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Shepherd Center Systematic Review Group

Locomotor Training Interventions to Improve Neurological Outcomes after SCI Summary of a Research Synthesis Shepherd Center Study Group. Shepherd Center Systematic Review Group. Leadership team: Lesley Hudson, MS, David Apple, MD, Deborah Backus, PhD, PT Neural Reviewers: David Apple, MD

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Shepherd Center Systematic Review Group

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  1. Locomotor Training Interventions to Improve Neurological Outcomes after SCISummary of a Research SynthesisShepherd Center Study Group Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) at Boston University Center for Psychiatric Rehabilitation

  2. Shepherd Center Systematic Review Group • Leadership team: Lesley Hudson, MS, David Apple, MD, Deborah Backus, PhD, PT • Neural Reviewers: • David Apple, MD • Lesley Hudson, MA • Jennith Bernstein, PT • Amanda Gillot, PT • Jennifer Huggins, OT • Ashley Kim, OT • Data coordinator: Rebecca Acevedo Compiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) at Boston University Center for Psychiatric Rehabilitation

  3. Table of Contents • Background and purpose of review pp. 4 • Overview of methods pp. 10 • Experimental design studies pp. 16 • Quasi-Experimental design studies pp. 39 • Descriptive design studies pp. 49 • Case Studies and Reports pp. 50 • Acknowledgements pp. 81 Compiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) at Boston University Center for Psychiatric Rehabilitation

  4. Rationale for Review • Tremendous advances in neuroscience research, as well as the development of new technology geared toward spinal cord injury (SCI) have led to the expectation of “cure” and "lifetime recovery" after SCI • Enter the term “spinal cord injury” on the web and you will find multiple sites dedicated to the pursuit of the cure or neurorecovery • Much focus on “activity-based” programs • Little evidence related to neural recovery after participation in activity-based programs Compiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) at Boston University Center for Psychiatric Rehabilitation

  5. Rationale for Review • Evidence from animal models of SCI suggests that the use of intense and repeatedsensory stimulation, and intense motor practice, or exercise, can elicit plastic changes throughout the neural axis (Hutchinson et al 2004;Ying wt al. 2008;Gazula et al. 2004;Goldschmidt et al. 2008; McDonald et al, 2002; Perez et al 2004) Compiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) at Boston University Center for Psychiatric Rehabilitation

  6. Rationale for Review • Evidence from other patient populations (eg. Stroke) suggests that intense, focused, repeated active movement of impaired limbs, especially when combined with sensory augmentation, is beneficial for improving function, and inducing neural changes in the cerebral cortex Compiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) at Boston University Center for Psychiatric Rehabilitation

  7. Rationale for Review • The assumption: • Intense activity, in the form of repeated active movement, often combined with augmented sensory stimulation, can lead to neural or functional improvements, or both, in humans with any level of injury, with any degree of completeness of injury • Has led to the development of activity-based programs around the globe, inviting individuals with complete or incomplete tetraplegia or paraplegia, at any age to participate in order to achieve their maximal potential, and perhaps even full recovery of walking! Compiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) at Boston University Center for Psychiatric Rehabilitation

  8. Rationale for Review • Several questions remain unanswered: • Do the findings in animal models of SCI translate to humans with SCI? • Which individuals with SCI (i.e. age, gender, level of injury, completeness of injury) actually improve in function? • Is there neural recovery that can explain improvements in function in humans? • Is neural recovery necessary, or sufficient, for substantial and meaningful functional recovery after SCI? Compiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) at Boston University Center for Psychiatric Rehabilitation

  9. Purpose of Review • Main objective: • To evaluate all literature between 1998 and 2008 related to the efficacy for improving neural activity and function with the use of intense therapies, often referred to as “activity-based interventions”, in individuals with paralysis and sensory loss due to spinal cord injury (SCI) • “Activity-based interventions”: • Include any therapy activity, or intervention, that is focused on improving muscle function and sensory perception below the level of injury, and not simply accommodation or compensation for the paralysis and sensory loss due to the SCI, in order to improve overall function after SCI Compiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) at Boston University Center for Psychiatric Rehabilitation

  10. Methods Employed: Important Consideration • ABints do NOT include the use of electrical stimulation or robotics as neuroprosthetics, or tools to replace the lost function below the level of injury Compiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) at Boston University Center for Psychiatric Rehabilitation

  11. Methods EmployedDefinitions and Focus • Overall study included any study describing the effects of activity-based interventions on neural and/or functional recovery after spinal cord injury (SCI), and includes interventions that combine intense active movement with one or more of the following: • Facilitation techniques to activate muscles below the level of injury (such as the use of tactile or vibratory stimulation) • Electrical stimulation (surface or indwelling) • Upper extremity robotics; and intense strength training • Locomotor training (manual or robotic) – this presentation presents evidence related to locomotor training interventions Compiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) at Boston University Center for Psychiatric Rehabilitation

  12. Methods Employed: MoreDefinitions • “Neural recovery” or “changes in neural function”: • Measurable changes in neural circuitry or neuronal activity at any level of the neural axis in response to injury or learning • Given that AIS and the ASIA motor scores are often used as markers for neural recovery at this time, studies that include AIS classification, ASIA sensory or motor scores, or muscle strength changes, will be included in the classification of neural outcomes for the purpose of this review • Other measures of neurological changes include: • Measurement of activity in a neural circuit, such as via a reflex • Increases in neural factors, such as BDNF • Demonstrations of supraspinal activity with imaging tools or stimulation, such as functional magnetic resonance or transcranial magnetic stimulation, respectively. Compiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) at Boston University Center for Psychiatric Rehabilitation

  13. Methods Employed: Definitions • “Functional ability”: • Includes any skill that leads to improved mobility (locomotion, bed mobility, transfers) or activities of daily living: • Typical outcome measures include, but are not limited to, the: • Functional Independence Measure (FIM) • Spinal Cord Independence Measure (SCIM) • Walking Index for Spinal Cord Injury (WISCI) • Jebsen Hand Function Test (JHFT) • Action Research Arm Test Compiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) at Boston University Center for Psychiatric Rehabilitation

  14. Methods Employed: Study Designs Included • Experimental: Employed methods including a random assignment and a control group or a reasonably constructed comparison group • Quasi-experimental: No random assignment, but either with a control group or a reasonably constructed comparison group • Descriptive: Neither a control group, nor randomization, is used. These included case studies and reports, studies employing repeated measures, and Pre-post designs. Compiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) at Boston University Center for Psychiatric Rehabilitation

  15. Methods Employed: Study Designs Included • 40 articles pulled from the literature and 21 articles met rigor and meaningfulness criteria: • Descriptive (n=16) • Experimental (n=3) • Quasi-experimental (n=2) Compiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) at Boston University Center for Psychiatric Rehabilitation

  16. Studies Using Experimental Design Compiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) at Boston University Center for Psychiatric Rehabilitation

  17. Dobkin et al. 2006Study Design • Single-blinded, randomized, multi-center clinical trial • Compared the efficacy of manual locomotor training (LT) with overground gait (OG) training to overground training in adults with acute spinal cord injury (SCI) Compiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) at Boston University Center for Psychiatric Rehabilitation

  18. Dobkin et al. 2006Participants • n=146 subjects • From 6 regional centers • Receiving inpatient rehabilitation for the first time • Classified with an incomplete injury (American Spinal Injury Association Impairment Scale (AIS) score of B, C, or D), between spinal level and L3 Compiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) at Boston University Center for Psychiatric Rehabilitation

  19. Dobkin et al. 2006Participants • The level of injury was further delineated: • Those with injuries between C5 and T10/11 were classified as upper motor neuron injuries • Those with injuries T12 to L3 were classified as lower motor neuron injuries • Those with lower motor neuron injury on one side and upper motor neuron injury on the other were classified with upper motor neuron injury • All were within 8 weeks of their SCI when enrolled • All were between 16 and 69 years old. Compiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) at Boston University Center for Psychiatric Rehabilitation

  20. Dobkin et al. 2006Methods • Subjects in both groups (locomotor training (LT) and overground (OG)) received the standard rehabilitation interventions provided in inpatient and outpatient therapy for mobility and activities of daily living training at their respective centers • Each group also received some form of LT • The LT group received manual locomotor training on the treadmill, followed by overground walking training • The OG group received overground walking training only • Neither group received any other form of specified walking training other than these specific interventions Compiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) at Boston University Center for Psychiatric Rehabilitation

  21. Dobkin et al. 2006LT Group • Stretched for up to 10 minutes • Followed by walking on the treadmill with harness support and manual assistance for 20 to 30 minutes (3 to 10 minute increments) • Amount of body weight support (BWS) and speed were adjusted so that the individual was able to walk at least 0.72 m/s, with the goal of walking at 1.07 m/s • Treadmill walking followed by 10 to 20 minutes of overground walking with assistance Compiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) at Boston University Center for Psychiatric Rehabilitation

  22. Dobkin et al. 2006OG Group • Spent their walking training time either standing or stepping, depending on their individual fatigue, and followed essentially the same order as those in the LM group: • stretching (10 minutes) • followed by standing or walking for 30 to 45 minutes • Those who could walk practiced in the parallel bars or overground with therapist assistance, assistive devices and orthotics as necessary • Not allowed to use the treadmill or harness at all during this 12-week training period Compiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) at Boston University Center for Psychiatric Rehabilitation

  23. Dobkin et al. 2006Both Groups • Trained for 12 weeks • Specific order of activities followed for all training, BUT the amount of time spent on each activity during a given session was tailored to the individual’s needs • Training 1 hr/day • Permitted to walk at other times during therapy, and to perform trunk and lower extremity strengthening exercises • Number of training sessions for individuals in both groups varied between 45 and 60 sessions • depending on how quickly they reached the highest functional walking speed (0.98 m/s) Compiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) at Boston University Center for Psychiatric Rehabilitation

  24. Dobkin et al. 2006Methods: Outcome Measures • Primary obtained: • pre-intervention • every 2 weeks for 12 weeks • at the end of the training intervention • at 6 months and 12 months after enrollment • Secondary obtained 3, 6, and 12 months post-enrollment Compiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) at Boston University Center for Psychiatric Rehabilitation

  25. Dobkin et al. 2006Methods: Outcome Measures • No neural-related primary outcome measures, only secondary outcome measures of neural changes: • ASIA lower extremity motor score (LEMS) • Ashworth scale • Functional outcome measures: • Primary: • FIM lower extremity score and overground walking speed • Secondary: • Distance walked 6-minute walk test • Berg Balance Scale • Walking Index for Spinal Cord injury (WISCI • SF-54 Compiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) at Boston University Center for Psychiatric Rehabilitation

  26. Dobkin et al. 2006Outcomes • No significant differences between the LT and OG groups in terms of most of the outcome measures, and specifically in terms of the neural outcome measures • Neither group experienced any significant change in Ashworth scores, or in frequency of spasms • No differences were found in adverse events, and neither group reported excess muscle strain, or joint pain. Compiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) at Boston University Center for Psychiatric Rehabilitation

  27. Dobkin et al. 2006Outcomes • The majority of subjects with AIS C classification in both the LT and OG groups achieved independent walking • The majority of those classified as AIS C had a FIM lower extremity score >/= “6” at 6 months post-enrollment • Individuals in both groups with AIS C or D classification demonstrated a significant increase in walking velocity, consistent with functional community ambulation • Speed continued to increase between 3 and 6 months, in both groups • For persons classified as AIS B, neither intervention led to improvements in overground walking Compiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) at Boston University Center for Psychiatric Rehabilitation

  28. Dobkin et al. 2006Methodological Considerations • Earlier LT studies were conducted in persons with chronic SCI, while this study was conducted in those with acute SCI • There may not have been enough of a contrast between the LT and OG groups • Both interventions were more intense and more task-specific than that which may be generally provided in traditional therapy, which may have lead to the lack of significant differences in outcomes between the two groups Compiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) at Boston University Center for Psychiatric Rehabilitation

  29. Field-Fote et al. 2005Overview • Compared different LT approaches in an RCT using functional outcome measures only (no neural) • Participants: • 27 adults with chronic (> 1 year post-SCI) motor-incomplete SCI • Randomly assigned, based LEMS, to one of four groups: • Treadmill training with manual assistance (similar Dobkin et al) (TM) • Treadmill training with stimulation (TS) • Over-ground walking with stimulation (OG) • Treadmill training with robotic assistance (LR) Compiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) at Boston University Center for Psychiatric Rehabilitation

  30. Field-Fote et al. 2005Methods: Training • All subjects/all groups trained with body-weight support (BWS) modified based on the amount of knee flexion during the stance phase or toe dragging during swing phase • Always </= 30% • All participated in training for: • 60-minute periods • 5 days/week • 12 weeks • Allowed to rest during each session as needed Compiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) at Boston University Center for Psychiatric Rehabilitation

  31. Field-Fote et al. 2005Methods: Training • Subjects in the treadmill training groups (TM, TS) were: • Allowed to use the handrails, but bear full weight through their arm • Encouraged to walk at their maximum walking speeds, as long as walking quality was maintained • Those in the treadmill training with robotic assistance (LR) were: • Progressed in walking speed based on a pre-determined algorithm until they could reach the maximum speed of 3.2 km/hr, or 2 miles/hr by 5 weeks Compiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) at Boston University Center for Psychiatric Rehabilitation

  32. Field-Fote et al. 2005Methods: Training • Subjects in the overground group (OS) were: • instructed to walk as fast as possible around the 80-foot track, and were allowed to use both the upper extremity assistive device and lower extremity orthotic with which they were most comfortable. There was no attempt to advance either device with training. Compiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) at Boston University Center for Psychiatric Rehabilitation

  33. Field-Fote et al. 2005Methods: Training • Subjects who performed training with electrical stimulation (TS, OS), all had the same relative placement of electrodes, positioned to get the most robust flexion withdrawal response. • Stimulation parameters were 300 to 600 ms train, 50 Hz, 5 to 20 mA. • These parameters were adjusted throughout the training sessions to prevent habituation. Compiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) at Boston University Center for Psychiatric Rehabilitation

  34. Field-Fote et al. 2005Methods: Outcome Measures • Assessed function only (no neural-related outcome measures): • 6-meter walk • 2-minute walking test • For all walking tests, the subjects were: • Allowed to walk at self-selected walking speeds • Videotaped for evaluation of walking performance • Allowed to use whichever assistive and/or orthotic devices to which they were accustomed Compiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) at Boston University Center for Psychiatric Rehabilitation

  35. Field-Fote et al. 2005Outcomes • n=7 in each group, except for the LR group (n=6) • # of training sessions over the 12-week training= 27 to 54 Compiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) at Boston University Center for Psychiatric Rehabilitation

  36. Field-Fote et al. 2005Outcomes • Subjects in all four groups: • Improved in walking performance • AND there was no significant difference between groups. • Subjects in each of the four groups demonstrated improvements in walking speed • Those with the most impairment in walking function showed the greatest improvements Compiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) at Boston University Center for Psychiatric Rehabilitation

  37. Field-Fote et al. 2005Conclusion • Power analysis suggested that more subjects would be required in each group in order to detect a significant difference • HOWEVER, there was a trend for greater improvement in walking in the electrical stimulation groups (TS, OS) • Although subjects did improve, none were able to discard their wheelchairs and walk independently or in the community • Further study is required Compiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) at Boston University Center for Psychiatric Rehabilitation

  38. Studies Using Quasi-experimental Design Compiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) at Boston University Center for Psychiatric Rehabilitation

  39. Grasso et al. 2004Overview • Evaluated the neural and functional outcomes in 22 adults: • 17 to 60 years old • Half with acute SCI (1 to 6 months post-SCI) • The injury levels ranged from C7 to L2 • Classified clinically as AIS A (n=5), AIS B (n=2), AIS C (n=4) • Half age-matched controls with no neurological impairment • All performed daily manual assisted locomotor training sessions • Worked on increasing speed and decreasing the amount of body-weight support and manual assistance required • Training time ranged from one to three months Compiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) at Boston University Center for Psychiatric Rehabilitation

  40. Grasso et al. 2004Methods: Outcome Measures • Neural: • Modified Ashworth Scale (MAS) • Kinematic data and electromyography (EMG) data collected during stepping attempts on the first day of training, and every 15 days thereafter • Functional • The Rivermeade Mobility Index (RMI) • The Walking Index of Spinal Cord Injury (WISCI) • The Garrett Scale (Garrett et al. 1987). Compiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) at Boston University Center for Psychiatric Rehabilitation

  41. Grasso et al. 2004Outcomes: Neural • In subjects with SCI who were able to step in the first session, stepping started very irregularly • The trajectory of the foot during stepping in these individuals progressed to the shape typically found in able-bodied individuals • The majority of these subjects (n = 8) also demonstrated a significantly greater end-point path, indicating a longer step length and greater foot clearance during stepping Compiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) at Boston University Center for Psychiatric Rehabilitation

  42. Grasso et al. 2004Outcomes: Neural (Kinematic) • Subjects with SCI demonstrated an increase in amplitude and decrease in variability, suggesting alterations in inter-segmental kinematic coordination, when compared to the able bodied subjects • The phase-relationship between limb segments remained abnormal • Most likely due to different muscle activation patterns from what is available in able-bodies individuals Compiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) at Boston University Center for Psychiatric Rehabilitation

  43. Grasso et al. 2004Outcomes: Neural (Kinematic) • Suggests that although the end-point was changed in persons with SCI and approximated “normal” (i.e. the foot position in space closely approximated that of the able-bodied subjects during stepping on the treadmill), the muscle activity deviated from that of the able-bodied subjects, and continued to deviate with training Compiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) at Boston University Center for Psychiatric Rehabilitation

  44. Grasso et al. 2004Outcomes: Neural (EMG) • The averaged and normalized EMG waveforms were mapped on published charts to determine segmental localization • In subjects classified with AIS C SCI: • Activity in the upper lumbar (L2 to 4) segments of the cord started later and lasted longer than in able-bodied subjects • Activity in the lower lumbar cord (L5 to S2) lasted for a shorter duration in those with SCI than those that were able-bodied subjects • This activation in L5 to S2 corresponds to weight acceptance and activation of the hip extensors and ankle plantarflexors. Compiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) at Boston University Center for Psychiatric Rehabilitation

  45. Grasso et al. 2004Outcomes: Neural (EMG) • Suggests that the control of stepping in persons with motor incomplete SCI had changed its distribution after training, and was different from that in the able-bodied population • Thus, neural plasticity was evident, but did not resemble that in able-bodied individuals Compiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) at Boston University Center for Psychiatric Rehabilitation

  46. Grasso et al. 2004Outcomes: Functional • Similar to what had already been reported • Those who could not walk before training (n=5) could walk within the treadmill environment post-training, but not overground • Three subjects were able to walk independently in the community post-training • The remainder maintained some degree of disability in walking overground Compiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) at Boston University Center for Psychiatric Rehabilitation

  47. Grasso et al. 2004Conclusion • Although some subjects demonstrated neural changes with LT training: • These changes were not identical to the patterns that are seen in the able bodied population • These changes appear to be correlated with functional changes in walking overground • Further study is required to gain a greater understanding of the neural effects of LT and to determine the relationship between such neural effects and functional outcomes in order to better understand and define the goals of interventions for persons with SCI Compiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) at Boston University Center for Psychiatric Rehabilitation

  48. Studies Using Descriptive Design Compiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) at Boston University Center for Psychiatric Rehabilitation

  49. Case Studies and Reports Compiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) at Boston University Center for Psychiatric Rehabilitation

  50. Behrman & Harkema 2000Methods • Training procedures were similar to those described previously in the Dobkin et al. study: • Subjects walked with BWS on a treadmill with manual assistance • Over-ground training was initiated when an individual could: • Maintain independent standing while supporting at least 80% of their body weight • Initiate stepping with appropriate kinematics in at least one leg • n=3 • Two with AIS C or D classification trained 3 times per week • One with AIS A trained 5 times per week Compiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) at Boston University Center for Psychiatric Rehabilitation

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