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

Published:August 04, 2014DOI:https://doi.org/10.1016/j.apmr.2014.07.400

      Highlights

      • We examined activity-based therapy (ABT) in people with chronic, motor-incomplete spinal cord injury.
      • Significant improvements in neurologic function and walking were observed.
      • No secondary health or quality-of-life benefits were evidenced from ABT.
      • Considerable variability was also noted in response to therapy.

      Abstract

      Objective

      To examine the effects of activity-based therapy (ABT) on neurologic function, walking ability, functional independence, metabolic health, and community participation.

      Design

      Randomized controlled trial with delayed treatment design.

      Setting

      Outpatient program in a private, nonprofit rehabilitation hospital.

      Participants

      Volunteer 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).

      Interventions

      A 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 Measures

      Neurologic 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).

      Results

      Significant 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).

      Conclusions

      ABT 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.

      Keywords

      List of Abbreviations:

      10MWT (10-meter walk test), ABT (activity-based therapy), AIS (ASIA Impairment Scale), FES (functional electrical stimulation), ISNCSCI (International Standards for Neurological Classification of Spinal Cord Injury), LEMS (lower extremity motor score), QUICKI (Quantitative Insulin Sensitivity Check), RNL (Reintegration to Normal Living), SCI (Spinal cord injury), SCI-FAI (Spinal Cord Injury Functional Ambulation Index), SCIM-III (Spinal Cord Independence Measure, version III), TUG (timed Up and Go)
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      References

        • Bauman W.A.
        • Spungen A.M.
        Carbohydrate and lipid metabolism in chronic spinal cord injury.
        J Spinal Cord Med. 2001; 24: 266-277
        • Groah S.L.
        • Weitzenkamp D.
        • Sett P.
        • Soni B.
        • Savic G.
        The relationship between neurological level of injury and symptomatic cardiovascular disease risk in the aging spinal injured.
        Spinal Cord. 2001; 39: 310-317
        • Spungen A.M.
        • Adkins R.H.
        • Stewart C.A.
        • et al.
        Factors influencing body composition in persons with spinal cord injury: a cross-sectional study.
        J Appl Physiol. 2003; 95: 2398-2407
        • Myers J.
        • Lee M.
        • Kiratli J.
        Cardiovascular disease in spinal cord injury: an overview of prevalence, risk, evaluation, and management.
        Arch Phys Med Rehabil. 2007; 86: 142-152
        • Hubli M.
        • Bolliger M.
        • Dietz V.
        Neuronal dysfunction in chronic spinal cord injury.
        Spinal Cord. 2011; 49: 582-587
        • Dietz V.
        • Grillner S.
        • Trepp A.
        • Hubli M.
        • Bolliger M.
        Changes in spinal reflex and locomotor activity after a complete spinal cord injury: a common mechanism?.
        Brain. 2009; 132: 2196-2205
        • Harkema S.J.
        • Dobkin B.H.
        • Edgerton V.R.
        Pattern generators in locomotion: implications for recovery of walking after spinal cord injury.
        Top Spinal Cord Inj Rehabil. 2000; 6: 82-96
        • Edgerton V.R.
        • Leon R.D.
        • Harkema S.J.
        Retraining the injured spinal cord.
        J Physiol. 2001; 533: 15-22
        • Edgerton V.R.
        • Roy R.R.
        Paralysis recovery in humans and model systems.
        Curr Opin Neurobiol. 2002; 12: 658-667
        • Ying Z.
        • Roy R.R.
        • Edgerton V.R.
        • Gomez-Pinilla F.
        Voluntary exercise increases neurotrophin-3 and its receptor TrkC in the spinal cord.
        Brain Res. 2003; 987: 93-99
        • Edgerton V.R.
        • Tillakaratne N.J.
        • Bigbee A.J.
        • De Leon R.D.
        • Roy R.R.
        Plasticity of the spinal neural circuitry after injury.
        Ann Rev Neurosci. 2004; 27: 145-167
        • Harkema S.J.
        Neural plasticity after human spinal cord injury: application of locomotor training to the rehabilitation of walking.
        Neuroscientist. 2001; 7: 455-468
      1. Edgerton VR, Harkema SJ, Dobkin BH, editors. Retraining the human spinal cord to walk. In: Lin V, editor. Spinal cord medicine. New York: Demos; 2002. p 843-52.

        • Behrman A.L.
        • Harkema S.J.
        Physical rehabilitation as an agent of recovery after spinal cord injury.
        Phys Med Rehabil Clin N Am. 2007; 18: 183-202
        • American Spinal Injury Association
        International Standards for Neurological Classification of Spinal Cord Injury, revised 2011.
        American Spinal Injury Association, Atlanta2011
        • Dromerick A.W.
        • Lum P.S.
        • Hidler J.
        Activity-based therapies.
        J Am Soc Exp NeuroTherapeut. 2006; 3: 428-438
        • Belegu V.
        • Oudega M.
        • Gary D.S.
        • McDonald J.W.
        Restoring function after spinal cord injury: promoting spontaneous regeneration with stem cells and activity-based therapies.
        Neurosurg Clin N Am. 2007; 18: 143-168
        • Sadowsky C.L.
        • McDonald J.W.
        Activity-based restorative therapies: concepts and applications in spinal cord injury-related neurorehabilitation.
        Dev Disabil Res Rev. 2009; 15: 112-116
        • Jones M.
        • Harness E.
        • Denison P.
        • Tefertiller C.
        • Evans N.
        • Larson C.
        Activity-based therapies in spinal cord injury: clinical focus and empirical evidence in three independent programs.
        Top Spinal Cord Inj Rehabil. 2012; 18: 34-42
        • Harness E.T.
        • Yozbatiran N.
        • Cramer S.C.
        Effect of intense exercise in chronic spinal cord injury.
        Spinal Cord. 2008; 46: 733-737
        • Larson C.
        • Denison P.
        Effectiveness of intense, activity-based physical therapy for individuals with spinal cord injury in promoting motor and sensory recovery: is olfactory mucosa autograft a factor?.
        J Spinal Cord Med. 2013; 36: 44-57
        • Field-Fote E.
        Combined use of body weight support, functional electric stimulation, and treadmill training to improve walking ability in individuals with chronic, incomplete spinal cord injury.
        Arch Phys Med Rehabil. 2001; 82: 818-824
        • Buehner J.J.
        • Forrest G.F.
        • Schmidt-Read M.
        • White S.
        • Tansey K.
        • Basso D.M.
        Relationship between ASIA examination and functional outcomes in the NeuroRecovery Network Locomotor Training Program.
        Arch Phys Med Rehabil. 2012; 93: 1530-1540
        • Behrman A.L.
        • Harkema S.J.
        Locomotor training after human spinal cord injury: a series of case studies.
        Phys Ther. 2000; 80: 688-700
        • Nooijen C.F.
        • ter Hoeve N.
        • Field-Fote E.X.
        Gait quality is improved by locomotor training in individuals with SCI regardless of training approach.
        J Neuroeng Rehabil. 2009; 6: 36
        • Kirshblum S.
        • Millis S.
        • McKinley W.
        • Tulsky D.
        Late neurologic recovery after traumatic spinal cord injury.
        Arch Phys Med Rehabil. 2004; 85: 1811-1817
        • Podsiadlo D.
        • Richardson S.
        The timed “Up & Go”: a test of basic functional mobility for frail elderly persons.
        J Am Geriatr Soc. 1991; 39: 142-148
        • Field-Fote E.
        • Fluet G.
        • Schafer S.
        • et al.
        The Spinal Cord Injury Functional Ambulation Inventory (SCI-FAI).
        J Rehabil Med. 2001; 33: 177-181
        • Itzkovich M.
        • Gelernter I.
        • Biering-Sorensen F.
        • et al.
        The Spinal Cord Independence Measure (SCIM) version III: reliability and validity in a multi-center international study.
        Disabil Rehabil. 2007; 29: 1926-1933
        • Wood-Dauphinee S.
        • Opzoomer M.A.
        • Williams J.I.
        • Marchand B.
        • Spitzer W.O.
        Assessment of global function: the Reintegration to Normal Living Index.
        Arch Phys Med Rehabil. 1988; 69: 583-590
        • Katz A.
        • Nambi S.S.
        • Mather K.
        • et al.
        Quantitative insulin sensitivity check index: a simple, accurate method for assessing insulin sensitivity in humans.
        J Clin Endocrinol Metab. 2000; 85: 2402-2410
        • Field-Fote E.
        • Roach K.E.
        Influence of a locomotor training approach on walking speed and distance in people with chronic spinal cord injury: a randomized clinical trial.
        Phys Ther. 2011; 91: 48-60
        • Hornby T.G.
        • Campbell D.D.
        • Zemon D.H.
        • Kahn J.H.
        Clinical and quantitative evaluation of robotic-assisted treadmill walking to retrain ambulation following spinal cord injury.
        Top Spinal Cord Inj Rehabil. 2005; 11: 1-17
        • Curt A.
        • Hubertus J.A.
        • Klaus D.
        • Dietz V.
        • EM-SCI Study Group
        Recovery from a spinal cord injury: significance of compensation, neural plasticity, and repair.
        J Neurotrauma. 2008; 25: 677-685
        • May L.A.
        • Warren S.
        Measuring quality of life of persons with spinal cord injury: external and structural validity.
        Spinal Cord. 2002; 40: 341-350
        • Tooth L.R.
        • McKenna K.T.
        • Smith M.
        • O’Rourke P.K.
        Reliability of scores between stroke patients and significant others on the Reintegration to Normal Living (RNL) Index.
        Disabil Rehabil. 2003; 25: 433-440
        • Hedley A.
        • Ogden C.
        • Johnson C.L.
        • Carroll M.D.
        • Curtin L.R.
        • Flegal K.M.
        Prevalence of overweight and obesity among US children, adolescents, and adults, 1999-2002.
        JAMA. 2004; 291: 2847-2850
        • Gupta N.
        • White K.T.
        • Sandford P.R.
        Body mass index in spinal cord injury: a retrospective study.
        Spinal Cord. 2006; 44: 92-94
        • Crane D.
        • Little J.
        • Burns S.
        Weight gain following spinal cord injury: a pilot study.
        J Spinal Cord Med. 2011; 34: 227-232

      References

        • American Spinal Injury Association
        International Standards for Neurological Classification of Spinal Cord Injury, revised 2011.
        American Spinal Injury Association, Atlanta2011
        • Hedel H.J.
        • Wirz M.
        • Dietz V.
        Assessing walking ability in subjects with spinal cord injury: validity and reliability of 3 walking tests.
        Arch Phys Med Rehabil. 2005; 86: 190-196
        • Field-Fote E.
        • Lindley S.
        • Sherman A.
        Locomotor training approaches for individuals with spinal cord injury: a preliminary report of walking-related outcomes.
        J Neurol Phys Ther. 2005; 29: 127-137
        • Podsiadlo D.
        • Richardson S.
        The timed “Up & Go”: a test of basic functional mobility for frail elderly persons.
        J Am Geriatr Soc. 1991; 39: 142-148
        • Field-Fote E.
        • Fluet G.
        • Schafer S.
        • et al.
        The spinal cord injury functional ambulation inventory (SCI-FAI).
        J Rehabil Med. 2001; 33: 177-181
        • Itzkovich M.
        • Gelernter I.
        • Biering-Sorensen F.
        • et al.
        The Spinal Cord Independence Measure (SCIM) version III: reliability and validity in a multi-center international study.
        Disabil Rehabil. 2007; 29: 1926-1933
        • Wood-Dauphinee S.
        • Opzoomer M.A.
        • Williams J.I.
        • Marchand B.
        • Spitzer W.O.
        Assessment of global function: the Reintegration to Normal Living Index.
        Arch Phys Med Rehabil. 1988; 69: 583-590
        • Catz A.
        • Itzkovich M.
        • Agranov E.
        • Ring H.
        • Tamir A.
        SCIM—spinal cord independence measure: a new disability scale for patients with spinal cord lesions.
        Spinal Cord. 1997; 35: 850-856
        • Catz A.
        • Itzkovich M.
        • Agranov E.
        • Ring H.
        • Tamir A.
        The spinal cord independence measure (SCIM): sensitivity to functional changes in subgroups of spinal cord lesion patients.
        Spinal Cord. 2001; 39: 97-100
        • Itzokovich M.
        • Tripolski M.
        • Zeileg G.
        • et al.
        Rasch analysis of the Catz-Itzokovich spinal cord independence measure.
        Spinal Cord. 2002; 40: 396-407
        • May L.A.
        • Warren S.
        Measuring quality of life of persons with spinal cord injury: external and structural validity.
        Spinal Cord. 2002; 40: 341-350
        • Harker W.F.
        • Dawson D.R.
        • Boschen K.A.
        • Stuss D.T.
        A comparison of independent living outcomes following traumatic brain injury and spinal cord injury.
        Int J Rehabil Res. 2002; 25: 93-102
        • Katz A.
        • Nambi S.S.
        • Mather K.
        • et al.
        Quantitative insulin sensitivity check index: a simple, accurate method for assessing insulin sensitivity in humans.
        J Clin Endocrinol Metab. 2000; 85: 2402-2410