Longitudinal patterns of functional recovery in patients with incomplete spinal cord injury receiving activity-based rehabilitation

Lorenz DJ, Datta S, Harkema SJ. Longitudinal patterns of functional recovery in patients with incomplete spinal cord injury receiving activity-based rehabilitation.ObjectiveTo model the progression of 3 functional outcome measures from patients with incomplete spinal cord injury (SCI) receiving standardized locomotor training.DesignObservational cohort.SettingThe NeuroRecovery Network (NRN), a specialized network of treatment centers providing standardized, activity-based therapy for SCI patients.ParticipantsPatients (N=337) with incomplete SCI (grade C or D on the International Standards for Neurological Classification of Spinal Cord Injury scale) who were enrolled in the NRN between February 2008 and March 2011.InterventionAll enrolled patients received standardized locomotor training sessions, as established by NRN protocol, and were evaluated monthly for progress.Main Outcome MeasuresBerg Balance Scale, 6-minute walk test, and 10-meter walk test. Progression over time was analyzed via the fitting of linear mixed effects models.ResultsThere was significant improvement on each outcome measure and significant attenuation of improvement over time. Patients varied significantly across groups defined by recovery status and American Spinal Injury Association Impairment Scale (AIS) grade at enrollment with respect to baseline performance and rates of change over time. Time since SCI was a significant determinant of the rate of recovery for all measures.ConclusionsLocomotor training, as implemented in the NRN, results in significant improvement in functional outcome measures as treatment sessions accumulate. Variability in patterns of recovery over time suggest that time since SCI and patient functional status at enrollment, as measured by the Neuromuscular Recovery Scale, are important predictors of performance and recovery as measured by the targeted outcome measures.     

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.     

Assessment of functional improvement without compensation reduces variability of outcome measures after human spinal cord injury

Behrman AL, Ardolino E, VanHiel LR, Kern M, Atkinson D, Lorenz DJ, Harkema SJ. Assessment of functional improvement without compensation reduces variability of outcome measures after human spinal cord injury.ObjectiveTo develop a scale (Neuromuscular Recovery Scale [NRS]) for classification of functional motor recovery after spinal cord injury (SCI) based on preinjury movement patterns that would reduce variability of the populations' level of function within each class, because assessment of functional improvement after SCI is problematic as a result of high variability of the populations' level of function and the insensitivity to change within the available outcome measures.DesignProspective observational cohort with longitudinal follow-up.SettingSeven outpatient rehabilitation centers from the Christopher and Dana Reeve Foundation NeuroRecovery Network (NRN).ParticipantsIndividuals (N=95) with American Spinal Injury Association Impairment Scale (AIS) grade C or AIS grade D having received at least 20 locomotor training treatment sessions in the NRN.InterventionsIntensive locomotor training including stepping on a treadmill with partial body weight support and manual facilitation and translation of skills into home and community activities.Main Outcome MeasuresBerg Balance Scale, six-minute walk test, and ten-meter walk test.ResultsIndividuals classified within each of the 4 phases of the NRS were functionally discrete, as shown by significant differences in the mean values of balance, gait speed, and walking endurance, and the variability of these measurements was significantly reduced by NRS classification. The magnitude of improvements in these outcomes was also significantly different among phase groups.ConclusionsAssessment with the NRS provides a classification for functional motor recovery without compensation, which reduces variability in performance and improvements for individuals with injuries classified as AIS grades C and D.     

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.     

Longitudinal Recovery and Reduced Costs After 120 Sessions of Locomotor Training for Motor Incomplete Spinal Cord Injury

Objective

To determine the impact of long-term, body weight–supported locomotor training after chronic, incomplete spinal cord injury (SCI), and to estimate the health care costs related to lost recovery potential and preventable secondary complications that may have occurred because of visit limits imposed by insurers.

Dynamic longitudinal evaluation of the utility of the berg balance scale in individuals with motor incomplete spinal cord injury

Datta S, Lorenz DJ, Harkema SJ. Dynamic longitudinal evaluation of the utility of the Berg Balance Scale in individuals with motor incomplete spinal cord injury.ObjectivesTo examine the utility of the Berg Balance Scale among patients with motor incomplete spinal cord injuries (SCIs), to determine how the utility of the Berg Balance Scale changes over time with activity-based therapy, and to identify differences in scale utility across patient groups defined by status of recovery.DesignProspective observational cohort.SettingThe NeuroRecovery Network (NRN), a network of clinical centers for patients with motor incomplete SCI.ParticipantsPatients with motor incomplete SCI (n=124) with American Spinal Injury Association Impairment Scale grade C or D, who were enrolled in the NRN between February 2008 and June 2009.InterventionStandardized locomotor training.Main Outcome MeasureThe Berg Balance Scale items were examined with longitudinal principal components analyses. Patients were categorized by phase using the Neuromuscular Recovery Scale.ResultsIn the full sample, the first principal component explained a large percentage of overall scale variance (77%), items were loaded homogeneously on the first principal component, and item scores were well correlated with first principal component scores. In subgroups of low and high functioning of patients, first principal component variance accounting was reduced (49%) and only a few of the simplest and most difficult items substantially loaded onto the first principal component. Item loading coefficients evolved over time as patients recovered, with simpler items becoming less important to the full scale and difficult items more important.ConclusionsThe utility of the Berg Balance Scale in patients with motor incomplete SCI in early and advanced phases of recovery is limited. Specific item utility changes as patients recover. Thus, a more comprehensive and dynamic instrument is necessary to adequately measure balance across the spectrum of patients with motor incomplete SCI.     

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.     

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.     

A Multivariate Examination of Temporal Changes in Berg Balance Scale Items for Patients With ASIA Impairment Scale C and D Spinal Cord Injuries

Datta S, Lorenz DJ, Morrison S, Ardolino E, Harkema SJ. A multivariate examination of temporal changes in Berg Balance Scale items for patients with ASIA Impairment Scale C and D spinal cord injuries.

Objective

To provide a multivariate examination of the Berg Balance Scale (BBS) in patients with spinal cord injury (SCI) as a first step in developing a balance tool for the SCI population.

Design

Observational cohort.

Setting

The NeuroRecovery Network (NRN), a specialized network of treatment centers providing standardized, activity-based therapy for patients with SCI.

Participants

Patients (N=97) with American Spinal Injury Association Impairment Scale C or D SCI who were enrolled in the NRN between March 1, 2005, and June 12, 2007.

Interventions

All enrolled patients received 3 to 5 locomotor training sessions a week, according to NRN protocol, and were periodically evaluated for progress on functional outcome measurements.

Main Outcome Measures

Scores on the items of the BBS, six-minute walk test distances, ten-meter walk test speeds, and scores on the SCI Functional Ambulation Index. Temporal rates of change of the BBS items were examined with a principal components and correlation analysis.

Results

The first principal component accounted for nearly half of the overall variability in the BBS, correlated well with rates of change in functional mobility measures, and had good stability in its composition as verified by a resampling analysis. Further analysis showed that the composition of the first principal component varied with the patient's level of recovery.

Conclusions

The BBS captures a significant amount of information about balance recovery in persons with SCI and may be a good foundation for a balance tool. However, the utility of BBS items may be dependent on a patient's level of recovery. A dynamic balance instrument for the SCI population may be needed.     

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.     

Establishing the NeuroRecovery Network: multisite rehabilitation centers that provide activity-based therapies and assessments for neurologic disorders

The mission of the NeuroRecovery Network (NRN) is to provide support for the implementation of specialized centers at rehabilitation sites in the United States. Currently, there are 7 NRN centers that provide standardized activity-based interventions designed from scientific and clinical evidence for recovery of mobility, posture, standing, and walking and improvements in health and quality of life in individuals with spinal cord injury. Extensive outcome measures evaluating function, health, and quality of life are used to determine the efficacy of the program. NRN members consist of scientists, clinicians, and administrators who collaborate to achieve the goals and objectives of the network within an organizational structure by designing and implementing a clinical model that provides consistent interventions and evaluations and a general education and training program.     

Lokomat全自动机器人步态训练与评定系统对不完全性脊髓损伤患者步行功能的影响

背景：机器人设备能够在精确控制的环境下为患者提供安全可重复性的高强度较长时间的步态训练,其在康复领域的应用有其明显的优势。目的：探讨Lokomat-全自动机器人步态训练与评定系统在改善不完全性脊髓损伤患者步行功能方面的作用。方法：2名男性不完全性脊髓损伤患者参加Lokomat步态训练5.5个月,于训练前、训练后6,12周及训练5.5个月后对患者进行下肢运动功能评分（Lower Extremity Motor Scores,LEMS）、10m最快步速、6min步行耐力及Berg平衡量表测试。结果与结论：两名患者经过Lokomat自动步态训练,虽然LEMS分数无明显提高,但其10m最快步速、6min步行耐力、Berg平衡量表评分均较训练前改善。这说明机器人自动步态训练能够有助于改善不完全性脊髓损伤患者的步行能力。     

Establishing the NeuroRecovery Network Community Fitness and Wellness facilities: multi-site fitness facilities provide activity-based interventions and assessments for evidence-based functional gains in neurologic disorders

Abstract

Background: Physical fitness is a necessity for those living with a spinal cord injury, yet access to fitness facilities, equipment, and specially trained fitness experts are limited.

Methods: This article introduces the concept of a network of fitness facilities specially geared towards individuals with spinal cord injury and other neurological disorders.

Results: The Community Fitness and Wellness branch of the NeuroRecovery Network was created to provide a continuum of care after traditional rehabilitation for individuals living with a spinal cord injury and other neurological disorders. Community Fitness and Wellness facilities translate activity-based interventions performed during rehabilitation into a community setting as well as provide other fitness and wellness opportunities. Community Fitness and Wellness facilities are staffed by professionals with training on the specialized needs of individuals living with spinal cord injury or other neurological disorders. Standardized assessments evaluate functional, health, and quality of life gains at regular intervals. A national database gathers information on standardized interventions and assessment outcomes providing a mechanism for evaluation of interventions performed in the community setting.

Conclusions: The establishment of Community Fitness and Wellness facilities allows for the quick translation and evaluation of novel, effective approaches from research to individuals in the community.

• Implications for Rehabilitation

• Fitness needs of individuals with spinal cord injury living in the community necessitate the use of special equipment and trained staff.

• Community Fitness and Wellness Programs offer specially trained staff and adaptive equipment providing a continuity of care for those with spinal cord injuries and other neurological disorders.

     

Activity-Based Therapy for Recovery of Walking in Individuals With Chronic Spinal Cord Injury: Results From a Randomized Clinical Trial

ObjectiveTo examine the effects of activity-based therapy (ABT) on neurologic function, walking ability, functional independence, metabolic health, and community participation.DesignRandomized controlled trial with delayed treatment design.SettingOutpatient program in a private, nonprofit rehabilitation hospital.ParticipantsVolunteer sample of adults (N=48; 37 men and 11 women; age, 18–66y) with chronic (≥12mo postinjury), motor-incomplete (ASIA Impairment Scale grade C or D) spinal cord injury (SCI).InterventionsA total of 9h/wk of ABT for 24 weeks including developmental sequencing; resistance training; repetitive, patterned motor activity; and task-specific locomotor training. Algorithms were used to guide group allocation, functional electrical stimulation utilization, and locomotor training progression.Main Outcome MeasuresNeurologic function (International Standards for Neurological Classification of Spinal Cord Injury); walking speed and endurance (10-meter walk test, 6-minute walk test, and Timed Up and Go test); community participation (Spinal Cord Independence Measure, version III, and Reintegration to Normal Living Index); and metabolic function (weight, body mass index, and Quantitative Insulin Sensitivity Check).ResultsSignificant improvements in neurologic function were noted for experimental versus control groups (International Standards for Neurological Classification of Spinal Cord Injury total motor score [5.1±6.3 vs 0.9±5.0; P=.024] and lower extremity motor score [4.2±5.2 vs −0.6±4.2; P=.004]). Significant differences between experimental and control groups were observed for 10-meter walk test speed (0.096±0.14m/s vs 0.027±0.10m/s; P=.036) and 6-minute walk test total distance (35.97±48.2m vs 3.0±25.5m; P=.002).ConclusionsABT has the potential to promote neurologic recovery and enhance walking ability in individuals with chronic, motor-incomplete SCI. However, further analysis is needed to determine for whom ABT is going to lead to meaningful clinical benefits.     

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     

Impact of a limited trial of walking training using body weight support and a treadmill on the gait characteristics of an individual with chronic,incomplete spinal cord injury

Studies showing improvement in locomotor ability for individuals with chronic spinal cord injury (SCI) use training times that may be prohibitive for clinics. The purpose of this study was to examine the impact of a limited period of training on the gait characteristics of a man with chronic, incomplete SCI. The participant was a minimally ambulatory 59-year-old man almost 3 years post C₃ central cord injury with an ASIA Impairment Scale (AIS) classification of C. The participant received 11 training sessions using body weight support and a treadmill (BWST) over a 6-week period. The Six Minute Walk Test (6?MWT), and gait characteristics measured with motion analysis were obtained pretraining and posttraining. The participant made improvements on all measured gait characteristics. The participant's walking speed and comfort level on the treadmill improved enough for him to use community resources. This participant was able to make improvements in his gait with a much shorter training time period than those reported in previous locomotor training studies. Although this man did not obtain community ambulation status, his decreased dependence on his power chair at home and his new ability to use an available treadmill allow for continued walking practice outside the clinic.     

Quantifying muscle coactivation in individuals with incomplete spinal cord injury using wavelets

BackgroundIndividuals with incomplete spinal cord injury often have decreased gait function and coactivation of antagonistic muscle pairs. Common ways of quantifying coactivation using electromyographic signals do not consider frequency information in the signal. As electromyographic signals from different motor unit types have different frequency components and muscle fiber type can change in individuals with spinal cord injury, it may be beneficial to consider frequency components. The aims were to demonstrate the utility of using a method which considers temporal and frequency components of the electromyographical signal to quantify coactivation in lower extremity muscles in individuals with incomplete spinal cord injury through 1) comparison with able-bodied individuals and 2) comparison before and after body weight supported treadmill training.MethodsFrequency decomposition techniques were applied to electromyographical signals to consider the temporal and frequency components of the electromyographical signals to quantify coactivation over a range of frequencies.ResultsOur main findings show that correlation coefficients between total EMG intensities of rectus femoris-biceps femoris and medial gastrocnemius-tibialis anterior were significantly different between able-bodied individuals and those with incomplete spinal cord injury (p = 0006, p = 0.01). The correlation spectra of medial gastrocnemius-tibialis anterior of the spinal cord injury group were substantially different than those the able-bodied group, while the EMG normalcy score was significantly different (p = 0.002). We also found that there was a change in coactivation of ankle muscles after body weight supported treadmill training.InterpretationOur findings indicate that there may be frequency specific differences in muscle coactivation between able-bodied individuals and those with incomplete spinal cord injury. Changes in coactivation were also observed before and after body weight supported treadmill training. These differences may reflect the changes in recruitment patterns of different motor unit types.     

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.     

Robotic Locomotor Training Leads to Cardiovascular Changes in Individuals With Incomplete Spinal Cord Injury Over a 24-Week Rehabilitation Period: A Randomized Controlled Pilot Study

ObjectiveTo describe the effect of robotic locomotor training (RLT) and activity-based training (ABT) on cardiovascular indices during various physiological positions in individuals with spinal cord injury.DesignRandomized controlled pilot study.SettingPrivate practice: Therapy & Beyond Centre - Walking with Brandon Foundation, Sports Science Institute of South Africa, Cape Town, South Africa.ParticipantsParticipants with chronic traumatic motor incomplete tetraplegia (N=16) who resided in the Western Cape, South Africa.InterventionRobotic locomotor training (Ekso GT) and activity-based training over a 24-week intervention.Main Outcome MeasuresBrachial and ankle blood pressure, heart rate, heart rate variability, and cardiovascular efficiency during 4 physiological positions.ResultsNo differences between groups or over time were evident in resting systolic and diastolic blood pressure, ankle systolic pressure, ankle brachial pressure index, and heart rate variability. Standing heart rate at 24 weeks was significantly higher in the ABT group (95.58±12.61 beats/min) compared with the RLT group (75.14±14.96 beats/min) (P=.05). In the RLT group, no significant changes in heart rate variability (standard deviation R-R interval and root mean square of successive differences) was found between the standing and 6-minute walk test physiological positions throughout the intervention. Cardiovascular efficiency in the RLT group during the 6-minute walk test improved from 11.1±2.6 at baseline to 7.5±2.8 beats per meter walked at 6 weeks and was maintained from 6 to 24 weeks.ConclusionsLarge effect sizes and significant differences between groups found in this pilot study support the clinical effectiveness of RLT and ABT for changing cardiovascular indices as early as 6 weeks and up to 24 weeks of rehabilitation. RLT may be more effective than ABT in improving cardiac responses to orthostatic stress. Based on heart rate variability metrics, the stimulus of standing has comparable effects to RLT on the parasympathetic nervous system. Cardiovascular efficiency of exoskeleton walking improved, particularly over the first 6 weeks. Both the RLT and ABT interventions were limited in their effect on brachial and ankle blood pressure. A randomized controlled trial with a larger sample size is warranted to further examine these findings.     

Satisfaction and perceptions of long-term manual wheelchair users with a spinal cord injury upon completion of a locomotor training program with an overground robotic exoskeleton

Aim: The main objectives of this study were to quantify clients’ satisfaction and perception upon completion of a locomotor training program with an overground robotic exoskeleton.

Methods: A group of 14 wheelchair users with a spinal cord injury, who finished a 6–8-week locomotor training program with the robotic exoskeleton (18 training sessions), were invited to complete a web-based electronic questionnaire. This questionnaire encompassed 41 statements organized around seven key domains: overall satisfaction related to the training program, satisfaction related to the overground robotic exoskeleton, satisfaction related to the program attributes, perceived learnability, perceived health benefits and risks and perceived motivation to engage in physical activity. Each statement was rated using a visual analogue scale ranging from “0?=?totally disagree” to “100?=?completely agree”.

Results: Overall, respondents unanimously considered themselves satisfied with the locomotor training program with the robotic exoskeleton (95.7?±?0.7%) and provided positive feedback about the robotic exoskeleton itself (82.3?±?6.9%), the attributes of the locomotor training program (84.5?±?6.9%) and their ability to learn to perform sit–stand transfers and walk with the robotic exoskeleton (79.6?±?17%). Respondents perceived some health benefits (67.9?±?16.7%) and have reported no fear of developing secondary complications or of potential risk for themselves linked to the use of the robotic exoskeleton (16.7?±?8.2%). At the end of the program, respondents felt motivated to engage in a regular physical activity program (91.3?±?0.1%).

Conclusion: This study provides new insights on satisfaction and perceptions of wheelchair users while also confirming the relevance to continue to improve such technologies, and informing the development of future clinical trials.

• Implications for Rehabilitation

• All long-term manual wheelchair users with a spinal cord injury who participated in the study are unanimously satisfied upon completion of a 6–8-week locomotor training program with the robotic exoskeleton and would recommend the program to their peers.

• All long-term manual wheelchair users with a spinal cord injury who participated in the study offered positive feedback about the robotic exoskeleton itself and feel it is easy to learn to perform sit–stand transfers and walk with the robotic exoskeleton.

• All long-term manual wheelchair users with a spinal cord injury who participated in the study predominantly perceived improvements in their overall health status, upper limb strength and endurance as well as in their sleep and psychological well-being upon completion of a 6–8-week locomotor training program with the robotic exoskeleton.

• All long-term manual wheelchair users with a spinal cord injury who participated in the study unanimously felt motivated to engage in a regular physical activity program adapted to their condition and most of them do plan to continue to participate in moderate-to-strenuous physical exercise.

• Additional research on clients’ perspectives, especially satisfaction with the overground exoskeleton and locomotor training program attributes, is needed.