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LOCOMOTOR TRAINING FOR INCOMPLETE SCIAmy E. Rosen, SPT
www.abc.net.au/rampup/articles/2011/06/02/3233648.htm Credit: DOUGBERRY (iStockphoto)
"We live in a time when the words impossible and unsolvable are no longer part of the scientific community's vocabulary. Each day we move closer to trials that will not just minimize the symptoms of disease and injury but eliminate them. “
-Christopher Reeve
http://www.beliefnet.com/Inspiration/2010/06/Inspiring-Quotes-by-Christopher-Reeve.aspx?p=12#cDYwEvy52Cxc0G2y.99
Spinal Cord Injury
AIS classification1
Individuals can get better2
22% of AIS A converted to AIS B or better by rehabilitation discharge Year 1: 30% improved to AIS B or better
8% AIS C, 7.1% AIS D AIS B converted to 27.2% AIS C, 23.6% AIS D
Year 1: 29.6% improved to C, 36.8% to D 77.2% of AIS C converted to AIS D
Year 1: 82.5% improved to D or E 1.5% of AIS D converted to AIS E
Year 1:14.1% improved to E
Neural plasticity
Within the CNS
“Activity-dependent plasticity” promotes functional reorganization of the neuromuscular system3
Enhance the natural recovery process through early, intensive and task-specific therapies4
Locomotor Training
A rehabilitation strategy designed to enhance to recovery of postural control, balance, standing, walking, health, and quality of life after neurological injury or disease based on scientific and clinical evidence3,5,6
Influence of CPG5
Load Receptor Input Hip Joint Afferents Interlimb Coordination
Locomotion Training for iSCI
Estimated that with 10% of descending spinal tracts, some locomotor function can recover5,7
Long term effects with increased leg extensor EMG activity5
AIS classification indications6
Strongly dependent on visual input to compensate for proprioceptive deficits and impaired balance6
Increased demand on cortical control Increased risk of falls
Christina Morawietz, MSc, Fiona Moffat, MSc
Effects of Locomotor Training After Incomplete Spinal Cord Injury: A Systematic Review8
Systematic Review
Published 2013
Objective: “To provide an overview of, and evaluate the current evidence on, locomotor training approaches for gait rehabilitation in individuals with incomplete spinal cord injury to identify the most effective therapies.”
Locomotor Training defined by any therapeutic program aimed at the recovery of walking through intense practice of the task of walking
Articles: From first date of publication to May 2013
Article Retrieval
Inclusion/Exclusion Criteria
Initial Search 8656 potential relevant records Excluded duplicates within and between databases
Full-text articles and eligible: 113 Excluded-No RCT: 103, Wrong Population: 1
Left 9 articles for Quality Assessment Quality Assessment: PEDro Scale
Eight RCTs
PEDro Scores of 4-8
5 for Acute/Subacute, ≤1 year post injury 3 for Chronic, ≥1 year post injury
Parameters examined
Initial Walking Capacity Gait Velocity Distance Gait Parameters FIM Score
Acute
Chronic
Outcomes
Gait Velocity and Distance Modest support for BWSTT
and robotic assistance-based therapies over conventional PT
Gait Velocity and Distance Functional ambulation
improved in most participants
Not explicitly in favor of 1 therapy over another
ACUTE CHRONIC
Improvements in Acute participants were significantly greater than Chronic
>1year postinjury demonstrated greater variation in performance within the various studies
Implications for Rehab
Continues to be a lack of high-quality of data on effectiveness of locomotor therapy after SCI
Training at faster speeds, making more steps, or training longer has been associated with better outcomes in neurological rehabilitation
All included therapies showed potential for improvement
Other Potential Benefits of Locomotor Training
http://www.wpclipart.com/science/biology/human_locomotion.png.html
Lokomat and iSCI Cardiorespiratory9
November 2013 N= 10AIS C and D Intervention: 24 sessions within 10-16wks
Intensity: VO2 &HR Measure: % VO2R, %HRR, and METs
Fitness test: Arm crank exercise test & Robotic Walking Test Pre- and Post- Intervention
Outcomes
Outcome Measures Eight for Cardiorespiratory Fitness Nine for Robotic Walking Intensity
Arm Crank Exercise Test Resting and submaximal HR was significantly less
Robotic Walking Test %HRR significantly lower from last to first tested
Conclusion: Lokomat may also improve cardiorespiratory fitness
Balance & Ambulation with iSCI3
2012: Prospective observational cohort N= 196
AIS C or D Range from 32 days to >25 years since SCI
Intervention: 1hr. step training using BWS and manual facilitation on treadmill, then 30min. overground amb. and community integrations Received at least 20 treatments
Outcome measure Berg Balance 6-min walk 10-meter walk
Outcomes
Functional Improvements Found Berg Balance
Significantly improved by avg. of 9.6 points Fall Risk Improvements
6 MWT Significantly improved by avg. of 63m
10 MWT Significantly improved by avg. of 0.20m/s
Conclusion: significant functional recovery can continue to occur even years after injury Greatest improvements with training closer to time of injury
Walking Index for Spinal Cord Injury10
Documenting changes in levels of walking 0-20 scale
Accounts for amount of assistance Persons, device, and bracing
Ambulation of 10 meters Inter & Intra Rater Reliability: Excellent Validity compared to 10MWT, TUG and 6MWT
Overall Excellent Correlations
WISCI II
http://nursing-care.org/44-living/038-living.html
Food for thought3,8,9
iSCI patients vary significantly Acute Participants
Impossible to account for the amount of spontaneous recovery occurring
Little is know about optimal timing, intensity and frequency of locomotor training
Different locomotor approaches might play a role at different stages and elements of the rehabilitation process
Further research & development of standardized, sensitive outcome measures
Our job to facilitate as much functional gains as possible
Thank you.
References
1. Rehabilitation Measures Database. Rehab Measures: International Standard for Neurological Classification of Spinal Cord Injury (ASIA Impairment Scale). Copyright 2011. Available at http://www.rehabmeasures.org/Lists/RehabMeasures/PrintView.aspx?ID=956
2. Marino RJ, et al. Upper- and lower-extremity motor recovery after traumatic cervical spinal cord injury: An Update From the National Spinal Cord Injury Database. arch Phys Med Rehbil. March 2011; 92: 369-375.
3. Harkema S, Schmidt-Read M, Lorenz D, Edgerton V, Behrman A. Balance and Ambulation Improvements in Individuals With Chronic Incomplete Spinal Cord Injury Using Locomotor Training–Based Rehabilitation. Archives Of Physical Medicine & Rehabilitation. September 2012;93(9):1508-1517.
4. Foud K, Tetzlaff W. Rehabilitive training and plasticity following spinal cord injury. Exp Neurol. 2012; 235:91-9
5. Dietz V, Harkema S. Locomotor activity in spinal cord-injured persons. Journal Of Applied Physiology (Bethesda, Md.: 1985). May 2004;96(5):1954-1960
6. Van Hedel HJA, Dietz V. Rehabilitation of locomotion after spinal cord injury. Restorative Neurology and Neuroscience. 2011; 28:123-134
7. Basso DM. Neuroanatomical substrates of functional recover after experimental spinal cord injury: implications of basic science research for human spinal cord injury. Phys Ther 2000; 80: 808-817
8. Morawietz C, Moffat F. Effects of locomotor training after incomplete spinal cord injury: A systematic review. Archives of Physical Medicine and Rehabilitation. 2013; 94: 2297-308
9. Hoekstra F, van Nunen M, Gerrits K, Stolwijk-Swüste J, Crins M, Janssen T. Effect of robotic gait training on cardiorespiratory system in incomplete spinal cord injury. Journal Of Rehabilitation Research & Development. December 16, 2013;50(10):1411-1422.
10. Rehabilitation Measures Database. Rehab Measures: Walking Index for Spinal Cord Injury. Last modified 11/6/2013. Available at http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=957