SCI).

Methods: Self-selected and maximum walking speeds and soleus H-reflexes (H/M ratios) during standing and stance and swing phases of walking (self-selected velocity) were obtained from 4 individuals with American Spinal Injury Association impairment classification D. Data were collected immediately before and after a single bout of locomotor training with body weight support on a treadmill. The pretraining H/M ratios of the SCI subjects were also compared with values from 4 able-bodied subjects who did not receive the intervention. Maximum H/M ratios while standing and during midstance and midswing phases of overground walking were considerably greater in the SCI subjects than in the control subjects.

Results: After the single bout of training, self-selected and maximum overground walking speeds of the subjects with SCI increased by 26% and 25%, respectively. Furthermore, H-reflexes were significantly more depressed in the SCI subjects during overground walking (28% less during stance, 34% less during swing).

Conclusions: Although preliminary, these findings indicate that a single bout of locomotor training produced immediate increases in walking velocity and acute neurophysiologic changes in individuals with incomplete SCI.     

A clinically meaningful training effect in walking speed using functional electrical stimulation for motor-incomplete spinal cord injury

Context/Objective: The study aimed to investigate the presence of a training effect for rehabilitation of walking function in motor-incomplete spinal cord injury (SCI) through daily use of functional electrical stimulation (FES).

Setting: A specialist FES outpatient centre.

Participants: Thirty-five participants (mean age 53, SD 15, range 18-80; mean years since diagnosis 9, range 5 months - 39 years) with drop foot and motor-incomplete SCI (T12 or higher, ASIA Impairment Scale C and D) able to ambulate 10 metres with the use of a walking stick or frame.

Interventions: FES of the peroneal nerve, glutei and hamstrings as clinically indicated over six months in the community.

Outcome Measures: The data was analysed for a training effect (difference between unassisted ten metre walking speed at baseline and after six months) and orthotic effects (difference between walking speed with and without FES) initially on day one and after six months. The data was further analysed for a minimum clinically important difference (MCID) (>0.06 m/s).

Results: A clinically meaningful, significant change was observed for initial orthotic effect (0.13m/s, CI: 0.04-0.17, P?=?0.013), total orthotic effect (0.11m/s, CI: 0.04-0.18, P?=?0.017) and training effect (0.09m/s, CI: 0.02-0.16, P?=?0.025).

Conclusion: The results suggest that daily independent use of FES may produce clinically meaningful changes in walking speed which are significant for motor-incomplete SCI. Further research exploring the mechanism for the presence of a training effect may be beneficial in targeting therapies for future rehabilitation.     

A Prediction Model for Determining Over Ground Walking Speed After Locomotor Training in Persons With Motor Incomplete Spinal Cord Injury

Background/Objective: To develop and test a clinically relevant model for predicting the recovery of over ground walking speed after 36 sessions of progressive body weight-supported treadmill training (BWSTT) in individuals with motor incomplete spinal cord injury (SCI).

Design: A retrospective review and stepwise regression analysis of a SCI clinical outcomes data set.

Setting: Outpatient SCI laboratory.

Subjects: Thirty individuals with a motor incomplete SCI who had participated in locomotor training with BWSTT. Eight individuals with similar diagnoses were used to prospectively test the prediction model.

Main Outcome Measures: Over ground walking speed was assessed using the 10-m walking test.

Methods: The locomotor training program consisted of 36 sessions of sequential comprehensive training comprised of robotic assisted BWSTT, followed by manual assisted BWSTT, and over ground walking. The dose of locomotor training was standardized throughout the protocol.

Results: Clinical characteristics with predictive value for walking speed were time from injury onset, the presence or absence of voluntary bowel and bladder voiding, a functional spasticity assessment, and over ground walking speed before locomotor training. The model identified that these characteristics accounted for 78.3% of the variability in the actual final over ground walking speed after 36 sessions of locomotor training. The model was successful in prospectively predicting over ground walking speed in the 8 test participants within 4.15 ± 2.22 cm/s in their recovered walking speed.

Conclusions: This prediction model can identify individuals who are most likely to experience success using locomotor training by determining an expected magnitude of training effect, thereby allowing individualized decisions regarding the use of this intensive approach to rehabilitation.     

Vertical ground reaction force-based analysis of powered exoskeleton-assisted walking in persons with motor-complete paraplegia

Objective

To use vertical ground reaction force (vGRF) to show the magnitude and pattern of mechanical loading in persons with spinal cord injury (SCI) during powered exoskeleton-assisted walking.

Research design

A cross-sectional study was performed to analyze vGRF during powered exoskeleton-assisted walking (ReWalk™: Argo Medical Technologies, Inc, Marlborough, MA, USA) compared with vGRF of able-bodied gait.

Setting

Veterans Affairs Medical Center.

Participants

Six persons with thoracic motor-complete SCI (T1–T11 AIS A/B) and three age-, height-, weight- and gender-matched able-bodied volunteers participated.

Interventions

SCI participants were trained to ambulate over ground using a ReWalk™. vGRF was recorded using the F-Scan™ system (TekScan, Boston, MA, USA).

Outcome measures

Peak stance average (PSA) was computed from vGRF and normalized across all participants by percent body weight. Peak vGRF was determined for heel strike, mid-stance, and toe-off. Relative linear impulse and harmonic analysis provided quantitative support for analysis of powered exoskeletal gait.

Results

Participants with motor-complete SCI, ambulating independently with a ReWalk™, demonstrated mechanical loading magnitudes and patterns similar to able-bodied gait. Harmonic analysis of PSA profile by Fourier transform contrasted frequency of stance phase gait components between able-bodied and powered exoskeleton-assisted walking.

Conclusion

Powered exoskeleton-assisted walking in persons with motor-complete SCI generated vGRF similar in magnitude and pattern to that of able-bodied walking. This suggests the potential for powered exoskeleton-assisted walking to provide a mechanism for mechanical loading to the lower extremities. vGRF profile can be used to examine both magnitude of loading and gait mechanics of powered exoskeleton-assisted walking among participants of different weight, gait speed, and level of assist.     

Midsagittal tissue bridges are associated with walking ability in incomplete spinal cord injury: A magnetic resonance imaging case series

Context: Following spinal cord injury (SCI), early prediction of future walking ability is difficult, due to factors such as spinal shock, sedation, impending surgery, and secondary long bone fracture. Accurate, objective biomarkers used in the acute stage of SCI would inform individualized patient management and enhance both patient/family expectations and treatment outcomes. Using magnetic resonance imaging (MRI) and specifically a midsagittal T2-weighted image, the amount of tissue bridging (measured as spared spinal cord tissue) shows potential to serve as such a biomarker. Ten participants with incomplete SCI received MRI of the spinal cord. Using the midsagittal T2-weighted image, anterior and posterior tissue bridges were calculated as the distance from cerebrospinal fluid to the damage. Then, the midsagittal tissue bridge ratio was calculated as the sum of anterior and posterior tissue bridges divided by the spinal cord diameter. Each participant also performed a 6-minute walk test, where the total distance walked was measured within six minutes.

Findings: The midsagittal tissue bridge ratio measure demonstrated a high level of inter-rater reliability (ICC?=?0.90). Midsagittal tissue bridge ratios were significantly related to distance walked in six minutes (R?=?0.68, P?=?0.03).

Conclusion/clinical relevance: We uniquely demonstrated that midsagittal tissue bridge ratios were correlated walking ability. These preliminary findings suggest potential for this measure to be considered a prognostic biomarker of residual walking ability following SCI.     

Associations of Mode of Locomotion and Independence in Locomotion With Long-Term Outcomes After Spinal Cord Injury

Background/Objective: To explore the association of mode of locomotion (ambulation vs wheelchair use) and independence in locomotion (independent vs require assistance) with health, participation, and subjective well-being (SWB) after spinal cord injury (SCI).

Research Design: Secondary analysis was conducted on survey data collected from 2 rehabilitation hospitals in the Midwest and a specialty hospital in the southeastern United States. The 1,493 participants were a minimum of 18 years of age and had traumatic SCI of at least 1 year duration at enrollment.

Main Outcome Measures: Three sets of outcome measures were used: SWB, participation, and health. SWB was measured by 8 scales and a measure of depressive symptoms, participation by 3 items, health by general health ratings, days in poor health, hospitalizations, and treatments.

Results: Small but significant associations were observed between independence in locomotion and every outcome. Ambulation was associated with greater participation but a mixed pattern of favorable and unfavorable health and SWB outcomes. Supplemental analyses were conducted on those who ambulated but who were dependent on others to do so (n = 117), because this group reported poor outcomes in several areas. Individuals who were independent in wheelchair use reported substantially better outcomes than nonwheelchair users and those dependent on others in wheelchair use.

Conclusions: Although ambulation is often a recovery goal, individuals with SCI who ambulate do not uniformly report better outcomes than wheelchair users, and those who depend on others for assistance with ambulation may experience a unique set of problems.     

Examining health-care utilization in the first year following spinal cord injury

Abstract

Objective

To identify factors associated with health-care utilization during the first year after inpatient rehabilitation (IR) in individuals with traumatic spinal cord injury (SCI).

Design

Prospective cohort.

Methods

One hundred and sixty-eight patients were prospectively enrolled and followed over 1 year after discharge from an SCI Model System IR program. Telephone follow-up occurred at 3, 6, 9, and 12 months. Participants were grouped into four impairment levels (C1–4 American Spinal Injury Association (ASIA) Impairment Scale (AIS) A–C, C5–C8 AIS A–C, paraplegia AIS A–C, and all AIS D). Three domains of health-care utilization were examined: hospital care, outpatient provider visits, and home services.

Results

Health-care utilization in the first year following IR was high with 45% of subjects reporting re-hospitalization. Twenty percent of patients were initially discharged to a skilled nursing facility (SNF), and an additional 10% required SNF care during this first year. Overall, those with C1–4 AIS A–C used the most services. Participants discharged home used less health care compared to those discharged elsewhere. SCI due to falls (vs. vehicular crashes) was associated with fewer in-home service visits. Age, sex, race, and education were unrelated to higher use.

Conclusion

Those with greater neurological impairment or not discharged home after IR had higher health-care utilization, while age was not associated with utilization. Targeted efforts to reduce genitourinary and respiratory complications may reduce the need for hospital care in the first year after IR.     

Decrease of spasticity after hybrid assistive limb® training for a patient with C4 quadriplegia due to chronic SCI

Context: Recently, locomotor training with robotic assistance has been found effective in treating spinal cord injury (SCI). Our case report examined locomotor training using the robotic suit hybrid assistive limb (HAL) in a patient with complete C4 quadriplegia due to chronic SCI. This is the first report examining HAL in complete C4 quadriplegia.

Findings: The patient was a 19-year-old man who dislocated C3/4 during judo 4 years previously. Following the injury, he underwent C3/4 posterior spinal fusion but remained paralyzed despite rehabilitation. There was muscle atrophy under C5 level and no sensation around the anus, but partial sensation of pressure remained in the limbs. The American Spinal Injury Association impairment scale was Grade A (complete motor C4 lesion).

HAL training was administered in 10 sessions (twice per week). The training sessions consisted of treadmill walking with HAL. For safety, 2 physicians and 1 therapist supported the subject for balance and weight-bearing. The device's cybernic autonomous control mode provides autonomic physical support based on predefined walking patterns.

We evaluated the adverse events, walking time and distance, and the difference in muscle spasticity before and after HAL-training using a modified Ashworth scale (mAs).

No adverse events were observed that required discontinuation of rehabilitation. Walking distance and time increased from 25.2 meters/7.6 minutes to 148.3 meter/15 minutes. The mAs score decreased after HAL training.

Conclusion: Our case report indicates that HAL training is feasible and effective for complete C4 quadriplegia in chronic SCI.     

Time and Effort Required by Persons with Spinal Cord Injury to Learn to Use a Powered Exoskeleton for Assisted Walking

Background:

Powered exoskeletons have been demonstrated as being safe for persons with spinal cord injury (SCI), but little is known about how users learn to manage these devices.

Objective:

To quantify the time and effort required by persons with SCI to learn to use an exoskeleton for assisted walking.

Methods:

A convenience sample was enrolled to learn to use the first-generation Ekso powered exoskeleton to walk. Participants were given up to 24 weekly sessions of instruction. Data were collected on assistance level, walking distance and speed, heart rate, perceived exertion, and adverse events. Time and effort was quantified by the number of sessions required for participants to stand up, walk for 30 minutes, and sit down, initially with minimal and subsequently with contact guard assistance.

Results:

Of 22 enrolled participants, 9 screen-failed, and 7 had complete data. All of these 7 were men; 2 had tetraplegia and 5 had motor-complete injuries. Of these, 5 participants could stand, walk, and sit with contact guard or close supervision assistance, and 2 required minimal to moderate assistance. Walk times ranged from 28 to 94 minutes with average speeds ranging from 0.11 to 0.21 m/s. For all participants, heart rate changes and reported perceived exertion were consistent with light to moderate exercise.

Conclusion:

This study provides preliminary evidence that persons with neurological weakness due to SCI can learn to walk with little or no assistance and light to somewhat hard perceived exertion using a powered exoskeleton. Persons with different severities of injury, including those with motor complete C7 tetraplegia and motor incomplete C4 tetraplegia, may be able to learn to use this device.     

Interdisciplinary bodyweight management program for persons with SCI

Objective: Persons with spinal cord injury (SCI) have a higher prevalence of being overweight than the general population, which is thought to be due to a variety of metabolic, physiologic and psychological changes. The quality improvement project described in this work was designed to help overweight persons with SCI lose bodyweight through nutrition, exercise, and behavioral management strategies.

Methods: Eighteen persons with SCI who were overweight were enrolled in a 12-week interdisciplinary weight management program. Participants were limited to persons at least one-year post-acute SCI with an established overweight status. Measurements, including a person's weight, body mass index, and waist circumference (WaC), were taken at the program's start, at its end, and six months post program.

Results: Seventeen out of 18 participants experienced weight loss, (WaC) decreased (P?<?0.001), and the program was effective at reducing weight (P?<?0.001). Six months following participation in the program participants did experience a significant change in weight or waist size six months post program, thus indicating that subjects did not regain weight after completion of the program.

Conclusion: This quality improvement project provided indications of the benefits of an SCI-specific interdisciplinary weight management program. Clinical research evaluating methods for helping persons with SCI achieve a healthy bodyweight is indicated.