Shepherd Center Systematic Review Group

Locomotor Training Interventions to Improve Neurological Outcomes after SCI

Summary of a Research SynthesisShepherd Center Study Group

1

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

Shepherd Center Systematic Review GroupLeadership team: Lesley Hudson, MS, David Apple,

MD, Deborah Backus, PhD, PTNeural Reviewers:

David Apple, MDLesley Hudson, MAJennith Bernstein, PTAmanda Gillot, PTJennifer Huggins, OTAshley Kim, OT

Data coordinator: Rebecca Acevedo

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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

Table of ContentsBackground and purpose of review

pp. 4Overview of methods pp. 10Experimental design studies

pp. 16Quasi-Experimental design studies

pp. 39Descriptive design studies pp. 49Case Studies and Reports pp. 50Acknowledgements pp. 81


(H133A050006) at Boston University Center for Psychiatric Rehabilitation3

Rationale for ReviewTremendous 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” programsLittle evidence related to neural recovery after

participation in activity-based programs

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Rationale for ReviewEvidence from animal models of SCI suggests that

the use of intense and repeated sensory 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)

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Rationale for ReviewEvidence 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

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Rationale for ReviewThe 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!

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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

Rationale for ReviewSeveral 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?

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Purpose of ReviewMain 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

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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

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Methods EmployedDefinitions and FocusOverall 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

trainingLocomotor training (manual or robotic) – this

presentation presents evidence related to locomotor training interventions

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Methods Employed: More Definitions“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 learningGiven 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 BDNFDemonstrations of supraspinal activity with imaging

tools or stimulation, such as functional magnetic resonance or transcranial magnetic stimulation, respectively.

12Compiled 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

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

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Methods Employed: Study Designs IncludedExperimental: 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.

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Methods Employed: Study Designs Included40 articles pulled from the literature and 21

articles met rigor and meaningfulness criteria:Descriptive (n=16)Experimental (n=3) Quasi-experimental (n=2)

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Studies Using Experimental Design

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Dobkin et al. 2006Study DesignSingle-blinded, randomized, multi-center

clinical trialCompared the efficacy of manual

locomotor training (LT) with overground gait (OG) training to overground training in adults with acute spinal cord injury (SCI)

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Dobkin et al. 2006Participantsn=146 subjects From 6 regional centersReceiving inpatient rehabilitation for the first

timeClassified with an incomplete injury (American

Spinal Injury Association Impairment Scale (AIS) score of B, C, or D), between spinal level and L3

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Dobkin et al. 2006ParticipantsThe 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.

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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 LTThe 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

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Dobkin et al. 2006LT GroupStretched for up to 10 minutesFollowed 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

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Dobkin et al. 2006OG GroupSpent 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

minutesThose 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

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Dobkin et al. 2006Both GroupsTrained 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/dayPermitted 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 sessionsdepending on how quickly they reached the highest

functional walking speed (0.98 m/s)23



Dobkin et al. 2006Methods: Outcome Measures

Primary obtained:pre-interventionevery 2 weeks for 12 weeksat the end of the training interventionat 6 months and 12 months after enrollment

Secondary obtained 3, 6, and 12 months post-enrollment

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Dobkin et al. 2006Methods: Outcome MeasuresNo 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 testBerg Balance ScaleWalking Index for Spinal Cord injury (WISCISF-5425



Dobkin et al. 2006OutcomesNo 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.



Dobkin et al. 2006OutcomesThe 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 ambulationSpeed continued to increase between 3 and 6

months, in both groupsFor persons classified as AIS B, neither

intervention led to improvements in overground walking



Dobkin et al. 2006Methodological ConsiderationsEarlier 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 groupsBoth 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



Field-Fote et al. 2005OverviewCompared 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)29



Field-Fote et al. 2005Methods: TrainingAll 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 phaseAlways </= 30%

All participated in training for:60-minute periods5 days/week 12 weeks

Allowed to rest during each session as needed

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Field-Fote et al. 2005Methods: TrainingSubjects in the treadmill training groups (TM,

TS) were:Allowed to use the handrails, but bear full

weight through their armEncouraged 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 weeks31



Field-Fote et al. 2005Methods: TrainingSubjects 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.



Field-Fote et al. 2005Methods: TrainingSubjects 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.



Field-Fote et al. 2005Methods: Outcome MeasuresAssessed function only (no neural-related

outcome measures):6-meter walk2-minute walking test

For all walking tests, the subjects were:Allowed to walk at self-selected walking

speedsVideotaped for evaluation of walking

performanceAllowed to use whichever assistive and/or

orthotic devices to which they were accustomedCompiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination &


34

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



Field-Fote et al. 2005OutcomesSubjects in all four groups:

Improved in walking performanceAND there was no significant difference

between groups.Subjects in each of the four groups

demonstrated improvements in walking speedThose with the most impairment in walking

function showed the greatest improvements



Field-Fote et al. 2005ConclusionPower 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



Studies Using Quasi-experimental Design

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Grasso et al. 2004OverviewEvaluated the neural and functional

outcomes in 22 adults:17 to 60 years oldHalf with acute SCI (1 to 6 months post-SCI)

The injury levels ranged from C7 to L2Classified clinically as AIS A (n=5), AIS B (n=2), AIS

C (n=4)Half age-matched controls with no neurological

impairmentAll performed daily manual assisted

locomotor training sessionsWorked on increasing speed and decreasing the

amount of body-weight support and manual assistance required

Training time ranged from one to three months



Grasso et al. 2004Methods: Outcome MeasuresNeural:

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

FunctionalThe Rivermeade Mobility Index (RMI)The Walking Index of Spinal Cord Injury

(WISCI)The Garrett Scale (Garrett et al. 1987).



Grasso et al. 2004Outcomes: NeuralIn subjects with SCI who were able to step

in the first session, stepping started very irregularlyThe 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



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 subjectsThe phase-relationship between limb

segments remained abnormalMost likely due to different muscle activation

patterns from what is available in able-bodies individuals



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



Grasso et al. 2004Outcomes: Neural (EMG)The averaged and normalized EMG

waveforms were mapped on published charts to determine segmental localizationIn 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 subjectsThis activation in L5 to S2 corresponds to weight

acceptance and activation of the hip extensors and ankle plantarflexors.



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



Grasso et al. 2004Outcomes: FunctionalSimilar 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



Grasso et al. 2004ConclusionAlthough some subjects demonstrated neural

changes with LT training:These changes were not identical to the patterns

that are seen in the able bodied populationThese changes appear to be correlated with

functional changes in walking overgroundFurther 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 SCICompiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination &


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Studies Using Descriptive Design

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Case Studies and Reports

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Behrman & Harkema 2000MethodsTraining procedures were similar to those

described previously in the Dobkin et al. study:Subjects walked with BWS on a treadmill with

manual assistanceOver-ground training was initiated when an

individual could:Maintain independent standing while supporting at

least 80% of their body weightInitiate stepping with appropriate kinematics in at least

one leg

n=3Two with AIS C or D classification trained 3 times

per weekOne with AIS A trained 5 times per week



Behrman & Harkema 2000Outcomes

NeuralASIA lower extremity motor score (LEMS)



Behrman & Harkema 2000OutcomesReported that three adults with motor

incomplete SCI (AIS C or D), and one subject with complete (AIS A) SCI, improved walking over the treadmillThe subject classified with an AIS A

paraplegia:Did not improve in ASIA LEMSBUT did improve in stepping on the treadmillDid not receive overground training and was not

evaluated for overground walking



Behrman & Harkema 2000Outcomes

Both subjects with AIS C SCI, improved in ASIA LEMS, as well as stepping on the treadmill

Subject with AIS D SCI did not show improvements in LEMS that corresponded with improvements in walking, not only on the treadmill but overground as well



Behrman & Harkema 2000Important Considerations

Time post-injury and the AIS varied Three subjects with motor incomplete SCI injured < 1

year

Subjects that were motor incomplete were also all males, whereas the one with complete SCI was a female

Ages varied between 20 years old for two subjects, 43 and 45 for the other two



Behrman et al. 2005Summary of one case studyReported that a 55-year-old man with an

acute SCI and incomplete (AIS D) tetraplegia at C6/7 who particpated in manual LT (same protocol as defined previously)Did not demonstrate significant changes in

neural function (i.e., improvements in LEMS)HOWEVER, did demonstrate improvements in

walking functionAfter 45 sessions of manual locomotor training, 5

times a week for 9 weeks, he demonstrated improvements in walking speed, distance, and kinematics overgroundCompiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination &


55

Behrman et al. 2008Case Report: MethodsEvaluated neural and functional outcomes

following LT in a pediatric subject 4.5-year-old child with AIS C tetraplegia

(C6/7)One year post-SCI

Intervention:Manual LT and overground walking each

session16 months

Neural outcome measures:ASIA LEMSASIA somatosensory scoresCompiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination &


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Behrman et al. 2008Methods: OutcomesEvaluations were performed 5 days prior to

initiation of training, and upon completion of training

At the completion of 76 sessions:Demonstrated no significant increases in

LEMS or sensory scores on the ASIA examHOWEVER, demonstrated improvement in

walking independenceCould ambulate in the community with a rolling

walker and with a self-selected gait speed of 0.29 m/s and maximum speed of 0.48 m/s



Behrman et al. 2008Summary of case study in a child

Suggests that the methods most appropriate for improving walking function after SCI in children may be similar to those utilized in adults



Prosser 2007Overview

Reported similar findings to those of Behrman et al.

Subject5-year old girl with SCI at C4, AIS CBrown-Sequard patternMild head injury as well

LT was added to her inpatient PT programApproximately one month after her injury



Prosser 2007Methods: TrainingBWS system slightly different from the system

used by Behrman and colleagues:BWS was measured with the subject standing over a

scale and bearing down with her weight The weight on the scale was subtracted from her

body-weight to determine the percent of support she was receiving

Overground training was initiated 10 weeks after her injury when she was able to independently step with her right leg on the treadmillInitially, the subject used a rolling walker and an

articulating ankle-foot orthosis (AFO) on her left leg, and walked with assistance of two people overground.



Prosser 2007Methods: Training

The focus, throughout both treadmill and overground training was on kinematics of gait

LT performed 3 to 4 times per week, for a total of 6 monthsRanged form 10 minutes for the first three

sessions to 20 minutes for the remainder of the sessions



Prosser 2007Methods: Outcome Measures

Primary outcome measuresASIA Impairment ScaleThe Functional Independence Measure for

Children (WeeFIM II) mobility scoreThe WISCI II



Prosser 2007Outcomes

During 6 months of training, the subject was able to:Decrease BWS over the duration of the

locomotor intervention, from 80% support to 10% support

Increase her speed from 0.27 m/s to 0.98 to 1.12 m/s



Prosser 2007Outcomes

At the completion of training:Neural:

LEMS increased from 4/50 to 29/50Functional

She progressed from the rolling walker, AFO, and assistance of two people, to walking with bilateral Loftstrand crutches, the AFO, and supervision only overground

The WeeFIM II scores improved from 5/35 to 21/35 in mobility

The WISCI II from 0 to 12



Prosser 2007Important ConsiderationsThis is a case studyDuring the acute phase of recoveryThe subject also received concurrent inpatient

therapyTHEREFORE, it is not possible to determine

causality between locomotor training and improvements in walking function

HOWEVER, this report does demonstrate that manual LT can be used in at least some clients in the pediatric population with no harm to the subject and further study is warrantedCompiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination &


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Wirz et al. 2005Overview

Multicenter case seriesFunctional (primary outcome measures)

and neural (secondary outcome measures) outcomesPre- and post-training with robotic LT



Wirz et al. 2005Methods

20 adults16 to 64 years oldMotor incomplete (AIS C or D) tetraplegia (n

= 11) and paraplegia (n = 9)Levels of injury ranged from C5 to L1

Including subjects with lower motor neuron injury, unlike the locomotor training studies already reported

All 2 to 17 years post-SCI



Wirz et al. 2005MethodsSimilar to the manual LT that was described

previously, BUT used a robotic systemSubjects were provided with BWS and robotic

assistance while walking on a treadmillFor robotic assistance, the legs were positioned in the

orthoses of a “Driven Gait Orthosis” that was powered by a computer while subjects walked on the treadmill, which assisted them in their stepping motion

Subjects trained:In approximately 45-minute sessions3 to 5 times per weekFor 8 weeks



Wirz et al. 2005Outcome Measures: Functional

The WISCI IIThe 10-Meter Walk Test (10MWT)6-Minute Walk Test (6MWT)Timed Up & Go (TUG)



Wirz et al. 2005Outcome Measures: Neural

ASIA LEMSThe Ashworth ScaleThe Spinal Cord Assessment Tools for

Spasticity (SCATS)



Wirz et al. 2005Outcomes: FunctionalAll of the subjects who were unable to walk

prior to the intervention were able to walk overground after the interventionOnly two of those who could ambulate prior

to the intervention demonstrated functional improvements on the WSICI II

Subjects who were able to walk overground demonstrated significant increases in gait speed and distance walked, and there was no difference in rate of improvement between the first 4 weeks and the final 4 weeks of training



Wirz et al. 2005 Outcomes: Functional

All but two of the subjects tested in the TUG demonstrated improvements in balanceAs measured by a decrease in the time to perform

the test, with the greatest change during the first four weeks of training

There was less improvement in persons with injuries above T11, and in those who were not taking anti-spasticity medications

There was a significant correlation between the pre-training performance and the magnitude of improvements for the 10MWT and the 6MWTSlower walkers had the greatest improvements in

gait speed and distanceCompiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination &


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Wirz et al. 2005Outcomes: NeuralOnly 10 subjects were tested in relation to

neural outcomes, and only at one of the centers

The only significant increase in LEMS was between the 4 and 8-week assessmentsIn the majority of the subjects (90%), the

changes in LEMS did not correlate with the changes in performance on the walking function tests (10MWT, 6MWT, TUG)

There was also a significant decrease in spasticity, but only in the extensor spasm score as measured with the SCATS



Wirz et al. 2005Conclusions



Protas et al. 2001 OverviewIncreased number of neural measures,

including not simply ASIA and Ashworth outcome measures, but also:Added the Brain Motor Control Assessment

(BMCA) (Sherwood, McKay & Dimitrijevic 1996, Sherwood, Priebe & Graves 1997)Employs surface EMG during a standardized protocol to

assess changes in EMG activity as an indirect measure of motor control Involves having the subject perform voluntary

movements, reinforcement maneuvers, and reflex stimulation while EMG is recorded at multiple muscles

Three subjects with chronic, motor incomplete, thoracic SCI were enrolled to train on a treadmill 1 hour per day, 5 days per week, for 12 weeks



Protas et al. 2001MethodsManual LT training was similar to those

studies reported earlierSubjects walked with BWS on the treadmill,

with trainers providing manual assistance and verbal cueing to facilitate optimal kinematics during steppingSubjects walked until they reported fatigue, and

then were allowed to rest before continuing

Over-ground walking in this study, however, was initiated in all subjects after 3 weeks of training, regardless of the amount of BWS, walking speed, or stepping kinematics.



Protas et al. 2001 Outcomes

All 3 subjects tripled their gait speed and endurance s a result of training, and that these changes are independent of the neural outcomes, reflecting functional changes



Protas et al. 2001 Outcomes

Neural changes included:Changes reflected on the BMCA:

Shift in EMG activity toward that which is seen in able bodied subjects in two of the subjects

No other consistent findings related to neural function across all three subjects

No significant changes in motor function, and no significant changes in Ashworth scoresOne subject reported a reduction in his clonus as training

progressed



Thank you!

National Institute Disability Rehabilitation Research

Shepherd Center

Lesley Hudson, MS David Apple, MD Jennith Bernstein, PT Amanda Gillot, PT Ashley Kim, OT Elizabeth Sasso, PT Kristen Casperson, PT Brian Smith, PT Anna Berry, PT Angela Cooke, RN

79

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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Shepherd Center Systematic Review Group