Recovery of walking in nonambulatory children with chronic spinal cord injuries: Case series.

The immature central nervous system is recognized as having substantial neuroplastic capacity. In this study, we explored the hypothesis that rehabilitation can exploit that potential and elicit reciprocal walking in nonambulatory children with chronic, severe (i.e., lower extremity motor score < 10/50) spinal cord injuries (SCIs). Seven male subjects (3-12 years of age) who were at least 1-year post-SCI and incapable of discrete leg movements believed to be required for walking, enrolled in activity-based locomotor training (ABLT; clinicaltrials.gov NCT00488280). Six children completed the study. Following a minimum of 49 sessions of ABLT, three of the six children achieved walking with reverse rolling walkers. Stepping development, however, was not accompanied by improvement in discrete leg movements as underscored by the persistence of synergistic movements and little change in lower extremity motor scores. Interestingly, acoustic startle responses exhibited by the three responding children suggested preserved reticulospinal inputs to circuitry below the level of injury capable of mediating leg movements. On the other hand, no indication of corticospinal integrity was obtained with transcranial magnetic stimulation evoked responses in the same individuals. These findings suggest some children who are not predicted to improve motor and locomotor function may have a reserve of adaptive plasticity that can emerge in response to rehabilitative strategies such as ABLT. Further studies are warranted to determine whether a critical need exists to re-examine rehabilitation approaches for pediatric SCI with poor prognosis for any ambulatory recovery.

Safety and Feasibility of Cervical and Thoracic Transcutaneous Spinal Cord Stimulation to Improve Hand Motor Function in Children With Chronic Spinal Cord Injury.

OBJECTIVE: In adults with cervical spinal cord injury (SCI), transcutaneous spinal stimulation (scTS) has improved upper extremity strength and control. This novel noninvasive neurotherapeutic approach combined with training may modulate the inherent developmental plasticity of children with SCI, providing even greater improvements than training or stimulation alone. Because children with SCI represent a vulnerable population, we first must establish the safety and feasibility of any potential novel therapeutic approach. The objectives of this pilot study were to determine the safety, feasibility, and proof of principle of cervical and thoracic scTS for short-term effect on upper extremity strength in children with SCI. MATERIALS AND METHODS: In this nonrandomized, within-subject repeated measure design, seven participants with chronic cervical SCI performed upper extremity motor tasks without and with cervical (C3-C4 and C6-C7) and thoracic (T10-T11) site scTS. Safety and feasibility of using cervical and thoracic sites scTS were determined by the frequency count of anticipated and unanticipated risks (eg, pain, numbness). Proof-of-principle concept was tested via change in force production during hand motor tasks. RESULTS: All seven participants tolerated cervical and thoracic scTS across the three days, with a wide range of stimulation intensities (cervical sites = 20-70 mA and thoracic site = 25-190 mA). Skin redness at the stimulation sites was observed in four of 21 assessments (19%) and dissipated in a few hours. No episode of autonomic dysreflexia was observed or reported. Hemodynamic parameters (systolic blood pressure and heart rate) remained within stable limits (p > 0.05) throughout the assessment time points at baseline, with scTS, and after the experiment. Hand-grip and wrist-extension strength increased (p < 0.05) with scTS. CONCLUSIONS: We indicated that short-term application of scTS via two cervical and one thoracic site is safe and feasible in children with SCI and resulted in immediate improvements in hand-grip and wrist-extension strength in the presence of scTS. CLINICAL TRIAL REGISTRATION: The Clinicaltrials.gov registration number for the study is NCT04032990.

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

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.

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

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).

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

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.

Development and Initial Validation of the Pediatric Neuromuscular Recovery Scale.

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.

Test-retest reliability of the Neuromuscular Recovery Scale.

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.

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

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.

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

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.

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

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).

Body-weight-supported treadmill rehabilitation after stroke.

BACKGROUND: Locomotor training, including the use of body-weight support in treadmill stepping, is a physical therapy intervention used to improve recovery of the ability to walk after stroke. The effectiveness and appropriate timing of this intervention have not been established. METHODS: We stratified 408 participants who had had a stroke 2 months earlier according to the extent of walking impairment--moderate (able to walk 0.4 to <0.8 m per second) or severe (able to walk <0.4 m per second)--and randomly assigned them to one of three training groups. One group received training on a treadmill with the use of body-weight support 2 months after the stroke had occurred (early locomotor training), the second group received this training 6 months after the stroke had occurred (late locomotor training), and the third group participated in an exercise program at home managed by a physical therapist 2 months after the stroke (home-exercise program). Each intervention included 36 sessions of 90 minutes each for 12 to 16 weeks. The primary outcome was the proportion of participants in each group who had an improvement in functional walking ability 1 year after the stroke. RESULTS: At 1 year, 52.0% of all participants had increased functional walking ability. No significant differences in improvement were found between early locomotor training and home exercise (adjusted odds ratio for the primary outcome, 0.83; 95% confidence interval [CI], 0.50 to 1.39) or between late locomotor training and home exercise (adjusted odds ratio, 1.19; 95% CI, 0.72 to 1.99). All groups had similar improvements in walking speed, motor recovery, balance, functional status, and quality of life. Neither the delay in initiating the late locomotor training nor the severity of the initial impairment affected the outcome at 1 year. Ten related serious adverse events were reported (occurring in 2.2% of participants undergoing early locomotor training, 3.5% of those undergoing late locomotor training, and 1.6% of those engaging in home exercise). As compared with the home-exercise group, each of the groups receiving locomotor training had a higher frequency of dizziness or faintness during treatment (P=0.008). Among patients with severe walking impairment, multiple falls were more common in the group receiving early locomotor training than in the other two groups (P=0.02). CONCLUSIONS: Locomotor training, including the use of body-weight support in stepping on a treadmill, was not shown to be superior to progressive exercise at home managed by a physical therapist. (Funded by the National Institute of Neurological Disorders and Stroke and the National Center for Medical Rehabilitation Research; LEAPS ClinicalTrials.gov number, NCT00243919.).

Development of a rocking chair for use by children with spinal cord injuries.

PURPOSE: Activity-based locomotor training improves intrinsic trunk control in children with spinal cord injury (SCI). To reinforce these improvements, there is a need to develop community integration activities to allow a patient to apply the retrained nervous system at home. One activity that has been explored is rocking in a rocking chair. This paper describes the design, fabrication, and evaluation of a rocking chair for children with SCI. MATERIALS AND METHODS: The Quality Function Deployment (QFD) design process was used. Fundamental needs and features for the rocking chair were defined in a focus group with experienced therapists, and needs were then rated for importance. A House of Quality (HOQ) matrix was developed to correlate needs with design features, and a prototype design was generated. Virtual motion studies and finite element analysis (FEA) were utilized to assess the design. The chair was fabricated and physical testing was performed, including tipping and static and dynamic load assessments. RESULTS AND CONCLUSIONS: The needs identified through the QFD process were categorized into (1) safety, (2) therapeutic, (3) practical and aesthetic, and (4) data to track chair use. Features selected to meet these needs include safety stops, padding, straps, a stable base, armrests, adjustable footrest, and sensors to capture rocking data. FEA showed a factor of safety (FOS) > 5. Physical testing confirmed physical integrity, load-bearing capacity, and stability of the prototype glider rocking chair. The prototype provides a safe tool for further investigation of rocking for promotion of trunk muscle activation in children with SCI.

Rocking in a rocking chair promotes carryover of gained trunk control capacity, from clinic to home in a population that is non-ambulatory.Rocking provides opportunity for self-practice in population with severely compromised capacity.Rocking is a movement that may be performed when other types of movement cannot be readily performed, e.g., resistance exercise, movement against gravity.Rocking creates opportunity for repetitive, voluntary, self-directed movement that is inherently pleasurable and reinforcing.

Spinal Cord Transcutaneous Stimulation in Cervical Spinal Cord Injury: A Review Examining Upper Extremity Neuromotor Control, Recovery Mechanisms, and Future Directions.

Cervical spinal cord injury (SCI) results in significant sensorimotor impairments below the injury level, notably in the upper extremities (UEs), impacting daily activities and quality of life. Regaining UE function remains the top priority for individuals post-cervical SCI. Recent advances in understanding adaptive plasticity within the sensorimotor system have led to the development of novel non-invasive neurostimulation strategies, such as spinal cord transcutaneous stimulation (scTS), to facilitate UE motor recovery after SCI. This comprehensive review investigates the neuromotor control of UE, the typical recovery trajectories following SCI, and the therapeutic potential of scTS to enhance UE motor function in individuals with cervical SCI. Although limited in number with smaller sample sizes, the included research articles consistently suggest that scTS, when combined with task-specific training, improves voluntary control of arm and hand function and sensation. Further, the reported improvements translate to the recovery of various UE functional tasks and positively impact the quality of life in individuals with cervical SCI. Several methodological limitations, including stimulation site selection and parameters, training strategies, and sensitive outcome measures, require further advancements to allow successful translation of scTS from research to clinical settings. This review also summarizes the current literature and proposes future directions to support establishing approaches for scTS as a viable neuro-rehabilitative tool.

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

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.

Locomotor rehabilitation of individuals with chronic stroke: difference between responders and nonresponders.

OBJECTIVES: To identify the clinical measures associated with improved walking speed after locomotor rehabilitation in individuals poststroke and how those who respond with clinically meaningful changes in walking speed differ from those with smaller speed increases. DESIGN: A single group pre-post intervention study. Participants were stratified on the basis of a walking speed change of greater than (responders) or less than (nonresponders) .16m/s. Paired sample t tests were run to assess changes in each group, and correlations were run between the change in each variable and change in walking speed. SETTING: Outpatient interdisciplinary rehabilitation research center. PARTICIPANTS: Hemiparetic subjects (N=27) (17 left hemiparesis; 19 men; age: 58.74±12.97y; 22.70±16.38mo poststroke). INTERVENTION: A 12-week locomotor intervention incorporating training on a treadmill with body weight support and manual trainers accompanied by training overground walking. MAIN OUTCOME MEASURES: Measures of motor control, balance, functional walking ability, and endurance were collected at pre- and postintervention assessments. RESULTS: Eighteen responders and 9 nonresponders differed by age (responders=63.6y, nonresponders=49.0y, P=.001) and the lower extremity Fugl-Meyer Assessment score (responders=24.7, nonresponders=19.9, P=.003). Responders demonstrated an average improvement of .27m/s in walking speed as well as significant gains in all variables except daily step activity and paretic step ratio. Conversely, nonresponders demonstrated statistically significant improvements only in walking speed and endurance. However, the walking speed increase of .10m/s was not clinically meaningful. Change in walking speed was negatively correlated with changes in motor control in the nonresponder group, implying that walking speed gains may have been accomplished via compensatory mechanisms. CONCLUSIONS: This study is a step toward discerning the underlying factors contributing to improved walking performance.

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

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.

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

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.

Activity-Based Restorative Therapy Promotes Progression from Asymmetry to Symmetry in Posture and Gait in a Child with Chronic, Incomplete Spinal Cord Injury.

Incomplete spinal cord injuries (ISCI) in pediatrics and adults can lead to asymmetric motor impairments exhibiting as asymmetries of posture and gait. Recently, rehabilitation guidelines for adults with neurologic injuries have focused on gaining a functional gait pattern as measured by speed and distance, even if asymmetry deficits persist. Activity-based restorative therapies (ABRT) take advantage of activity-dependent neuroplasticity to change an individual's neuromuscular capacity. This is a report of an ambulatory child with chronic ISCI presenting with significant postural and gait asymmetries who enrolled in an ABRT program. Across 79 ABRT sessions, the child gained symmetry during sitting, standing, and walking. Even though this child was a functional ambulator at enrollment, targeting symmetry of movements via improved neuromuscular capacity further enhanced her achievement of kinematically appropriate function for participation in daily activities.

Case report: training neck and head control in children with chronic paralysis due to acute flaccid myelitis.

Background: Acute flaccid myelitis (AFM) occurs rarely in children and adolescents when damage to spinal motor neurons rapidly causes flaccid paralysis of limb, trunk, and neck muscles and potentially respiratory failure. When neck muscles are weakened or paralyzed, a child loses head control, severely compromising engagement with their environment. Compensation for lack of head control is achieved with external support devices attached to a wheelchair, but there is no indication in the AFM literature of therapeutic efforts to restore head control. In this case series, we explore the possibility of the recovery of head control when children with AFM received activity-based restorative therapies (ABRTs) guided by principles targeting motor control. Case description: Three children, two male and one female, aged 6, 9, and 7, with a history of AFM-onset at 5, 7, and 4 years respectively, enrolled in an activity-based restorative therapies outpatient program targeting activation of the neuromuscular system below the lesion. Each of them lacked head control, was either ventilator-dependent or had a tracheostomy, and was a power wheelchair user via hand/foot control. Methods: Activity-based restorative therapies were provided 5 days/week: 1.5 h of activity-based locomotor training and 1.5 h of activity-based neuromuscular electrical stimulation. Results: An approach to addressing head/neck control developed iteratively across disciplines, from complete compensation with passive external head support to emerging head control during diverse tasks, e.g., sitting, reaching, driving a power chair, sit-to-stand, standing, stepping on a treadmill, and walking. Key principles identified and employed were (a) passive facilitation, (b) external head support, (c) posterior head support, (d) graded manual facilitation, and (e) independent head control. Discussion: The recovery of head control in children with paralysis due to AFM may be accelerated when executing a step-wise progression to effectively target and challenge head control in parallel with activity-based restorative therapies. In treating three children with a chronic lack of head control, a therapeutic strategy was iteratively developed guided by scientific principles, e.g., segmental assessment of control, to promote recovery of head control. While this strategy is encouraging, gaps in sensitive and responsive measurement instruments and treatment technologies persist in guiding assistance, challenging, and promoting independent head control.

Transcutaneous Spinal Stimulation From Adults to Children: A Review.

Neuromodulation via spinal stimulation is a promising therapy that can augment the neuromuscular capacity for voluntary movements, standing, stepping, and posture in individuals with spinal cord injury (SCI). The spinal locomotor-related neuronal network known as a central pattern generator (CPG) can generate a stepping-like motor output in the absence of movement-related afferent signals from the limbs. Using epidural stimulation (EP) in conjunction with activity-based locomotor training (ABLT), the neural circuits can be neuromodulated to facilitate the recovery of locomotor functions in persons with SCI. Recently, transcutaneous spinal stimulation (scTS) has been developed as a noninvasive alternative to EP. Early studies of scTS at thoracolumbar, coccygeal, and cervical regions have demonstrated its effectiveness in producing voluntary leg movements, posture control, and independent standing and improving upper extremity function in adults with chronic SCI. In pediatric studies, the technology of spinal neuromodulation is not yet widespread. There are a limited number of publications reporting on the use of scTS in children and adolescents with either cerebral palsy, spina bifida, or SCI.