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