Advertisement

An Intensive Intervention for Improving Gait, Balance, and Mobility in Individuals With Chronic Incomplete Spinal Cord Injury: A Pilot Study of Activity Tolerance and Benefits

Published:August 11, 2011DOI:https://doi.org/10.1016/j.apmr.2011.05.006

      Abstract

      Fritz SL, Merlo-Rains AM, Rivers ED, Peters DM, Goodman A, Watson ET, Carmichael BM, McClenaghan BA. An intensive intervention for improving gait, balance, and mobility in individuals with chronic incomplete spinal cord injury: a pilot study of activity tolerance and benefits.

      Objective

      To determine the tolerance to and benefits of an intensive mobility training (IMT) approach for individuals with incomplete spinal cord injury (ISCI).

      Design

      Prospective pretest-posttest study with 6-month follow-up.

      Setting

      University research laboratory.

      Participants

      A volunteer sample of individuals with ISCI (N=15; >6mo postinjury and able to walk at least 3.05m with or without assistance). Follow-up data were collected for 10 of the participants.

      Interventions

      Participants received IMT for 3h/d for 10 weekdays, participating in activities that encouraged repetitive, task-specific training of their lower extremities in a massed practice schedule.

      Main Outcome Measures

      Amount of time spent in therapeutic activities and rest was used to assess participants' tolerance to the intervention. Treatment outcomes were assessed pretest, posttest, and 6 months after the intervention and included the Berg Balance Scale (BBS), Dynamic Gait Index (DGI), 6-minute walk test, gait speed, and Spinal Cord Injury Functional Ambulation Inventory.

      Results

      Individuals in the higher functioning ISCI group (BBS score ≥45 and gait speed ≥0.6m/s) spent more time in the intensive therapy on average than individuals in the lower functioning ISCI group. Effect sizes were comparable for changes in balance and mobility assessments between the lower and higher functioning groups, with the largest effect sizes observed for the DGI.

      Conclusions

      This dosage of IMT may be a more appropriate treatment approach for higher functioning ISCI individuals, as they were better able to tolerate the length of the session and demonstrated higher effect sizes postintervention.

      Key Words

      List of Abbreviations:

      ASIA (American Spinal Injury Association), BBS (Berg Balance Scale), BWSTT (body weight–supported treadmill training), CIMT (constraint-induced movement therapy), DGI (Dynamic Gait Index), IMT (intensive mobility training), ISCI (incomplete spinal cord injury), LE (lower extremity), MDC (minimal detectable change), SCI (spinal cord injury), SCI-FAI (Spinal Cord Injury Functional Ambulation Inventory), 6MWT (6-minute walk test)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

      1. Spinal cord injury facts and figures at a glance 2010.
        (Accessed December 2010)
        • Waters R.L.
        • Yakura J.S.
        • Adkins R.H.
        Gait performance after spinal cord injury.
        Clin Orthop Relat Res. 1993; : 87-96
        • Field-Fote E.C.
        Spinal cord control of movement: implications for locomotor rehabilitation following spinal cord injury.
        Phys Ther. 2000; 80: 477-484
        • Behrman A.L.
        • Harkema S.J.
        Locomotor training after human spinal cord injury: a series of case studies.
        Phys Ther. 2000; 80: 688-700
        • Pepin A.
        • Norman K.E.
        • Barbeau H.
        Treadmill walking in incomplete spinal-cord-injured subjects: 1. Adaptation to changes in speed.
        Spinal Cord. 2003; 41: 257-270
        • van der Salm A.
        • Nene A.V.
        • Maxwell D.J.
        • Veltink P.H.
        • Hermens H.J.
        • Ijzerman M.J.
        Gait impairments in a group of patients with incomplete spinal cord injury and their relevance regarding therapeutic approaches using functional electrical stimulation.
        Artif Organs. 2005; 29: 8-14
        • Behrman A.L.
        • Bowden M.G.
        • Nair P.M.
        Neuroplasticity after spinal cord injury and training: an emerging paradigm shift in rehabilitation and walking recovery.
        Phys Ther. 2006; 86: 1406-1425
        • Barbeau H.
        Locomotor training in neurorehabilitation: emerging rehabilitation concepts.
        Neurorehabil Neural Repair. 2003; 17: 3-11
        • Dietz V.
        • Harkema S.J.
        Locomotor activity in spinal cord-injured persons.
        J Appl Physiol. 2004; 96: 1954-1960
        • Taub E.
        Constraint-induced movement therapy and massed practice.
        Stroke. 2000; 31: 986-988
        • Schmidt R.A.
        • Lee T.D.
        Motor control and learning: a behavioral emphasis.
        in: 4th ed. Human Kinetics, Champaign2005: 285-322
        • Carr J.
        • Shepherd R.
        Neurological rehabilitation.
        Butterworth & Heinemann, Oxford1998
        • Hicks A.L.
        • Adams M.M.
        • Martin Ginis K.
        • et al.
        Long-term body-weight-supported treadmill training and subsequent follow-up in persons with chronic SCI: effects on functional walking ability and measures of subjective well-being.
        Spinal Cord. 2005; 43: 291-298
        • Wernig A.
        • Nanassy A.
        • Muller S.
        Maintenance of locomotor abilities following Laufband (treadmill) therapy in para- and tetraplegic persons: follow-up studies.
        Spinal Cord. 1998; 36: 744-749
        • Wirz M.
        • Zemon D.H.
        • Rupp R.
        • et al.
        Effectiveness of automated locomotor training in patients with chronic incomplete spinal cord injury: a multicenter trial.
        Arch Phys Med Rehabil. 2005; 86: 672-680
        • Mehrholz J.
        • Kugler J.
        • Pohl M.
        Locomotor training for walking after spinal cord injury.
        Cochrane Database Syst Rev. 2008; (CD006676)
        • Dobkin B.
        • Barbeau H.
        • Deforge D.
        • et al.
        The evolution of walking-related outcomes over the first 12 weeks of rehabilitation for incomplete traumatic spinal cord injury: the multicenter randomized Spinal Cord Injury Locomotor Trial.
        Neurorehabil Neural Repair. 2007; 21: 25-35
        • Taub E.
        • Morris D.
        Constraint-induced movement therapy to enhance recovery after stroke.
        Curr Atheroscler Rep. 2001; 3: 279-286
        • Grotta J.C.
        • Noser E.A.
        • Ro T.
        • et al.
        Constraint-induced movement therapy.
        Stroke. 2004; 35: 2699-2701
        • Wolf S.L.
        • Winstein C.J.
        • Miller J.P.
        • et al.
        Effect of constraint-induced movement therapy on upper extremity function 3 to 9 months after stroke: the EXCITE randomized clinical trial.
        JAMA. 2006; 296: 2095-2104
        • Vearrier L.A.
        • Langan J.
        • Shumway-Cook A.
        • Woollacott M.
        An intensive massed practice approach to retraining balance post-stroke.
        Gait Posture. 2005; 22: 154-163
        • Fritz S.L.
        • Pittman A.L.
        • Robinson A.C.
        • Orton S.C.
        • Rivers E.D.
        An intense intervention for improving gait, balance, and mobility for individuals with chronic stroke: a pilot study.
        J Neurol Phys Ther. 2007; 31: 71-76
        • Marklund I.
        • Klassbo M.
        Effects of lower limb intensive mass practice in poststroke patients: single-subject experimental design with long-term follow-up.
        Clin Rehabil. 2006; 20: 568-576
        • Stock R.
        • Mork P.J.
        The effect of an intensive exercise programme on leg function in chronic stroke patients: a pilot study with one-year follow-up.
        Clin Rehabil. 2009; 23: 790-799
        • Beekhuizen K.S.
        • Field-Fote E.C.
        Massed practice versus massed practice with stimulation: effects on upper extremity function and cortical plasticity in individuals with incomplete cervical spinal cord injury.
        Neurorehabil Neural Repair. 2005; 19: 33-45
        • Hoffman L.R.
        • Field-Fote E.C.
        Functional and corticomotor changes in individuals with tetraplegia following unimanual or bimanual massed practice training with somatosensory stimulation: a pilot study.
        J Neurol Phys Ther. 2010; 34: 193-201
        • Light K.E.
        • Reilly M.A.
        • Behrman A.L.
        • Spirduso W.W.
        Greater benefits of practice on reaction time in older versus younger participants.
        J Aging Phys Act. 1996; 4: 27-41
        • Lang C.E.
        • MacDonald J.R.
        • Gnip C.
        Counting repetitions: an observational study of outpatient therapy for people with hemiparesis post-stroke.
        J Neurol Phys Ther. 2007; 31: 3-10
        • Hesse S.
        • Werner C.
        • von Frankenberg S.
        • Bardeleben A.
        Treadmill training with partial body weight support after stroke.
        Phys Med Rehabil Clin N Am. 2003; 14: S111-S123
        • Dahl A.E.
        • Askim T.
        • Stock R.
        • Langorgen E.
        • Lydersen S.
        • Indredavik B.
        Short- and long-term outcome of constraint-induced movement therapy after stroke: a randomized controlled feasibility trial.
        Clin Rehabil. 2008; 22: 436-447
        • Field-Fote E.C.
        • 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
        • Behrman A.L.
        • Lawless-Dixon A.R.
        • Davis S.B.
        • et al.
        Locomotor training progression and outcomes after incomplete spinal cord injury.
        Phys Ther. 2005; 85: 1356-1371
        • Steeves J.D.
        • Lammertse D.
        • Curt A.
        • et al.
        Guidelines for the conduct of clinical trials for spinal cord injury (SCI) as developed by the ICCP panel: clinical trial outcome measures.
        Spinal Cord. 2007; 45: 206-221
        • Carlson K.
        • Schmidt F.
        Impact of experimental design on effect size: findings from the research literature on training.
        J Appl Psychol. 1999; 84: 851-862
        • Stevens J.
        Applied multivariate statistics for the social sciences.
        4th ed. Lawrence Erlbaum Associates, Mahwah2002
        • Taub E.
        • Uswatte G.
        • Pidikiti R.
        Constraint-induced movement therapy: a new family of techniques with broad application to physical rehabilitation—a clinical review.
        J Rehabil Res Dev. 1999; 36: 237-251
        • Steffen T.
        • Seney M.
        Test-retest reliability and minimal detectable change on balance and ambulation tests, the 36-Item Short-Form Health Survey, and the Unified Parkinson Disease Rating Scale in people with parkinsonism.
        Phys Ther. 2008; 88: 733-746
        • Donoghue D.
        • Stokes E.K.
        How much change is true change?.
        J Rehabil Med. 2009; 41: 343-346
        • Lam T.
        • Noonan V.K.
        • Eng J.J.
        A systematic review of functional ambulation outcome measures in spinal cord injury.
        Spinal Cord. 2008; 46: 246-254
        • Protas E.J.
        • Holmes S.A.
        • Qureshy H.
        • Johnson A.
        • Lee D.
        • Sherwood A.M.
        Supported treadmill ambulation training after spinal cord injury: a pilot study.
        Arch Phys Med Rehabil. 2001; 82: 825-831
        • Field-Fote E.C.
        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
        • Gardner M.B.
        • Holden M.K.
        • Leikauskas J.M.
        • Richard R.L.
        Partial body weight support with treadmill locomotion to improve gait after incomplete spinal cord injury: a single-subject experimental design.
        Phys Ther. 1998; 78: 361-374
        • Zorner B.
        • Blanckenhorn W.U.
        • Dietz V.
        • Curt A.
        Clinical algorithm for improved prediction of ambulation and patient stratification after incomplete spinal cord injury.
        J Neurotrauma. 2010; 27: 241-252
        • Waters R.L.
        • Adkins R.
        • Yakura J.
        • Vigil D.
        Prediction of ambulatory performance based on motor scores derived from standards of the American Spinal Injury Association.
        Arch Phys Med Rehabil. 1994; 75: 756-760
        • McDonough A.L.
        • Batavia M.
        • Chen F.C.
        • Kwon S.
        • Ziai J.
        The validity and reliability of the GAITRite system's measurements: a preliminary evaluation.
        Arch Phys Med Rehabil. 2001; 82: 419-425
        • Bilney B.
        • Morris M.
        • Webster K.
        Concurrent related validity of the GAITRite walkway system for quantification of the spatial and temporal parameters of gait.
        Gait Posture. 2003; 17: 68-74
        • Field-Fote E.C.
        • Fluet G.G.
        • Schafer S.D.
        • et al.
        The Spinal Cord Injury Functional Ambulation Inventory (SCI-FAI).
        J Rehabil Med. 2001; 33: 177-181
        • Lemay J.F.
        • Nadeau S.
        Standing balance assessment in ASIA D paraplegic and tetraplegic participants: concurrent validity of the Berg Balance Scale.
        Spinal Cord. 2010; 48: 245-250
        • Wirz M.
        • Muller R.
        • Bastiaenen C.
        Falls in persons with spinal cord injury: validity and reliability of the Berg Balance Scale.
        Neurorehabil Neural Repair. 2010; 24: 70-77
        • Datta S.
        • Lorenz D.J.
        • Morrison S.
        • Ardolino E.
        • Harkema S.J.
        A multivariate examination of temporal changes in Berg Balance Scale items for patients with ASIA Impairment Scale C and D spinal cord injuries.
        Arch Phys Med Rehabil. 2009; 90: 1208-1217
        • Chiu Y.P.
        • Fritz S.L.
        • Light K.E.
        • Velozo C.A.
        Use of item response analysis to investigate measurement properties and clinical validity of data for the Dynamic Gait Index.
        Phys Ther. 2006; 86: 778-787
        • Steffen T.M.
        • Hacker T.A.
        • Mollinger L.
        Age- and gender-related test performance in community-dwelling elderly people: six-minute walk test, Berg Balance Scale, Timed Up & Go test, and gait speeds.
        Phys Ther. 2002; 82: 128-137
        • van 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
        • Furlan J.C.
        • Noonan V.
        • Singh A.
        • Fehlings M.G.
        Assessment of disability in patients with acute traumatic spinal cord injury: a systematic review of the literature.
        J Neurotrauma. 2010; 27: 1-27
        • Jackson A.B.
        • Carnel C.T.
        • Ditunno J.F.
        • et al.
        Outcome measures for gait and ambulation in the spinal cord injury population.
        J Spinal Cord Med. 2008; 31: 487-499