Publications by authors named "Andrea Behrman"

85 Publications

Impact of Activity-Based Therapy on Respiratory Outcomes in a Medically Complex Child.

Children (Basel) 2021 Jan 9;8(1). Epub 2021 Jan 9.

Department of Neurological Surgery, University of Louisville, Louisville, KY 40202, USA.

Introduction: Activity-based therapies (ABTs) focus on activating the neuromuscular system below the level of spinal cord injury (SCI) promoting neuromuscular capacity.

Case Description: A 2 year 7 month old with history of prematurity at 29 weeks, neonatal epidural abscess, resultant cervical SCI, respiratory failure, and global developmental delays presented for enrollment in an outpatient activity-based therapy program. Upon presentation to this program, he required nighttime mechanical ventilation via tracheostomy and daytime suctioning. He could not perform any age-appropriate activities and was described by his mother as 'present', neither engaged nor attentive. During and after 7 months of participation in ABTs including locomotor training and neuromuscular electrical stimulation, the patient demonstrated unexpected changes in his respiratory status leading to ventilator weaning with concomitant improvements in head and trunk control, participation, development, and quality of life.

Discussion: ABT was not only safe for a medically complex child, but also this intervention had a remarkable effect on unresolved respiratory capacity and a more widespread impact on other functions as well as development. A child with a chronic, severe SCI demonstrated positive and impactful improvements in health, functional status, and quality of life during an episode of ABT.
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http://dx.doi.org/10.3390/children8010036DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7827889PMC
January 2021

Single and sequential voluntary cough in children with chronic spinal cord injury.

Respir Physiol Neurobiol 2021 03 24;285:103604. Epub 2020 Dec 24.

Department of Neurological Surgery, University of Louisville, 220 Abraham Flexner Way 15(th) floor, Louisville, KY, 40202, United States. Electronic address:

We investigated the impact of spinal cord injury (SCI) on cough capacity in 10 children (Mean ± SD, age 8 ± 4 years) and compared it to 15 typically developing children (age 8 ± 3 years). Participants underwent spirometry, single and sequential cough assessment with surface-electromyography from respiratory muscles. Inspiratory phase duration, inspiratory phase peak flow, inspiratory phase rise time, compression phase duration, expiratory phase rise time, expiratory phase peak airflow (EPPF) and cough volume acceleration (CVA) parameters of single and sequential cough were measured. Root mean square (RMS) values of right pectoralis-major, intercostal, rectus-abdominus (RA), and oblique (OB) muscles were calculated and mean of three trials were compared. The significance criterion was set at P < 0.05. The SCI group produced significantly lower lung volumes, EPPF, CVA, and RMS values of RA and OB during expiratory phases of single and sequential coughs. The decrease in activation in expiratory muscles in the SCI group accounts for the impaired expiratory flow and may contribute to risk of respiratory complications.
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http://dx.doi.org/10.1016/j.resp.2020.103604DOI Listing
March 2021

Contribution of Trunk Muscles to Upright Sitting with Segmental Support in Children with Spinal Cord Injury.

Children (Basel) 2020 Dec 8;7(12). Epub 2020 Dec 8.

Department of Neurological Surgery, University of Louisville, Louisville, KY 40202, USA.

To investigate and compare trunk control and muscle activation during uncompensated sitting in children with and without spinal cord injury (SCI). Static sitting trunk control in ten typically developing (TD) children (5 females, 5 males, mean (SD) age of 6 (2)y) and 26 children with SCI (9 females, 17 males, 5(2)y) was assessed and compared using the Segmental Assessment of Trunk Control (SATCo) test while recording surface electromyography (EMG) from trunk muscles. The SCI group scored significantly lower on the SATCo compared to the TD group. The SCI group produced significantly higher thoracic-paraspinal activation at the lower-ribs, and, below-ribs support levels, and rectus-abdominus activation at below-ribs, pelvis, and no-support levels than the TD group. The SCI group produced significantly higher lumbar-paraspinal activation at inferior-scapula and no-support levels. Children with SCI demonstrated impaired trunk control with the ability to activate trunk muscles above and below the injury level.
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http://dx.doi.org/10.3390/children7120278DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7762575PMC
December 2020

Spinal cord injury in infancy: activity-based therapy impact on health, function, and quality of life in chronic injury.

Spinal Cord Ser Cases 2020 03 10;6(1):13. Epub 2020 Mar 10.

Kosair Charities Center for Pediatric NeuroRecovery, University of Louisville, Louisville, KY, USA.

Introduction: Spinal cord injury (SCI) in infancy magnifies the complexity of a devastating diagnosis. Children injured so young have high incidences of scoliosis, hip dysplasia, and respiratory complications leading to poor health and outcomes. We report the medical history, progression of rehabilitation, usual care and activity-based therapy, and outcomes for a child injured in infancy. Activity-based therapy (ABT) aims to activate the neuromuscular system above and below the lesion through daily, task-specific training to improve the neuromuscular capacity, and outcomes for children with acquired SCI.

Case Presentation: A 3-month-old infant suffered a cervical SCI from a surgical complication with resultant tetraplegia. Until age 3, her medical complications included scoliosis, kyphosis, and pneumonia. Even with extensive physical and occupational therapy, she was fully dependent on caregivers for mobility and unable to roll, come to sit, sit, stand or walk. She initiated ABT at ~3 years old, participating for 8 months. The child's overall neuromuscular capacity improved significantly, especially for head and trunk control, contributing to major advances in respiratory health, novel engagement with her environment, and improved physical abilities.

Discussion: From injury during infancy until 3 years old, this child's health, abilities, and complications were consistent with the predicted path of early-onset SCI. Due to her age at injury, severity and chronicity of injury, she demonstrated unexpected, meaningful changes in her neuromuscular capacity during and post-ABT associated with improved health, function and quality of life for herself and her caregivers.
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http://dx.doi.org/10.1038/s41394-020-0261-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7064539PMC
March 2020

Muscle Activation Patterns During Movement Attempts in Children With Acquired Spinal Cord Injury: Neurophysiological Assessment of Residual Motor Function Below the Level of Lesion.

Front Neurol 2019 20;10:1295. Epub 2019 Dec 20.

Kosair Charities Center for Pediatric NeuroRecovery, University of Louisville, Louisville, KY, United States.

Characterization of residual neuromotor capacity after spinal cord injury (SCI) is challenging. The current gold standard for measurement of sensorimotor function after SCI, the International Society for Neurological Classification of Spinal Cord Injury (ISNCSCI) exam, seeks to determine isolated intentional muscle activation, however many individuals with SCI exhibit intentional movements and muscle activation patterns which are not confined to specific joint or muscle. Further, isolated muscle activation is a feature of the neuromuscular system that emerges during development, and thus may not be an appropriate measurement standard for children younger than 6. We utilized neurophysiological assessment methodology, long studied in adult SCI populations, to evaluate residual neuromotor capacity in 24 children with SCI, as well as 19 typically developing (TD) children. Surface electromyography (EMG) signals were recorded from 11 muscles bilaterally, representing spinal motor output from all regions (i.e., cervical, thoracic, and lumbosacral), during standardized movement attempts. EMG records were subjectively analyzed based on spatiotemporal muscle activation characteristics, while the voluntary response index (VRI) was utilized for objective analysis of unilateral leg movement tasks. Evidence of intentional leg muscle activation below the level of lesion was found in 11/24 children with SCI, and was classified based on activation pattern. Trace activation, bilateral (generalized) activation, and unilateral or isolated activation occurred in 32, 49, and 8% of movement tasks, respectively. Similarly, VRI analyses objectively identified significant differences between TD and SCI children in both magnitude ( < 0.01) and similarity index ( < 0.05) for all unilateral leg movement tasks. Activation of the erector spinae muscles, recorded at the T10-T12 vertebral level, was observed in all children with SCI, regardless of injury level or severity. Residual descending influence on spinal motor circuits may be present after SCI in children. Assessment of multi-muscle activation patterns during intentional movement attempts can provide objective evidence of the presence and extent of such residual muscle activation, and may provide an indicator of motor recovery potential following injury. The presence of residual intentional muscle activation has important implications for rehabilitation following pediatric-onset SCI.
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http://dx.doi.org/10.3389/fneur.2019.01295DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6933608PMC
December 2019

Activity-Based Therapy Targeting Neuromuscular Capacity After Pediatric-Onset Spinal Cord Injury.

Top Spinal Cord Inj Rehabil 2019 ;25(2):132-149

Pediatric NeuroRecovery Program, Spinal Cord Injury Outpatient Program, Frazier Rehab Institute, Louisville, Kentucky.

Activity-based therapies aim to improve neuromuscular capacity after spinal cord injury (SCI). The purpose of this prospective study was to report the impact of Activity-based Locomotor Training (AB-LT) on neuromuscular capacity in pediatric patients with SCI. Participants were enrolled for their first episode of AB-LT for a minimum of 60 daily, 1.5-hour sessions. The Segmental Assessment of Trunk Control (SATCo) and the Pediatric Neuromuscular Recovery Scale (Pediatric NRS) were assessed initially, every 20 sessions, and post 60 sessions. Twenty-six consecutive patients, mean age 5 years ( = 3), completed a mean 55 sessions ( = 4) within 63 weekdays ( = 9). The Pediatric NRS total score improved significantly, adjusted mean 11.4, from initial to post-60 sessions ( < .05) with an average adjusted evaluation-to-evaluation 3.7 change. SATCo scores improved significantly across 60 sessions, mean change 5.2, an estimated 1.7 change between evaluations ( < .05). Age at enrollment and chronicity had no effect; however, initial neuromuscular capacity scores were negatively correlated with change scores ( < .05). Sixty AB-LT sessions significantly improved trunk and neuromuscular capacity in children with SCI, regardless of age or chronicity at enrollment. Patients with lower initial scores made greater improvements than patients with higher initial neuromuscular capacity. Anecdotal parent reports of their child's functional change in the home and community highlight the synergy between quantitative change in neuromuscular capacity and meaningful, improved quality of life and the need for formal investigation of this relationship.
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http://dx.doi.org/10.1310/sci2502-132DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6496965PMC
December 2019

Interrater Reliability of the Pediatric Neuromuscular Recovery Scale for Spinal Cord Injury.

Top Spinal Cord Inj Rehabil 2019 ;25(2):121-131

Doctor of Physical Therapy Program - Austin, University of St. Augustine for Health Sciences, Austin, Texas.

In synergy with the mounting scientific evidence for the capacity of recovery after spinal cord injury (SCI) and training, new evidence-based therapies advancing neuromuscular recovery are emerging. There is a parallel need for outcome instruments that specifically address recovery. The Pediatric Neuromuscular Recovery Scale (Pediatric NRS) is one example with established content validity to assess neuromuscular capacity within task performance. The objective of this study was to determine interrater reliability of the Pediatric NRS to classify motor capacity in children after SCI. Pediatric physicians (3), occupational therapists (5), and physical therapists (6) received standardized training in scoring the scale, then rated video assessments of 32 children post SCI, 2-12 years of age, 78% non-ambulatory. Interrater reliability was analyzed using Kendall coefficient of concordance for individual Pediatric NRS items and overall score. The interrater reliability coefficient was determined to be near 1 for the overall Pediatric NRS score (ICC = 0.966; 95% CI, 0.89-0.98). Twelve of 16 individual items exhibited high concordance coefficients (Kendall's ≥ 0.8) and four items demonstrated concordance coefficients, < 0.8 and > 0.69. Interrater reliability was equivalent among groups defined by age and neurological level, but lower among non-ambulatory individuals. Strong interrater reliability was demonstrated by pediatric clinicians who scored children with SCI using the Pediatric NRS.
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http://dx.doi.org/10.1310/sci2502-121DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6496963PMC
December 2019

Sensitivity to change and responsiveness of the Segmental Assessment of Trunk Control (SATCo) in children with spinal cord injury.

Dev Neurorehabil 2019 May 22;22(4):260-271. Epub 2018 May 22.

c Department of Neurological Surgery , University of Louisville , Louisville , KY , USA.

Purpose: The purpose of this study was to assess the sensitivity and responsiveness of the Segmental Assessment of Trunk Control (SATCo) for evaluating trunk control in children with spinal cord injury (SCI) receiving activity-based locomotor training (AB-LT).

Methods: Prospective study of nine outcomes for consecutively enrolled children in outpatient AB-LT. To evaluate sensitivity to change, linear-mixed models were constructed and adjusted for covariates: age at and time since SCI. To evaluate responsiveness, standardized response means and 95% confidence intervals were estimated per outcome.

Results: SATCo scores increased significantly (p < 0.05) regardless of chronicity, initial score, and injury level. The SATCo was the most responsive measure and the only outcome demonstrating a large effect size after 3 months of therapy.

Conclusions: Children with SCI receiving AB-LT improved trunk control regardless of chronicity, initial impairment, or prior experience. SATCo sensitivity and responsiveness support its usefulness in measuring trunk control in children with SCI.
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http://dx.doi.org/10.1080/17518423.2018.1475429DOI Listing
May 2019

Retraining walking adaptability following incomplete spinal cord injury.

Spinal Cord Ser Cases 2017 14;3:17091. Epub 2017 Dec 14.

5Department of Neurological Surgery, Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY USA.

Introduction: Functional walking requires the ability to modify one's gait pattern to environmental demands and task goals-gait adaptability. Following incomplete spinal cord injury (ISCI), gait rehabilitation such as locomotor training (Basic-LT) emphasizes intense, repetitive stepping practice. Rehabilitation approaches focusing on practice of gait adaptability tasks have not been established for individuals with ISCIs but may promote recovery of higher level walking skills. The primary purpose of this case series was to describe and determine the feasibility of administering a gait adaptability retraining approach-Adapt-LT-by comparing the dose and intensity of Adapt-LT to Basic-LT.

Case Presentation: Three individuals with ISCIs (>1 year, AIS C or D) completed three weeks each (15 sessions) of Basic-LT and Adapt-LT. Interventions included practice on a treadmill with body weight support and practice overground (≥30 mins total). Adapt-LT focused on speed changes, obstacle negotiation, and backward walking. Training parameters (step counts, speeds, perceived exertion) were compared and outcomes assessed pre and post interventions. Based on completion of the protocol and similarities in training parameters in the two interventions, it was feasible to administer Adapt-LT with a similar dosage and intensity as Basic-LT. Additionally, the participants demonstrated gains in walking function and balance following each training type.

Discussion: Rehabilitation that includes stepping practice with adaptability tasks is feasible for individuals with ISCIs. Further investigation is needed to determine the efficacy of Adapt-LT.
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http://dx.doi.org/10.1038/s41394-017-0003-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5803746PMC
December 2017

Respiratory functional and motor control deficits in children with spinal cord injury.

Respir Physiol Neurobiol 2018 01 28;247:174-180. Epub 2017 Oct 28.

Department of Physiology, University of Louisville, Louisville, KY, USA; Department of Neurological Surgery, University of Louisville, Louisville, KY, USA. Electronic address:

Children with spinal cord injury (SCI) are at high risk for developing complications due to respiratory motor control deficits. However, underlying mechanisms of these abnormalities with respect to age, development, and injury characteristics are unclear. To evaluate the effect of SCI and age on respiratory motor control in children with SCI, we compared pulmonary function and respiratory motor control outcome measures in healthy typically developing (TD) children to age-matched children with chronic SCI. We hypothesized that the deficits in respiratory functional performance in children with SCI are due to the abnormal and age-dependent respiratory muscle activation patterns. Fourteen TD (age 7±2 yrs., Mean±SD) and twelve children with SCI (age 6±1 yrs.) were evaluated by assessing Forced Vital Capacity (FVC); Forced Expiratory Volume in 1sec (FEV); and respiratory electromyographic activity during maximum inspiratory and maximum expiratory airway pressure measurements (PI and PE). The results indicate a significant reduction (p<.01) of FVC, FEV and PE values in children with SCI compared to TD controls. During PE assessment, children with SCI produced significantly decreased (p<.01) activation of respiratory muscles below the neurological level of injury (rectus abdominous and external oblique muscles). In addition, children with SCI had significantly increased (p<.05) compensatory muscle activation above the level of injury (upper trapezius muscle). In the TD group, age, height, and weight significantly (p<.05) contributed towards increase in FVC and FEV. In children with SCI, only age was significantly (p<.05) correlated with FVC and FEV values. These findings indicate the degree of SCI-induced respiratory functional and motor control deficits in children are age-dependent.
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http://dx.doi.org/10.1016/j.resp.2017.10.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5698146PMC
January 2018

Activity-Based Therapy: From Basic Science to Clinical Application for Recovery After Spinal Cord Injury.

J Neurol Phys Ther 2017 07;41 Suppl 3:S39-S45

Department of Neurological Surgery (A.L.B.), Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, Kentucky; Doctor of Physical Therapy Program (E.M.A.), University of St. Augustine for Health Sciences, Austin, Texas; and Department of Neurological Surgery (S.J.H.), Frazier Rehab Institute and Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville.

Background And Purpose: Collaboration between scientists and clinicians effectively accelerated translation of scientific evidence for activity-based therapies (ABTs) into rehabilitation. This article addresses the basic scientific findings of activity-dependent plasticity that led to locomotor training, an ABT, and its principles to advance recovery in adult and pediatric populations with spinal cord injury (SCI). Expansion to new therapies based on these common principles is highlighted, for example, epidural stimulation. The article also describes a recently developed measure, the Neuromuscular Recovery Scale (NRS), and its psychometric properties.

Summary Of Key Points: Locomotor training has led to recovery of walking in some individuals with motor-incomplete SCI even years after injury. Recent studies resulted in individuals with motor-complete SCI regaining some voluntary movements and standing in the presence of epidural stimulation. The level of success for locomotor training and epidural stimulation appears dependent on spinal networks maintaining the appropriate central state of excitability for the desired task. As these new advances in restorative therapies required an outcome measure that measured performance without compensation, the NRS was developed. The NRS has strong psychometric properties in adults, and a pediatric version is under development. Application of locomotor training in children is still novel. Preliminary evidence suggests that locomotor training can improve trunk control and also foster participation in children with chronic SCI.

Recommendations For Clinical Practice: ABTs may effectively promote neuromuscular recovery and improve function and participation in adults and children post-SCI. Evaluation of outcomes with valid measures, such as the NRS, is necessary to document the ability to perform functional tasks and to assess progress as function improves.
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http://dx.doi.org/10.1097/NPT.0000000000000184DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5477660PMC
July 2017

The Interface of Clinical Decision-Making With Study Protocols for Knowledge Translation From a Walking Recovery Trial.

J Neurol Phys Ther 2017 Jan;41(1):59-67

Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles (J.H., J.T.); Malcom Randall VA Medical Center, University of Florida, Gainesville (D.R.); Rehabilitation Department, Florida Hospital Orlando (B.B., C.M.); MetroHealth Station, Los Angeles, California (A.C.); Nova Southeastern University, Tampa, Florida (J.G.); Camp Pendleton Hospital, Camp Pendleton, California (M.M.); Department of Biostatistics, University of Florida, Gainesville (S.W.); Department of Neurology, Wake Forest University Health Sciences, Winston-Salem, North Carolina (P.D.), and Department of Neurological Surgery-Pediatric Rehabilitation and Recovery Laboratory, University of Louisville, Louisville, Kentucky (A.B.).

Background And Purpose: Despite efforts to translate knowledge into clinical practice, barriers often arise in adapting the strict protocols of a randomized, controlled trial (RCT) to the individual patient. The Locomotor Experience Applied Post-Stroke (LEAPS) RCT demonstrated equal effectiveness of 2 intervention protocols for walking recovery poststroke; both protocols were more effective than usual care physical therapy. The purpose of this article was to provide knowledge-translation tools to facilitate implementation of the LEAPS RCT protocols into clinical practice.

Methods: Participants from 2 of the trial's intervention arms: (1) early Locomotor Training Program (LTP) and (2) Home Exercise Program (HEP) were chosen for case presentation. The two cases illustrate how the protocols are used in synergy with individual patient presentations and clinical expertise. Decision algorithms and guidelines for progression represent the interface between implementation of an RCT standardized intervention protocol and clinical decision-making.

Outcomes: In each case, the participant presents with a distinct clinical challenge that the therapist addresses by integrating the participant's unique presentation with the therapist's expertise while maintaining fidelity to the LEAPS protocol. Both participants progressed through an increasingly challenging intervention despite their own unique presentation.

Summary: Decision algorithms and exercise progression for the LTP and HEP protocols facilitate translation of the RCT protocol to the real world of clinical practice. The two case examples to facilitate translation of the LEAPS RCT into clinical practice by enhancing understanding of the protocols, their progression, and their application to individual participants.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A147).
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http://dx.doi.org/10.1097/NPT.0000000000000158DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5161105PMC
January 2017

Development and Initial Validation of the Pediatric Neuromuscular Recovery Scale.

Pediatr Phys Ther 2016 ;28(4):416-426

Doctor of Physical Therapy Program-Austin (Dr Ardolino), University of St. Augustine for Health Sciences, Austin, Texas; Jefferson School of Health Professions (Dr Mulcahey), Thomas Jefferson University, Philadelphia, Pennsylvania; Kosair Charities Center for Pediatric NeuroRecovery (Ms Trimble and Dr Argetsinger), Frazier Rehab Institute, Louisville, Kentucky; Shriners Hospitals for Children (Drs Bienkowski and Mullen), Philadelphia, Pennsylvania; and Department of Neurological Surgery (Dr Behrman), University of Louisville, Louisville, Kentucky.

Purpose: The Neuromuscular Recovery Scale (NRS) was developed to assess the capacity of adults' post-spinal cord injury (SCI) to perform functional tasks without compensation. Application of the NRS to children has been challenging. The purpose of this study was to develop and complete the initial validation of a pediatric version of the NRS.

Methods: First, the investigative team developed a draft Pediatric NRS. Next, a Delphi method was used to amend the draft by 12 pediatric experts. Finally, the revised Pediatric NRS was field-tested on a sample of children with SCI (n = 5) and without (n = 7).

Results: After the Delphi process and field testing, the Pediatric NRS consists of 13 items scored on a 12-point scale. All items, except 1, achieved 80% agreement by experts.

Conclusions: This is the first step in development and validation of a pediatric SCI scale that evaluates neuromuscular capacity, in the context of pediatric function, without compensation.
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http://dx.doi.org/10.1097/PEP.0000000000000285DOI Listing
February 2017

Comparison of Soleus H-Reflexes in Two Groups of Individuals With Motor Incomplete Spinal Cord Injury Walking With and Without a Walker.

Top Spinal Cord Inj Rehabil 2016 ;22(2):158-163

University of Louisville, Kentucky.

To compare phase- and task-dependent H-reflex modulation in standing and walking in 2 spinal cord injury (SCI) groups with and without a walker. Fourteen subjects with American Spinal Injury Association Impairment Scale D SCI (40±10 years) participated. Tibial nerve was stimulated to evoke 15 H-reflexes (at M-wave 7%-13% of maximum-M). H-reflex was greater in the walker group during stance (but not standing/swing). Differences in H-reflex modulation between groups walking with and without a walker may be explained by sensory mechanism that enhances central excitation, difference in motor activation levels between groups, and other complex mechanisms that influence balance or stability.
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http://dx.doi.org/10.1310/sci2016-0007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4896323PMC
January 2016

Neural Stem Cell Therapy and Rehabilitation in the Central Nervous System: Emerging Partnerships.

Phys Ther 2016 May 4;96(5):734-42. Epub 2016 Feb 4.

S.L. Wolf, PT, PhD, FAPTA, Department of Rehabilitation Medicine, Division of Physical Therapy, Emory University School of Medicine; Department of Cell Biology, Emory University School of Medicine; and Center of Excellence in Vision and Neurocognitive Rehabilitation, Atlanta, Georgia.

The goal of regenerative medicine is to restore function through therapy at levels such as the gene, cell, tissue, or organ. For many disorders, however, regenerative medicine approaches in isolation may not be optimally effective. Rehabilitation is a promising adjunct therapy given the beneficial impact that physical activity and other training modalities can offer. Accordingly, "regenerative rehabilitation" is an emerging concentration of study, with the specific goal of improving positive functional outcomes by enhancing tissue restoration following injury. This article focuses on one emerging example of regenerative rehabilitation-namely, the integration of clinically based protocols with stem cell technologies following central nervous system injury. For the purposes of this review, the state of stem cell technologies for the central nervous system is summarized, and a rationale for a synergistic benefit of carefully orchestrated rehabilitation protocols in conjunction with cellular therapies is provided. An overview of practical steps to increase the involvement of physical therapy in regenerative rehabilitation research also is provided.
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http://dx.doi.org/10.2522/ptj.20150063DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6281018PMC
May 2016

Locomotor Adaptability Task Promotes Intense and Task-Appropriate Output From the Paretic Leg During Walking.

Arch Phys Med Rehabil 2016 Mar 23;97(3):493-6. Epub 2015 Oct 23.

Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC; Department of Health Sciences and Research, Medical University of South Carolina, Charleston, SC; Division of Physical Therapy, Department of Health Professions, Medical University of South Carolina, Charleston, SC.

Objective: To test the hypothesis that participants with stroke will exhibit appropriate increase in muscle activation of the paretic leg when taking a long step with the nonparetic leg compared to during steady-state walking, with a consequent increase in biomechanical output and symmetry during the stance phase of the modified gait cycle.

Design: Single-session observational study.

Setting: Clinical research center in an outpatient hospital setting.

Participants: Adults with chronic poststroke hemiparesis (N=15).

Interventions: Participants walked on an instrumented treadmill while kinetic, kinematic, and electromyogram data were recorded. Participants performed steady-state walking and a separate trial of the long-step adaptability task in which they were instructed to intermittently take a longer step with the nonparetic leg.

Main Outcome Measures: Forward progression, propulsive force, and neuromuscular activation during walking.

Results: Participants performed the adaptability task successfully and demonstrated greater neuromuscular activation in appropriate paretic leg muscles, particularly increased activity in paretic plantarflexor muscles. Propulsion and forward progression by the paretic leg were also increased.

Conclusions: These findings support the assertion that the nonparetic long-step task may be effective for use in poststroke locomotor rehabilitation to engage the paretic leg and promote recovery of walking.
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http://dx.doi.org/10.1016/j.apmr.2015.10.081DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4769939PMC
March 2016

Responsiveness of the Neuromuscular Recovery Scale During Outpatient Activity-Dependent Rehabilitation for Spinal Cord Injury.

Neurorehabil Neural Repair 2016 07 10;30(6):528-38. Epub 2015 Sep 10.

The Ohio State University, Columbus, OH, USA

Background: The Neuromuscular Recovery Scale (NRS) was developed by researchers and clinicians to functionally classify people with spinal cord injury (SCI) by measuring functionally relevant motor tasks without compensation. Previous studies established strong interrater and test-retest reliability and validity of the scale.

Objective: To determine responsiveness of the NRS, a version including newly added upper-extremity items, in an outpatient rehabilitation setting.

Methods: Assessments using the NRS and 6 other instruments were conducted at enrollment and discharge from a locomotor training program for 72 outpatients with SCI classified as American Spinal Injury Association Impairment Scale grades A to D (International Standards for Neurological Classification of Spinal Cord Injury). Mixed-model t statistics for instruments were calculated and adjusted for confounding factors (eg, sample size, demographic variables) for all patients and subgroups stratified by injury level and/or severity. The resulting adjusted response means (ARMs) and 95% confidence intervals (CIs) were used to determine responsiveness, and significant differences between instruments were identified with pairwise comparisons.

Results: The NRS was significantly responsive for SCI outpatients (ARM = 1.05; CI = 0.75-1.35). Changes in motor function were detected across heterogeneous groups. Regardless of injury level or severity, the responsiveness of the NRS was equal to, and often significantly exceeded, the responsiveness of other instruments.

Conclusions: The NRS is a responsive measure that detects change in motor function during outpatient neurorehabilitation for SCI. There is potential utility for its application in randomized controlled trials and as a measure of clinical recovery across diverse SCI populations.
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http://dx.doi.org/10.1177/1545968315605181DOI Listing
July 2016

Validity of the Neuromuscular Recovery Scale: a measurement model approach.

Arch Phys Med Rehabil 2015 Aug 23;96(8):1385-96. Epub 2015 Apr 23.

Department of Neurological Surgery, University of Louisville, Louisville, KY; Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY.

Objective: To determine how well the Neuromuscular Recovery Scale (NRS) items fit the Rasch, 1-parameter, partial-credit measurement model.

Design: Confirmatory factor analysis (CFA) and principal components analysis (PCA) of residuals were used to determine dimensionality. The Rasch, 1-parameter, partial-credit rating scale model was used to determine rating scale structure, person/item fit, point-measure item correlations, item discrimination, and measurement precision.

Setting: Seven NeuroRecovery Network clinical sites.

Participants: Outpatients (N=188) with spinal cord injury.

Interventions: Not applicable.

Main Outcome Measure: NRS.

Results: While the NRS met 1 of 3 CFA criteria, the PCA revealed that the Rasch measurement dimension explained 76.9% of the variance. Ten of 11 items and 91% of the patients fit the Rasch model, with 9 of 11 items showing high discrimination. Sixty-nine percent of the ratings met criteria. The items showed a logical item-difficulty order, with Stand retraining as the easiest item and Walking as the most challenging item. The NRS showed no ceiling or floor effects and separated the sample into almost 5 statistically distinct strata; individuals with an American Spinal Injury Association Impairment Scale (AIS) D classification showed the most ability, and those with an AIS A classification showed the least ability. Items not meeting the rating scale criteria appear to be related to the low frequency counts.

Conclusions: The NRS met many of the Rasch model criteria for construct validity.
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http://dx.doi.org/10.1016/j.apmr.2015.04.004DOI Listing
August 2015

Test-retest reliability of the Neuromuscular Recovery Scale.

Arch Phys Med Rehabil 2015 Aug 14;96(8):1375-84. Epub 2015 Apr 14.

Department of Health and Rehabilitation Sciences, Ohio State University, Columbus, OH.

Objective: To determine the test-retest reliability of the Neuromuscular Recovery Scale (NRS), a measure to classify lower extremity and trunk recovery of individuals with spinal cord injury (SCI) to typical preinjury performance of functional tasks without use of external and behavioral compensation.

Design: Multicenter observational study.

Setting: Five outpatient rehabilitation clinics.

Participants: Physical therapists (N=13), trained and competent in conducting NRS, rated outpatients with SCI (N=69) using the NRS. Testing occurred on 2 days, separated by 24 to 48 hours, on the same patient by the same therapist.

Interventions: Not applicable.

Main Outcome Measures: Spearman rank correlation coefficients to compare NRS results. The NRS scores of motor performance were based on normal, preinjury function on 11 items: 4 treadmill-based items (standing and stepping), 7 overground/mat items (sitting, sit-up, reverse sit-up, trunk extension, sit to stand, standing, walking).

Results: Test-retest reliability was very strong for the NRS items. Ten of the 11 items exhibited Spearman correlation coefficients ≥.92, and lower bounds of the 95% confidence intervals (CIs) for these items met or exceeded .83. The exception was stand retraining (ρ=.84; 95% CI, .68-.96). The test-retest reliability of the measurement model-derived summary score was very strong (ρ=.99; 95% CI, .96-.99).

Conclusions: The NRS had excellent test-retest reliability when conducted by trained therapists in adults with chronic SCI across all levels of injury severity. All raters had undergone standardized training in use of the NRS. The minimal requirement of training to achieve test-retest reliability has not been established.
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http://dx.doi.org/10.1016/j.apmr.2015.03.022DOI Listing
August 2015

Interrater reliability of the Neuromuscular Recovery Scale for spinal cord injury.

Arch Phys Med Rehabil 2015 Aug 27;96(8):1397-403. Epub 2014 Dec 27.

Department of Neurological Surgery and Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY.

Objective: To determine the interrater reliability of the Neuromuscular Recovery Scale (NRS), an outcome measure designed to classify people with complete or incomplete spinal cord injury (SCI) into 4 phase-of-injury groups by assessing motor performance based on normal preinjury function and disallowing use of compensation for 4 treadmill-based items and 6 overground/mat items.

Design: Masked comparison, multicenter observational study.

Setting: Outpatient rehabilitation.

Participants: Raters (N=14) and a criterion standard expert assigned scores to 10 video NRS assessments of persons with SCI. The raters were volunteers from the NeuroRecovery Network.

Intervention: Not applicable.

Main Outcome Measure: Interrater reliability measured with the Kendall coefficient of concordance (W).

Results: Interrater reliability was generally strong (W=.91-.98; 95% confidence interval [CI], .65-.99), while lower reliability occurred for treadmill stand retraining (W=.87; 95% CI, .06-1) and seated trunk extension (W=.82; 95% CI, .28-.94). Less experienced raters assigned slightly lower scores than the expert for most items, but the difference was less than half a point and did not weaken concordance.

Conclusions: NRS had strong interrater reliability, a necessary first step in establishing its utility as a clinical and research outcome measure.
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http://dx.doi.org/10.1016/j.apmr.2014.11.026DOI Listing
August 2015

Prediction of responders for outcome measures of locomotor Experience Applied Post Stroke trial.

J Rehabil Res Dev 2014 ;51(1):39-50

Department of Neurology, Geffen School of Medicine, UCLA, 710 Westwood Plaza, Los Angeles, CA 90095.

The Locomotor Experience Applied Post Stroke rehabilitation trial found equivalent walking outcomes for body weight-supported treadmill plus overground walking practice versus home-based exercise that did not emphasize walking. From this large database, we examined several clinically important questions that provide insights into recovery of walking that may affect future trial designs. Using logistic regression analyses, we examined predictors of response based on a variety of walking speed-related outcomes and measures that captured disability, physical impairment, and quality of life. The most robust predictor was being closer at baseline to the primary outcome measure, which was the functional walking speed thresholds of 0.4 m/s (household walking) and 0.8 m/s (community walking). Regardless of baseline walking speed, a younger age and higher Berg Balance Scale score were relative predictors of responding, whether operationally defined by transitioning beyond each speed boundary or by a continuous change or a greater than median increase in walking speed. Of note, the cutoff values of 0.4 and 0.8 m/s had no particular significance compared with other walking speed changes despite their general use as descriptors of functional levels of walking. No evidence was found for any difference in predictors based on treatment group.
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http://dx.doi.org/10.1682/JRRD.2013.04.0080DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4374620PMC
January 2015

Phase dependent modulation of soleus H-reflex in healthy, non-injured individuals while walking with an ankle foot orthosis.

Gait Posture 2014 Apr 6;39(4):1086-91. Epub 2014 Feb 6.

Department of Physical Therapy, University of Florida, Gainesville, FL, USA; Brain Rehabilitation Research Center, Malcolm Randall VA Medical Center, Gainesville, FL, USA.

Objective: To examine the dynamic modulation of the soleus H-reflex while walking with a posterior leaf spring ankle foot orthosis (PAFO).

Methods: Soleus H-reflexes were evoked on randomly chosen lower limb of fourteen healthy individuals (age range of 22-36 years, 7 women) while walking on a treadmill with and without a PAFO. In order to capture excitability across the duration of the gait cycle, H-reflexes were evoked at heel strike (HS), HS+100ms, HS+200ms, HS+300ms, HS+400ms in the stance phase and at toe-off (TO), TO+100ms, TO+200ms, TO+300ms, TO+400ms in the swing phase respectively.

Results: H-reflex excitability was significantly higher in the form of greater slope of the rise in H-reflex amplitude across the swing phase (p=0.024) and greater mean H-reflex amplitude (p=0.014) in the swing phase of walking with a PAFO. There was no change in the slope (p=0.25) or the mean amplitude of H-reflexes (p=0.22) in the stance phase of walking with a PAFO. Mean background EMG activity between the two walking conditions was not significantly different for both the tibialis anterior (p=0.69) and soleus muscles (p=0.59).

Conclusion: PAFO increased reflex excitability in the swing phase of walking in healthy individuals. Altered sensory input originating from joint, muscle and cutaneous receptors may be the underlying mechanism for greater reflex excitability. The neurophysiological effect of PAFOs on reflex modulation during walking needs to be tested in persons with neurological injury. The relationship between the sensory input and the reflex output during walking may assist in determining if there exists a neurological disadvantage of using a compensatory device such as a PAFO.
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http://dx.doi.org/10.1016/j.gaitpost.2014.01.017DOI Listing
April 2014

Long-term facilitation of ventilation in humans with chronic spinal cord injury.

Am J Respir Crit Care Med 2014 Jan;189(1):57-65

1 Brain Rehabilitation Research Center, Malcom Randall Veterans Affairs Medical Center, Gainesville, Florida.

Rationale: Intermittent stimulation of the respiratory system with hypoxia causes persistent increases in respiratory motor output (i.e., long-term facilitation) in animals with spinal cord injury. This paradigm, therefore, has been touted as a potential respiratory rehabilitation strategy.

Objectives: To determine whether acute (daily) exposure to intermittent hypoxia can also evoke long-term facilitation of ventilation after chronic spinal cord injury in humans, and whether repeated daily exposure to intermittent hypoxia enhances the magnitude of this response.

Methods: Eight individuals with incomplete spinal cord injury (>1 yr; cervical [n = 6], thoracic [n = 2]) were exposed to intermittent hypoxia (eight 2-min intervals of 8% oxygen) for 10 days. During all exposures, end-tidal carbon dioxide levels were maintained, on average, 2 mm Hg above resting values. Minute ventilation, tidal volume, and breathing frequency were measured before (baseline), during, and 30 minutes after intermittent hypoxia. Sham protocols consisted of exposure to room air and were administered to a subset of the participants (n = 4).

Measurements And Main Results: Minute ventilation increased significantly for 30 minutes after acute exposure to intermittent hypoxia (P < 0.001), but not after sham exposure. However, the magnitude of ventilatory long-term facilitation was not enhanced over 10 days of intermittent hypoxia exposures.

Conclusions: Ventilatory long-term facilitation can be evoked by brief periods of hypoxia in humans with chronic spinal cord injury. Thus, intermittent hypoxia may represent a strategy for inducing respiratory neuroplasticity after declines in respiratory function that are related to neurological impairment. Clinical trial registered with www.clinicaltrials.gov (NCT01272011).
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http://dx.doi.org/10.1164/rccm.201305-0848OCDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3919124PMC
January 2014

Adherence to accelerometry measurement of community ambulation poststroke.

Phys Ther 2014 Jan 12;94(1):101-10. Epub 2013 Sep 12.

S. Barak, PhD, Pediatric Rehabilitation Department, Edmond and Lily Safra Children's Hospital, Pediatric Rehabilitation Department, Sheba Medical Center, Ramat-Gan 52621, Israel, and Physical Education Department, Kaye Academic College of Education, Beer Sheva, Israel.

Background: The step activity monitor (SAM) quantifies steps taken in the home and community by patient populations. Although the SAM has been used to study individuals after stroke, adherence to the use of SAMs has not been addressed. Participants' adherence to wearing the monitor is critical for obtaining accurate assessments.

Objective: The purpose of this study was to determine the rate of and predictors for inferred adherence to the use of the SAM after stroke.

Design: A cross-sectional design was used.

Methods: Community-dwelling individuals (n=408) 2 months after stroke with moderate-to-severe gait impairment (gait speed of ≤0.8 m/s) were studied. Step activity was assessed for 2 days with the SAM. Inferred adherence was established in 3 periods: 6:00 am to 12:00 pm, 12:01 pm to 6:00 pm, and 6:01 pm to 12:00 am. Adherence was defined as activity recorded in all 3 periods. The percentage of participant adherence for the first day, second day, both days, and either day was calculated. Demographic and clinical characteristics of adherers and nonadherers were compared. Independent adherence predictors were identified by means of stepwise logistic regression.

Results: Inferred adherence rates for the first day, second day, both days, and either day were 68%, 61%, 53%, and 76%, respectively. Upper and lower extremity impairment, balance control, and endurance were significantly different between adherers and nonadherers. On the other hand, older age, greater balance self-efficacy, and better walking endurance were significant predictors of adherence.

Limitations: Participants were individuals with subacute stroke. Therefore, the findings of this study may not be generalized to individuals during the acute and chronic phases of stroke recovery.

Conclusions: Strategies to improve adherence are needed when collecting data for more than 1 day and in samples with younger individuals and those with low levels of balance self-efficacy and walking endurance.
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http://dx.doi.org/10.2522/ptj.20120473DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3892677PMC
January 2014

Thinking through every step: how people with spinal cord injuries relearn to walk.

Qual Health Res 2013 Aug 17;23(8):1027-41. Epub 2013 Jun 17.

University of Florida, Department of Sociology, Criminology, and Law, 3219 Turlington Hall, PO Box 117330, Gainesville, FL 32611, USA.

In this article we explore how people with incomplete spinal cord injury (iSCI) create meaning out of their changing bodies as they undergo a therapeutic intervention called locomotor training (LT). Therapeutic interventions like LT are used to promote the recovery of walking ability among individuals with iSCI. The chronological nature of this study--interviews at three points throughout the 12-week intervention--enhances understanding of the recovering self after spinal cord injury. Drawing on a constructivist theoretical framework, we organize data according to three narrative frames. Participants interpreted LT as (a) a physical change that was meaningful because of its social significance, (b) a coping strategy for dealing with the uncertainty of long-term recovery, and (c) a moral strategy to reconstitute the self. We offer findings that lay the conceptual groundwork for generating new knowledge about what is important to people with iSCI as they relearn how to walk.
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http://dx.doi.org/10.1177/1049732313494119DOI Listing
August 2013

Modular control of varied locomotor tasks in children with incomplete spinal cord injuries.

J Neurophysiol 2013 Sep 12;110(6):1415-25. Epub 2013 Jun 12.

Department of Physical Therapy, University of Florida, Gainesville, Florida;

A module is a functional unit of the nervous system that specifies functionally relevant patterns of muscle activation. In adults, four to five modules account for muscle activation during walking. Neurological injury alters modular control and is associated with walking impairments. The effect of neurological injury on modular control in children is unknown and may differ from adults due to their immature and developing nervous systems. We examined modular control of locomotor tasks in children with incomplete spinal cord injuries (ISCIs) and control children. Five controls (8.6 ± 2.7 yr of age) and five children with ISCIs (8.6 ± 3.7 yr of age performed treadmill walking, overground walking, pedaling, supine lower extremity flexion/extension, stair climbing, and crawling. Electromyograms (EMGs) were recorded in bilateral leg muscles. Nonnegative matrix factorization was applied, and the minimum number of modules required to achieve 90% of the "variance accounted for" (VAF) was calculated. On average, 3.5 modules explained muscle activation in the controls, whereas 2.4 modules were required in the children with ISCIs. To determine if control is similar across tasks, the module weightings identified from treadmill walking were used to reconstruct the EMGs from each of the other tasks. This resulted in VAF values exceeding 86% for each child and each locomotor task. Our results suggest that 1) modularity is constrained in children with ISCIs and 2) for each child, similar neural control mechanisms are used across locomotor tasks. These findings suggest that interventions that activate the neuromuscular system to enhance walking also may influence the control of other locomotor tasks.
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http://dx.doi.org/10.1152/jn.00676.2012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3763159PMC
September 2013

Does exercise tolerance testing at 60 days poststroke predict rehabilitation performance?

Arch Phys Med Rehabil 2013 Jul 30;94(7):1223-9. Epub 2013 Mar 30.

Department of Physical Therapy, University of Florida, Gainesville, FL, USA.

Objective: To assess the relationship between exercise tolerance test (ETT) performance at 6 weeks poststroke and subsequent performance in a treadmill and overground locomotor training program (LTP).

Design: Prospective cohort study.

Setting: Exercise testing laboratory in either a primary care hospital or outpatient clinic.

Participants: Community-dwelling individuals (N=469), 54.9±19.0 days poststroke, enrolled in the Locomotor Experience Applied Post-Stroke randomized controlled trial.

Interventions: Not applicable.

Main Outcome Measures: For participants randomly assigned to LTP, the number of sessions needed to attain the training goal of 20 minutes of treadmill stepping was determined. Regression analyses determined the contribution of ETT performance (cycling duration), age, and 6-minute walk test (6MWT) distance to attainment of the stepping duration goal.

Results: Age, 6MWT, and ETT performance individually accounted for 10.74%, 10.82%, and 10.76%, respectively, of the variance in the number of sessions needed to attain 20 minutes of stepping. When age and 6MWT were included in the model, the additional contribution of ETT performance was rendered nonsignificant (P=.150).

Conclusions: To the extent that ETT performance can be viewed as a measure of cardiovascular fitness rather than neurologic impairment, cardiovascular fitness at the time of the ETT did not make a significant unique contribution to the number of sessions needed to achieve 20 minutes of stepping. The 6MWT, which involves less intensive exercise than the ETT and therefore is likely to be predominantly affected by neurologic impairment and muscular condition, appeared to account for as much variance as the ETT.
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http://dx.doi.org/10.1016/j.apmr.2013.01.031DOI Listing
July 2013

Minimal detectable change for spatial and temporal measurements of gait after incomplete spinal cord injury.

Top Spinal Cord Inj Rehabil 2012 ;18(3):273-81

School of Health and Medical Sciences, Seton Hall University , South Orange, New Jersey.

Background And Purpose: Gait deviations in individuals after incomplete spinal cord injury (ISCI) that are quantified using spatiotemporal (ST) parameters are often targeted during therapeutic interventions. The purpose of our study was to establish reliability and responsiveness of ST parameters of gait after ISCI using an instrumented walkway (GaitMat II).

Methods: Sixteen individuals with ISCI participated in the study. Each subject completed at least 2 walking trials at self-selected (SS) walking speed. Intraclass correlation coefficients model 2, 1 (ICC2,1) with 95% confidence intervals (CIs), standard error of measurement (SEM), SEM percent change (SEM%), the minimal detectable change (MDC), and the MDC percent change (MDC%) were determined for 8 ST parameters including step length, single limb support, and double limb support time for the more and less impaired limb, cadence, and speed.

Results: Excellent test-retest agreement (0.84-0.99) was observed in all ST parameters. SEM% ranged from 8% to 29%, while MDC% ranged from 21% (cadence) to 80% (double limb support time). MDC% values were relatively higher (5-12 MDC%) for the more versus less impaired limb.

Discussion: SEM% results indicate that small to moderate changes were needed to indicate a real change in walking performance. Differences in MDC% values between limbs indicated that variability in parameters might be sensitive to level of motor impairment.

Conclusion: In individuals with ISCI, different gait, balance, or strength training programs can be compared and contrasted based on a quantifiable and meaningful change in the ST parameter of interest.
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http://dx.doi.org/10.1310/sci1803-273DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3584781PMC
July 2013

Restorative rehabilitation entails a paradigm shift in pediatric incomplete spinal cord injury in adolescence: an illustrative case series.

J Pediatr Rehabil Med 2012 ;5(4):245-59

Department of Neurological Surgery and Kentucky Spinal Cord Injury Research Center, University of Louisville, Kentucky, Louisville, KY, USA.

Physical rehabilitation after spinal cord injury (SCI) in adult and pediatric populations has traditionally compensated for paralysis and weakness using wheelchairs, assistive devices, and braces to achieve seated mobility, upright standing, or bracewalking. Recent evidence indicates efficacy of activity-based therapies in adults with SCI, specifically locomotor training (LT), to activate the neuromuscular system below the injury level and improve walking and postural control by restoring pre-morbid movements. The purpose of this paper is to demonstrate the feasibility of LT, using repetitive stepping practice on a treadmill and translated to over ground and the community, to meet the unique needs and demands of pediatric, adolescent rehabilitation. Three outpatient adolescents, T5 AIS D, age 15 (primary wheelchair user), T5 AIS C, age 14 (primary wheelchair user), and C2, AIS D, 14 years (primary ambulator), received a standardized protocol of LT 4-5 times per week for 75, 293, and 40 total sessions, respectively, across 1-3 episodes of care. Two adolescents became full-time ambulators, and one adolescent improved locomotor skills, kinematics, and endurance with two individuals lacking significant increases in strength to account for the benefits. Motivational strategies were developmentally specific, parental involvement critical for carryover, and musculoskeletal considerations paramount with growth and maturation. In comparison to adults, adolescents' continued musculoskeletal, cognitive, and social growth and maturation necessitate repeated episodes of therapy and bi-annual re-evaluations to identify needs and address new goals. The use of activity-based therapies, i.e. LT, represents a paradigm shift in pediatric rehabilitation towards activation of the neuromuscular system below the lesion via task-specific training and experience, minimizing compensation strategies, and targeting recovery of function achieved via use of pre-morbid movement patterns.
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http://dx.doi.org/10.3233/PRM-2012-00225DOI Listing
July 2013

Clinical trials in neurorehabilitation.

Handb Clin Neurol 2013 ;110:61-6

Department of Physical Therapy, University of Florida and Brain Rehabilitation Research Center, Gainesville, FL, USA.

The clinical trial is essential to testing efficacy and effectiveness of therapeutic interventions. Neurorehabilitation presents unique challenges in the execution of clinical trials due to the complexity of both human interface with complex interventions and clinical/research staff interaction. Attention to key elements, recruitment, retention, treatment fidelity, and control intervention selection, contributes to successful conduct of a trial. Alternatives to the randomized controlled trial and outcome measure selection are important considerations contributing to the merit of the trial. While clinical trial outcomes contribute to the scientific evidence, their true value and impact comes in the next step, translation to clinical practice and the improvement of patient outcomes and qualify of life. Translation of evidence into practice may best be achieved via partnerships of scientists, clinicians, and administrators resulting in a dynamic interface between science and practice, the laboratory, and the clinic.
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http://dx.doi.org/10.1016/B978-0-444-52901-5.00005-8DOI Listing
August 2013
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