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.     

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.     

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.     

The effects of backward walking training on balance and mobility in an individual with chronic incomplete spinal cord injury: A case report

Background/Purpose: Individuals with incomplete spinal cord injuries (ISCIs) commonly face persistent gait impairments. Backward walking training may be a useful rehabilitation approach, providing novel gait and balance challenges. However, little is known about the effects of this approach for individuals with ISCIs. The purpose of this case report was to describe the effects of backward walking training on strength, balance, and upright mobility in an individual with chronic ISCI. Methods: A 28-year-old female, 11-years post ISCI (C4, AIS D) completed 18-sessions of backward walking training on a treadmill with partial body-weight support and overground. Training emphasized stepping practice, speed, and kinematics. Outcome measures included: Lower Extremity Motor Score, Berg Balance Scale (BBS), Sensory Organization Test (SOT), 10-Meter Walk Test (10MWT), 3-meter backward walking test, Timed Up and Go (TUG), and Activities-Specific Balance Confidence (ABC) Scale. Results: Strength did not change. Improved balance was evident based on BBS (20 to 37/56) and SOT scores (27 to 40/100). Upright mobility improved based on TUG times (57 to 32.7 s), increased 10MWT speed (0.23 to 0.31 m/s), and backward gait speed (0.07 to 0.12 m/s). Additionally, self-reported balance confidence (ABC Scale) increased from 36.9% to 49.6%. Conclusions: The results suggest that backward walking may be a beneficial rehabilitation approach; examination of the clinical efficacy is warranted.     

Activity-Based Therapy for Recovery of Walking in Chronic Spinal Cord Injury: Results From a Secondary Analysis to Determine Responsiveness to Therapy

ObjectiveTo gain insight into who is likely to benefit from activity-based therapy (ABT), as assessed by secondary analysis of data obtained from a clinical trial.DesignSecondary analysis of results from a randomized controlled trial with delayed treatment design.SettingOutpatient program in a private, nonprofit rehabilitation hospital.ParticipantsVolunteer sample of adults (N=38; 27 men; 11 women; age, 22–63y) with chronic (≥12mo postinjury), motor-incomplete (American Spinal Injury Association [ASIA] Impairment Scale [AIS] 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 MeasuresWalking speed and endurance (10-meter walk test and 6-minute walk test) and functional ambulation (timed Up and Go test).ResultsThis secondary analysis identified likely responders to ABT on the basis of injury characteristics: AIS classification, time since injury, and initial walking ability. Training effects were the most clinically significant in AIS grade D participants with injuries <3 years in duration. This information, along with information about preliminary responsiveness to therapy (gains after 12wk), can help predict the degree of recovery likely from participation in an ABT program.ConclusionsABT has the potential to promote neurologic recovery and enhance walking ability in individuals with chronic, motor-incomplete SCI. However, not everyone with goals of walking recovery will benefit. Individuals with SCI should be advised of the time, effort, and resources required to undertake ABT. Practitioners are encouraged to use the findings from this trial to assist prospective participants in establishing realistic expectations for recovery.     

NeuroRecovery Network Provides Standardization of Locomotor Training for Persons With Incomplete Spinal Cord Injury

Morrison SA, Forrest GF, VanHiel LR, Davé M, D'Urso D. NeuroRecovery Network provides standardization of locomotor training for persons with incomplete spinal cord injury.ObjectiveTo illustrate the continuity of care afforded by a standardized locomotor training program across a multisite network setting within the Christopher and Dana Reeve Foundation NeuroRecovery Network (NRN).DesignSingle patient case study.SettingTwo geographically different hospital-based outpatient facilities.ParticipantsThis case highlights a 25-year-old man diagnosed with C4 motor incomplete spinal cord injury with American Spinal Injury Association Impairment Scale grade D.InterventionStandardized locomotor training program 5 sessions per week for 1.5 hours per session, for a total of 100 treatment sessions, with 40 sessions at 1 center and 60 at another.Main Outcome MeasuresTen-meter walk test and 6-minute walk test were assessed at admission and discharge across both facilities. For each of the 100 treatment sessions percent body weight support, average, and maximum treadmill speed were evaluated.ResultsLocomotor endurance, as measured by the 6-minute walk test, and overground gait speed showed consistent improvement from admission to discharge. Throughout training, the patient decreased the need for body weight support and was able to tolerate faster treadmill speeds.ConclusionsData indicate that the patient continued to improve on both treatment parameters and walking function. Standardization across the NRN centers provided a mechanism for delivering consistent and reproducible locomotor training programs across 2 facilities without disrupting training or recovery progression.     

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.     

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.

Characterizing Natural Recovery of People With Initial Motor Complete Tetraplegia

ObjectiveTo determine the differences in neurologic recovery in persons with initial cervical American Spinal Cord Injury Association Impairment Scale (AIS) grades A and B over time.DesignRetrospective analysis of data from people with traumatic cervical spinal cord injury (SCI) enrolled in the National Spinal Cord Injury Model Systems (SCIMS) database from 2011-2019.SettingSCIMS centers.ParticipantsIndividuals (N=187) with traumatic cervical (C1-C7 motor level) SCI admitted with initial AIS grade A and B injuries within 30 days of injury, age 16 years or older, upper extremity motor score (UEMS) ≤20 on both sides, and complete neurologic data at admission and follow-up between 6 months and 2 years.InterventionsNot applicable.Main Outcome MeasuresConversion in AIS grades, UEMS and lower extremity motor scores (LEMS), and sensory scores.ResultsMean time to initial and follow-up examinations were 16.1±7.3 days and 377.5±93.4 days, respectively. Conversion from an initial cervical AIS grades A and B to motor incomplete status was 13.4% and 50.0%, respectively. The mean UEMS change for people with initial AIS grades A and B did not differ (7.8±6.5 and 8.8±6.1; P=.307), but people with AIS grade B experienced significantly higher means of LEMS change (2.3±7.4 and 8.8±13.9 (P≤.001). The increased rate of conversion to motor incomplete status from initial AIS grade B appears to be the primary driving factor of increased overall motor recovery. Individuals with initial AIS grade B had greater improvement in sensory scores.ConclusionsWhile UEMS recovery is similar in persons with initial AIS grades A and B, the rate of conversion to motor incomplete status, LEMS, and sensory recovery are significantly different. This information is important for clinical as well as research considerations.     

Cardiovascular Status of Individuals With Incomplete Spinal Cord Injury From 7 NeuroRecovery Network Rehabilitation Centers

Sisto SA, Lorenz DJ, Hutchinson K, Wenzel L, Harkema SJ, Krassioukov A. Cardiovascular status of individuals with incomplete spinal cord injury from 7 NeuroRecovery Network rehabilitation centers.ObjectiveTo examine cardiovascular (CV) health in a large cohort of individuals with incomplete spinal cord injury (SCI). The CV health parameters of patients were compared based on American Spinal Injury Association Impairment Scale (AIS), neurologic level, sex, central cord syndrome, age, time since injury, Neuromuscular Recovery Scale, and total AIS motor score.DesignCross-sectional study.SettingSeven outpatient rehabilitation clinics.ParticipantsIndividuals (N=350) with incomplete AIS classification C and D were included in this analysis.InterventionsNot applicable.Main Outcome MeasuresHeart rate, systolic and diastolic blood pressure during resting sitting and supine positions and after an orthostatic challenge.ResultsCV parameters were highly variable and significantly differed based on patient position. Neurologic level (cervical, high and low thoracic) and age were most commonly associated with CV parameters where patients classified at the cervical level had the lowest resting CV parameters. After the orthostatic challenge, blood pressure was highest for the low thoracic group, and heart rate for the high thoracic group was higher. Time since SCI was negatively related to blood pressure at rest but not after orthostatic challenge. Men exhibited higher systolic blood pressure than women and lower heart rate. The prevalence of orthostatic hypotension (OH) was 21% and was related to the total motor score and resting seated blood pressures. Cervical injuries had the highest prevalence.ConclusionsResting CV parameters of blood pressure and heart rate are affected by position, age, and neurologic level. OH is more prevalent in cervical injuries, those with lower resting blood pressures and who are lower functioning. Results from this study provide reference for CV parameters for individuals with incomplete SCI. Future research is needed on the impact of exercise on CV parameters.     

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.     

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.     

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.     

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.     

Prevalence and Determinants of Pain in Spinal Cord Injury During Initial Inpatient Rehabilitation: Data From the Dutch Spinal Cord Injury Database

ObjectiveTo describe the prevalence and characteristics of spinal cord injury (SCI)-related pain during initial inpatient rehabilitation and to investigate relationships with demographic and lesion characteristics.DesignCohort during inpatient rehabilitation.SettingEight specialized SCI rehabilitation centers in the Netherlands.ParticipantsPatients with newly acquired SCI admitted for inpatient rehabilitation between November 2013 and August 2019 (N=1432).InterventionsNot applicable.Main Outcome MeasuresPresence of pain at admission and discharge. Logistic regression analyses were used to study the prevalence of pain related to sex, age, etiology, completeness, and level of injury.ResultsData from 1432 patients were available. Of these patients 64.6% were male, mean age was 56.8 years, 59.9% had a nontraumatic SCI, 63.9% were classified as American Spinal Cord Injury Association Impairment Scale (AIS) D and 56.5% had paraplegia. Prevalence of pain was 61.2% at admission (40.6% nociceptive pain [NocP], 30.2% neuropathic pain [NeuP], 5.4% other pain) and 51.5% at discharge (26.0% NocP, 31.4% NeuP, 5.7% other pain). Having NocP at admission was associated with traumatic SCI. AIS B had a lower risk of NocP than AIS D at admission. Having NocP at discharge was associated with female sex and traumatic SCI. AIS C had a lower risk of NocP at discharge than AIS D. Having NeuP at admission was associated with female sex. Having NeuP at discharge was associated with female sex, age younger than 65 years vs age older than 75 years and tetraplegia.ConclusionsSCI-related pain is highly prevalent during inpatient rehabilitation. Prevalence of NocP decreased during inpatient rehabilitation, and prevalence of NeuP stayed the same. Different patient and lesion characteristics were related to the presence of SCI-related pain. Healthcare professionals should be aware of these differences in screening patients on presence and development of pain during inpatient rehabilitation.     

Predicting Duration of Outpatient Physical Therapy Episodes for Individuals with Spinal Cord Injury Based on Locomotor Training Strategy

ObjectiveTo characterize individuals with spinal cord injuries (SCI) who use outpatient physical therapy or community wellness services for locomotor training and predict the duration of services, controlling for demographic, injury, quality of life, and service and financial characteristics. We explore how the duration of services is related to locomotor strategy.DesignObservational study of participants at 4 SCI Model Systems centers with survival. Weibull regression model to predict the duration of services.SettingRehabilitation and community wellness facilities at 4 SCI Model Systems centers.ParticipantsEligibility criteria were SCI or dysfunction resulting in motor impairment and the use of physical therapy or community wellness programs for locomotor/gait training. We excluded those who did not complete training or who experienced a disruption in training greater than 45 days. Our sample included 62 participants in conventional therapy and 37 participants in robotic exoskeleton training.InterventionsOutpatient physical therapy or community wellness services for locomotor/gait training.Main Outcome MeasuresSCI characteristics (level and completeness of injury) and the duration of services from medical records. Self-reported perceptions of SCI consequences using the SCI-Functional Index for basic mobility and SCI-Quality of Life measurement system for bowel difficulties, bladder difficulties, and pain interference.ResultsAfter controlling for predictors, the duration of services for the conventional therapy group was an average of 63% longer than for the robotic exoskeleton group, however each visit was 50% shorter in total time. Men had an 11% longer duration of services than women had. Participants with complete injuries had a duration of services that was approximately 1.72 times longer than participants with incomplete injuries. Perceived improvement was larger in the conventional group.ConclusionsLocomotor/gait training strategies are distinctive for individuals with SCI using a robotic exoskeleton in a community wellness facility as episodes are shorter but individual sessions are longer. Participants’ preferences and the ability to pay for ongoing services may be critical factors associated with the duration of outpatient services.     

Rehabilitation Length of Stay,Body Mass Index,and Functional Improvement Among Adults With Traumatic Spinal Cord Injury

ObjectiveTo examine the modifying effect of body mass index (BMI) on the association between rehabilitation length of stay (LOS), severity of injury, and motor FIM (mFIM) improvement in patients with traumatic spinal cord injury (TSCI).DesignRetrospective cohort study.SettingSeventeen SCI Model Systems (SCIMS) centers in the United States.ParticipantsA total of 3413 patients (N=3413) who had a TSCI were admitted to an SCIMS between October 2011 and August 2018.InterventionsNot applicable.Main Outcome MeasuresThe mFIM (12 items) improvement by discharge. Four rehabilitation LOS groups split by quartiles were created for each neurologic severity of injury group (C1-C4 level with American Spinal Injury Association Impairment Scale [AIS] ABC, C5-C8 AIS ABC, T1-S3 AIS ABC, AIS DE). The interrelationship among rehabilitation LOS, BMI, and mFIM improvement were examined using multivariate linear regressions. A stratified analysis was performed to examine the association between rehabilitation LOS and mFIM improvement by BMI status (underweight or normal weight, overweight, obesity) and neurologic groups.ResultsA total of 1099 (32.2%) and 821 (24.1%) patients were overweight and had obesity, respectively. Patients with obesity had less improvement in mFIM than those who were underweight or normal weight (unit of mFIM improvement, ?3.71). After stratifying by BMI status, among patients with obesity, those with the longest rehabilitation LOS showed greater improvement in mFIM than those in the shortest LOS (unit of mFIM improvement=4.78).ConclusionsLonger inpatient rehabilitation LOS may benefit patients with TSCI by increasing mFIM improvement by discharge. Obesity is negatively associated with mFIM improvement.     

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.