August 2014 in-service presentation for Spaulding Rehabiliation Hospital, Charlestown MA at the competition of clinical affiliation on the SCI unit. Review of current literature for improving evidence based practice.

1. LOCOMOTOR TRAINING
FOR INCOMPLETE SCI
Amy E. Rosen, SPT
www.abc.net.au/rampup/articles/2011/06/02/3233648.htm Credit: DOUGBERRY (iStockphoto)

2. "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

3. 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

4. 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

5. 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

6. 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

7. Christina Morawietz, MSc, Fiona Moffat, MSc
Effects of Locomotor Training After Incomplete Spinal
Cord Injury: A Systematic Review8

8. 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

9. 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

10. Eight RCTs
 PEDro Scores of 4-8
 5 for Acute/Subacute, ≤1 year post injury
 3 for Chronic, ≥1 year post injury

11. Parameters examined
 Initial Walking Capacity
 Gait Velocity
 Distance
 Gait Parameters
 FIM Score

12. Acute

13. Chronic

14. 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

15. 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

16. Other Potential Benefits of Locomotor Training
http://www.wpclipart.com/science/biology/human_locomotion.png.html

17. Lokomat and iSCI Cardiorespiratory9
 November 2013
 N= 10 AIS 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

18. 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

19. 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

20. 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

21. 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

22. http://nursing-care.org/44-living/038-living.html

23. 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

24. Thank you.

25. 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