A study was published this week showing that significant functional recovery can occur months to years after incomplete spinal cord injury with rehabilitation that involves intensive activity-based therapy.
To many that may not sound like news … haven’t we heard this before? Well, yes, it is fairly well-known that Locomotor (treadmill) Training benefits so-called ASIA C and D patients – that means they have some sensory and some motor function below the level of their spinal cord injury. What gives this currency now, though, is that it has been published in the medical literature and comes from a large study – 192 patients – in a tightly controlled and standardized program.
This new study is titled “Balance and Ambulation Improvements in Individuals With Chronic Incomplete Spinal Cord Injury Using Locomotor Training–Based Rehabilitation
It originates from the NeuroRecovery Network (NRN), a collaboration of seven specialized centers that offer activity-based rehabilitation in the clinical environment. The NRN, formed by the Reeve Foundation, is a partnership of basic scientists, clinical scientists, clinicians, and administrators. The basic idea: evaluate the effect of locomotor training and other evidence-based rehabilitative interventions in clinical environments.
The study, from lead author Susan Harkema, Ph.D., University of Louisville, is one of 13 papers in a series based on NRN research that will appear in the Archives of Physical Medicine. So far seven manuscripts have been submitted to the Archives: two have been published online ahead of the print version. (The second paper to come out this week, “Establishing the NeuroRecovery Network: Multisite Rehabilitation Centers That Provide Activity-Based Therapies and Assessments for Neurologic Disorders
,” is an overview of the NRN program itself. It did not present data but offers background and administrative detail.
Two other papers have been accepted for the series and are on hold for print. Others are still under review or yet to be submitted.
The functional recovery paper is based on a what is called a cohort study. This method follows a group over time; it is not a randomized trial with a control group. The 196 participants each got at least 20 sessions of Locomotor Training including step-training using body-weight support and manual assistance on a treadmill, followed by overground assessment and community integration.
Each was measured on three quantitative scales: the Berg Balance Scale; Six-Minute Walk Test; 10-Meter Walk Test. Only 12 percent of participants with chronic SCI failed to improve on the functional outcome measures reported.
From the paper:
Outcome measures at enrollment [before training] showed high variability between patients with AIS grades C and D. Significant improvement from enrollment to final evaluation was observed in balance and walking measures for patients with AIS grades C and D. The magnitude of improvement significantly differed between AIS groups for all measures. Time since SCI was not associated significantly with outcome measures at enrollment, but was related inversely to levels of improvement.
Time since injury ranged from 32 days to more than 25 years. The patients further removed from time of injury did not improve as much, however they still improved significantly.
Conclusions, from paper:
Results of this cohort study of 196 patients showed that significant functional recovery can occur months to years after incomplete SCI with rehabilitation that involves intensive activity-based therapy. Significant improvements in walking distance, speed, and balance were observed when locomotor training was delivered as a standardized therapy to individuals with clinically incomplete SCI .... Functional improvements occurred in 88 percent of NRN patients with AISA grade C and grade D classifications during episodes of care ranging from 20 to 251 sessions of treatment months to years after injury. These results support the concept that there is an intrinsic capacity of the human spinal cord circuitry that responds to task-specific sensory cues and can result in recovery in walking, as shown in other mammals.
These results clearly show what the rehab establishment has come to accept in recent years, in large part due to the work of the NRN: Rehab is medicine. intensive activity-based therapy can result in functional improvements in individuals with chronic incomplete SCI.
From the paper:
Evidence suggests that the human spinal circuitry has maintained properties similar to those of other vertebrates. However, many therapeutic interventions have not taken full advantage of these properties and focus primarily on using the uninjured components of the neuromuscular system to accommodate and compensate for neurologic deficits. For example, during the rehabilitation process, therapists will use assistive devices (eg, braces to support weak limbs, a wheelchair for mobility) or alternative behavioral strategies that tend to minimize the use of the injured components of the neuromuscular system as the means for patients to achieve a functional goal. Such strategies do not capitalize on the significant functional potential remaining below the lesion after SCI.
Our study presents the largest increase in gait speed and distance reported in a population of this magnitude for persons with chronic motor-incomplete SCI receiving manuallyfacilitated locomotor training, walking using bodyweight support in combination with functional electrical stimulation, or robotic-assisted locomotor training.
The study notes that it “does not provide information about whether locomotor training is a more effective therapeutic intervention than no therapy or other rehabilitation interventions and does not reach the level of evidence of a randomized clinical trial.” Still, it does show that even years after injury, “individuals have the capacity to improve balance and walking outcomes when provided with an intensive activity based therapy.”