Perspectives of parents partnering with physical therapists to deliver intensive rehabilitation for their young children with perinatal stroke: A qualitative study.

BACKGROUND: Parental participation in their young children's rehabilitation has been promoted to increase intervention intensity, but parents' perspectives on increased involvement remain unclear. The objective of this study was to explore parents' experiences partnering with physical therapists (PTs) to administer early, intensive rehabilitation to their young children with cerebral palsy (CP). METHODS: Twelve mothers and one father of children between 8 months and 3 years old with CP were interviewed. Semistructured interviews were conducted before and after parents partnered with a PT to deliver a 12 week activity-based intervention targeting their child's lower extremities. The intervention occurred in the child's home and in PT clinical sites. Interviews were audio recorded and transcribed verbatim. Interpretive description was used as the methodological framework. RESULTS: The three themes were (1) focus on maximizing the child's potential, (2) participation in intensive rehabilitation is challenging, and (3) the importance of a positive experience with therapy. Families discussed a number of barriers and facilitators to participating in intensive rehabilitation. CONCLUSIONS: These results provide considerations for clinicians and researchers to facilitate meaningful engagement of parents in their young children's rehabilitation. This is especially important with increasing evidence for early, activity-based interventions for young children with CP.

Parents' perceptions of functional electrical stimulation as an upper limb intervention for young children with hemiparesis: qualitative interviews with mothers.

BACKGROUND/OBJECTIVE: To explore parents' perceptions of an upper extremity (UE) intervention using functional electrical stimulation (FES) for young children with hemiparesis. METHODS: Parents of children aged 3-6 years with a history of perinatal stroke, impaired UE function, and participation in a 12-week FES intervention delivered at a hospital were included in this exploratory qualitative study. Nine mothers participated in a semi-structured interview < 1 week after their child completed the FES intervention (MyndMove®, MyndTec Inc.) targeting the hemiparetic UE. Open-ended questions queried parents' goals, perceived benefits, and challenges of the FES intervention. Interviews were audio recorded and transcribed verbatim. Qualitative conventional content analysis was used to analyze the transcripts. RESULTS: Five themes were identified. 1) Parents' expectations for the FES intervention. Mothers described setting functional, exploratory, and realistic goals, yet feeling initial apprehension towards FES. 2) Perceived improvement. Physical, functional, and psychological improvements were observed with FES; however, there was still room for improvement. 3) Factors influencing the FES intervention. Program structure, therapist factors, and child factors influenced perceived success. 4) Lack of access to intensive therapy. Mothers noted that FES is not provided in mainstream therapy; however, they wanted access to FES outside of the study. They also highlighted socioeconomic challenges to accessing FES. 5) Strategies to facilitate participation. The mothers provided suggestions for program structure and delivery, and session delivery. CONCLUSIONS: Mothers perceived the FES intervention to have physical, functional and psychological benefits for their children. Interest in continuing with FES highlights a need to improve access to this therapy for young children.

Parent-therapist partnership to ELEVATE gross motor function in children with perinatal stroke: protocol for a mixed methods randomized controlled trial.

BACKGROUND: There is increasing evidence for early, active rehabilitation to enhance motor function following early brain injury. This is clear for interventions targeting the upper extremity, whereas passive treatment approaches for the lower extremity persist. The purpose of this trial is to evaluate the effectiveness of early, intensive rehabilitation targeting the lower extremity and delivered in a parent-therapist partnership model for children with perinatal stroke. METHODS: We describe a protocol for a waitlist-control, single-blind, mixed methods effectiveness randomized controlled trial, with an embedded qualitative study using interpretative description. Participants are children with perinatal stroke aged eight months to three years with signs of hemiparesis. Participants will be randomly allocated to an immediate ELEVATE (Engaging the Lower Extremity Via Active Therapy Early) intervention group, or a waitlist-control group, who will receive usual care for six months. The ELEVATE intervention involves one hour of training four days per week for 12 weeks, with a pediatric therapist and a parent or guardian each delivering two sessions per week. The intervention targets the affected lower extremity by progressively challenging the child while standing and walking. The primary outcome measure is the Gross Motor Function Measure-66. Secondary outcomes include the Pediatric Quality of Life Inventory™, Young Children's Participation and Environment Measure, and an instrumented measure of spasticity. A cost-effectiveness analysis and qualitative component will explore benefit to costs ratios and parents' perspectives of early, intensive rehabilitation, and their role as a partner in the rehabilitation, respectively. DISCUSSION: This study has the potential to change current rehabilitation for young children with perinatal stroke if the ELEVATE intervention is effective. The parent interviews will provide further insight into benefits and challenges of a partnership model of rehabilitation. The mixed methods design will enable optimization for transfer of this collaborative approach into physical therapy practice. TRIAL REGISTRATION: ClinicalTrials.gov NCT03672864 . Registered 17 September 2018.

Perspectives of people with spinal cord injury learning to walk using a powered exoskeleton.

BACKGROUND: Powered exoskeletons for over ground walking were designed to help people with neurological impairments to walk again. Extended training in powered exoskeletons has led to changes in walking and physiological functions. Few studies have considered the perspective of the participants. The users' perspective is vital for adoption of assistive devices. We explored the expectations and experiences of persons with spinal cord injury, training with the ReWalk exoskeleton. METHODS: A qualitative research design with individual interviews was used. Eleven participants with spinal cord injury, taking part in 12 weeks of 4 times weekly training using the ReWalk, were interviewed before, immediately after, and 2 months after training. Interviews were audio recorded and transcribed verbatim. A six stage approach to thematic analysis was used. RESULTS: The theme consistently expressed was the exoskeleton allowed participants to do everyday activities, like everyone else, such as looking people in the eye or walking outside. Their experiences were captured in three categories: 1) learning, a description of both expectations for learning and perspectives on how learning occurred; 2) changing, perspectives on perceived changes with training; and 3) contributing, which captured participant perspectives on contributing to research, including the giving of direct feedback regarding the exoskeleton (i.e., what worked and what could be changed). CONCLUSIONS: Incorporating the view of the user in the design and refinement of exoskeletons will help ensure that the devices are appropriate for future users. Availability and support for the use of exoskeleton devices in community settings is an interim step to home use as the devices continue to improve. TRIAL REGISTRATION: www.clinicaltrials.gov ( NCT02322125 ). Registered Dec 22, 2014 - Retrospectively registered after the first 4 participants had enrolled in the study.

Retraining walking over ground in a powered exoskeleton after spinal cord injury: a prospective cohort study to examine functional gains and neuroplasticity.

BACKGROUND: Powered exoskeletons provide a way to stand and walk for people with severe spinal cord injury. Here, we used the ReWalk exoskeleton to determine the training dosage required for walking proficiency, the sensory and motor changes in the nervous system with training, and the functionality of the device in a home-like environment. METHODS: Participants with chronic (> 1 yr) motor complete or incomplete spinal cord injury, who were primarily wheelchair users, were trained to walk in the ReWalk for 12 weeks. Measures were taken before, during, immediately after, and 2-3 months after training. Measures included walking progression, sitting balance, skin sensation, spasticity, and strength of the corticospinal tracts. RESULTS: Twelve participants were enrolled with 10 completing training. Training progression and walking ability: The progression in training indicated about 45 sessions to reach 80% of final performance in training. By the end of training, participants walked at speeds of 0.28-0.60 m/s, and distances of 0.74-1.97 km in 1 h. The effort of walking was about 3.3 times that for manual wheelchair propulsion. One non-walker with an incomplete injury became a walker without the ReWalk after training. Sensory and motor measures: Sitting balance was improved in some, as seen from the limits of stability and sway speed. Neuropathic pain showed no long term changes. Change in spasticity was mixed with suggestion of differences between those with high versus low spasticity prior to training. The strength of motor pathways from the brain to back extensor muscles remained unchanged. Adverse events: Minor adverse events were encountered by the participants and trainer (skin abrasions, non-injurious falls). Field testing: The majority of participants could walk on uneven surfaces outdoors. Some limitations were encountered in home-like environments. CONCLUSION: For individuals with severe SCI, walking proficiency in the ReWalk requires about 45 sessions of training. The training was accompanied by functional improvements in some, especially in people with incomplete injuries. TRIAL REGISTRATION: NCT02322125 Registered 22 December 2014.

The Feasibility of Functional Electrical Stimulation to Improve Upper Extremity Function in a Two-year-old Child with Perinatal Stroke: A Case Report.

AIMS: To evaluate the effectiveness and feasibility (i.e. tolerability, adherence) of functional electrical stimulation (FES) for the upper extremity (UE) in a two-year-old child with perinatal stroke. METHODS: Forty hours of FES over eight weeks was prescribed. FES to the hemiplegic triceps, extensor carpi radialis longus and brevis, extensor carpi ulnaris and extensor digitorum was timed with reaching during play. Assessments were performed before, during, and two months post-intervention. UE function (Melbourne Assessment 2 (MA2), Assisting Hand Assessment (AHA)) and spasticity (Modified Tardieu with electrogoniometry and electromyography) were measured. The mother completed a semi-structured interview post-intervention. Descriptive statistics were used for adherence and UE measures. A repeated-measures ANOVA compared Modified Tardieu parameters (e.g. catch angle) over time. Conventional content analysis was used for the interview data. RESULTS: The child completed 39.2/40 hours. Immediately post-intervention, improvements were observed on MA2's Range of Motion subscale and catch angle (Modified Tardieu, p < 0.001). Two months post-intervention, improvements were observed on MA2's Accuracy and Fluency subscales. No change in AHA score occurred. Three themes emerged from the interview: (1) Ingredients for program success; (2) Information about the FES device; and (3) The child's response. CONCLUSIONS: UE FES was feasible in a two-year-old child with hemiplegia.

Training-Specific Neural Plasticity in Spinal Reflexes after Incomplete Spinal Cord Injury.

The neural plasticity of spinal reflexes after two contrasting forms of walking training was determined in individuals with chronic, motor-incomplete spinal cord injury (SCI). Endurance Training involved treadmill walking for as long as possible, and Precision Training involved walking precisely over obstacles and onto targets overground. Twenty participants started either Endurance or Precision Training for 2 months and then crossed over after a 2-month rest period to the other form of training for 2 months. Measures were taken before and after each phase of training and rest. The cutaneomuscular reflex (CMR) during walking was evoked in the soleus (SOL) and tibialis anterior muscles by stimulating the posterior tibial nerve at the ankle. Clonus was estimated from the EMG power in the SOL during unperturbed walking. The inhibitory component of the SOL CMR was enhanced after Endurance but not Precision Training. Clonus did not change after either form of training. Participants with lower reflex excitability tended to be better walkers (i.e., faster walking speeds) prior to training, and the reduction in clonus was significantly correlated with the improvement in walking speed and distance. Thus, reflex excitability responded in a training-specific way, with the reduction in reflex excitability related to improvements in walking function. Trial registration number is NCT01765153.

Characteristics of the developing human locomotor system: Similarities to other mammals.

Similarities in the development of locomotion between young children and other mammals are explored by reanalysis of data accrued over ~18 years. Supported stepping in children was tested on a treadmill. Although the time course of development is more protracted in humans compared to other mammals, the same trends are seen. For example, the duration of the stepping cycle shortens rapidly in the first 5 months of life. Hypermetric flexion of the hip and knee during stepping is seen in children <3 mo old. Stability of the locomotor rhythm both with respect to cycle duration within a limb and coupling between limbs improves slowly. Finally, coordination between the left and right legs can be manipulated with training, indicating experience-dependent learning at a young age. The possible reasons for these remarkably similar trends in development are explored as a function of maturational time tables for neural structures.

Long-latency, inhibitory spinal pathway to ankle flexors activated by homonymous group 1 afferents.

Inhibitory feedback from sensory pathways is important for controlling movement. Here, we characterize, for the first time, a long-latency, inhibitory spinal pathway to ankle flexors that is activated by low-threshold homonymous afferents. To examine this inhibitory pathway in uninjured, healthy participants, we suppressed motor-evoked potentials (MEPs), produced in the tibialis anterior (TA), by a prior stimulation to the homonymous common peroneal nerve (CPN). The TA MEP was suppressed by a triple-pulse stimulation to the CPN, applied 40, 50, and 60 ms earlier and at intensities of 0.5-0.7 times motor threshold (average suppression of test MEP was 33%). Whereas the triple-pulse stimulation was below M-wave and H-reflex threshold, it produced a long-latency inhibition of background muscle activity, approximately 65-115 ms after the CPN stimulation, a time period that overlapped with the test MEP. However, not all of the MEP suppression could be accounted for by this decrease in background muscle activity. Evoked responses from direct activation of the corticospinal tract, at the level of the brain stem or thoracic spinal cord, were also suppressed by low-threshold CPN stimulation. Our findings suggest that low-threshold muscle and cutaneous afferents from the CPN activate a long-latency, homonymous spinal inhibitory pathway to TA motoneurons. We propose that inhibitory feedback from spinal networks, activated by low-threshold homonymous afferents, helps regulate the activation of flexor motoneurons by the corticospinal tract.

Engaging the Lower Extremity via Active Therapy Early (ELEVATE) Is Feasible and May Improve Gross Motor Function in Children with Spastic Bilateral Cerebral Palsy: A Case Series.

Purpose: The feasibility of ELEVATE with respect to adherence and preliminary efficacy was determined for children with spastic bilateral cerebral palsy (CP) from encephalopathy of prematurity. Methods: A case series was used. Participants were randomized to receive ELEVATE immediately or delay the intervention by 3 months before receiving the intervention. The outcomes included feasibility measures of (1) number of children recruited, (2) percentage of sessions attended, (3) stride counts during the intervention, and preliminary efficacy measures of change over the intervention period in (4) Gross Motor Function Measure-66 (GMFM-66), and (5) kinematics and weight-bearing during treadmill walking. Results: Four boys under 3 years of age participated. All participants tolerated 60-minute intervention sessions four times/week for 12 weeks, and attended 75%-94% (min-max) of the targeted sessions. The median step count per session ranged from 833 to 2484 steps (min-max) during the final week of training. Participants showed an increase in GMFM-66 score of 2.4-7.5 points (min-max) over the 3-month intervention phase, as compared to a decrease of 1.7 for one participant and an increase of 1.3 for another over the delay period. Three participants demonstrated small improvements in their gait with the intervention. Conclusions: Engaging young children with bilateral CP in intensive rehabilitation targeting gross motor function was feasible and demonstrated preliminary efficacy. The results have guided the design of a larger clinical trial to assess efficacy of early, active interventions for children with spastic bilateral CP.

Objectif: les chercheurs ont déterminé la faisabilité d'ELEVATE en matière d'adhésion et d'efficacité préliminaire chez des enfants ayant une paralysie cérébrale spastique bilatérale (PC) causée par une encéphalopathie de la prématurité. Méthodologie: série de cas. Les participants ont été choisis au hasard entre l'utilisation immédiate d'ELEVATE ou son report de trois mois. Les résultats incluaient des mesures de fiabilité, soit 1) le nombre d'enfants recrutés, 2) le pourcentage de séances suivies, 3) le compte des foulées pendant l'intervention et les mesures d'efficacité préliminaire pendant la période de l'intervention sur le plan de 4) la mesure de la fonction motrice globale 66 (GMFM-66) et de 5) la cinématique et la mise en charge pendant la marche sur tapis roulant. Résultats: quatre garçons de moins de trois ans ont participé. Tous ont toléré des séances d'intervention de 60 minutes quatre fois par semaine pendant 12 semaines et ont assisté à 75 % à 94 % (minimum-maximum) des séances ciblées. Le compte médian de foulées par séance se situait entre 833 et 2 484 foulées (minimum­maximum) lors de la dernière semaine d'entraînement. Les participants ont présenté une augmentation de 2,4 à 7,5 points (minimum-maximum) au score du GMFM-66 pendant les trois mois de la phase d'intervention, par rapport à une diminution de 1,7 point chez un participant et à une augmentation de 1,3 point chez un autre pendant la période de report. Trois participants ont démonté de légères améliorations de leur démarche grâce à l'intervention. Conclusions: il est faisable de faire participer des jeunes enfants ayant une PC bilatérale à une réadaptation intensive visant la fonction motrice globale, et cette intervention a une efficacité préliminaire démontrée. Les résultats ont entraîné la conception d'une étude clinique plus vaste pour évaluer l'efficacité d'interventions précoces actives chez les enfants ayant une PC bilatérale spastique.

Younger is not always better: development of locomotor adaptation from childhood to adulthood.

New walking patterns can be learned over short timescales (i.e., adapted in minutes) using a split-belt treadmill that controls the speed of each leg independently. This leads to storage of a modified spatial and temporal motor pattern that is expressed as an aftereffect in regular walking conditions. Because split-belt walking is a novel task for adults and children alike, we used it to investigate how motor adaptation matures during human development. We also asked whether the immature pattern resembles that of people with cerebellar dysfunction, because we know that this adaptation depends on cerebellar integrity. Healthy children (3-18 years old) and adults, and individuals with cerebellar damage were adapted while walking on split belts (1:2 speed ratio). Adaptation and de-adaptation rates were quantified separately for temporal and spatial parameters. All healthy children and adults tested could learn the new timing at the same rate and showed significant aftereffects. However, children younger than 6 years old were unable to learn the new spatial coordination. Furthermore, children as old as age 11 years old showed slower rates of adaptation and de-adaptation of spatial parameters of walking. Young children showed patterns similar to cerebellar patients, with greater deficits in spatial versus temporal adaptation. Thus, although walking is a well-practiced, refined motor skill by late childhood (i.e., 11 years of age), the processes underlying learning new spatial relationships between the legs are still developing. The maturation of locomotor adaptation follows at least two time courses, which we propose is determined by the developmental state of the cerebellum.

Developmental constraints of quadrupedal coordination across crawling styles in human infants.

Human infants can crawl using several very different styles; this diversity appears at first glance to contradict our previous findings from hands-and-knees crawling, which suggested that there were strict limitations on coordination, imposed either mechanically or by the developing nervous system. To determine whether coordination was similarly restricted across crawling styles, we studied free crawling overground in 22 infants who used a number of different locomotor strategies. Despite the wide variety in the use of individual limbs and even the number of limbs used, the duration of the stance phase increased with duration of cycle, whereas the duration of the swing phase remained more constant. Additionally, all infants showed organized, rhythmic interlimb coordination. Alternating patterns (e.g., trotlike) predominated (86% of infants). Alternatively, yet much less frequently, all limbs used could work in synchrony (14% of infants). Pacelike patterns were never observed, even in infants that crawled with the belly remaining in contact with the ground so that stability was not a factor. To explore the robustness of the interlimb coordination, a perturbation that prolonged swing of the leg was imposed on 14 additional infants crawling on hands and knees overground or on the treadmill. The perturbation led to a resetting of the crawling pattern, but never to a change in the coordination of the limbs. The findings concur with those regarding other infant animals, together suggesting that the nervous system itself limits the coordination patterns available at a young age.

Training to achieve over ground walking after spinal cord injury: a review of who, what, when, and how.

OBJECTIVES: (1) To provide clinicians with the best evidence for effective retraining of walking after spinal cord injury (SCI) to achieve over ground walking. (2) To identify gaps in our knowledge to guide future research. METHODS: Articles that addressed the retraining of walking in adults with SCI and reported outcome measures of over ground walking ability were identified through a non-systematic search of the PubMed, Scopus, and CINAHL databases. No restriction was applied to the method of training. Selected articles were appraised using the Physiotherapy Evidence Database scale. Information was synthesized to answer who best responds to what type of treatment, how that treatment should be delivered, and at what stage after injury. RESULTS: Individuals with motor incomplete SCI (American Spinal Injury Association (ASIA) Impairment scale (AIS) C and D) are most likely to regain walking over ground. The effective methods of training all involved a substantial component of walking in the training, and if assistance was provided, partial assistance was more effective than total assistance. Walking training resulted in a change in over ground walking speed of 0.06-0.77 m/s, and 6 minute walk distance of 24-357 m. The effective training schedules ranged from 10 to 130 sessions, with a density of sessions ranging from 2 per week to 5 per week. Earlier training led to superior results both in the subacute (<6 months) and chronic phases (>6 months) after injury, but even individuals with chronic injuries of long duration can improve. CONCLUSIONS: Frequent, early treatment for individuals with motor incomplete SCI using walking as the active ingredient whether on the treadmill or over ground, generally leads to improved walking over ground. Much work remains for the future, including better quantification of treatment intensity, better outcome measures to quantify a broader range of walking skills, and better ways to retrain individuals with more severe lesions (AIS A and B).

Neural Plasticity in Spinal and Corticospinal Pathways Induced by Balance Training in Neurologically Intact Adults: A Systematic Review.

Balance training, defined here as training of postural equilibrium, improves postural control and reduces the rate of falls especially in older adults. This systematic review aimed to determine the neuroplasticity induced by such training in younger (18-30 years old) and older adults (≥65 years old). We focused on spinal and corticospinal pathways, as studied with electrophysiology, in people without neurological or other systemic disorders. We were specifically interested in the change in the excitability of these pathways before and after training. Searches were conducted in four databases: MEDLINE, CINAHL, Scopus, and Embase. A total of 1,172 abstracts were screened, and 14 articles were included. Quality of the studies was evaluated with the Downs and Black checklist. Twelve of the studies measured spinal reflexes, with ten measuring the soleus H-reflex. The H-reflex amplitude was consistently reduced in younger adults after balance training, while mixed results were found in older adults, with many showing an increase in the H-reflex after training. The differences in results between studies of younger vs. older adults may be related to the differences in their H-reflexes at baseline, with older adults showing much smaller H-reflexes than younger adults. Five studies measured corticospinal and intracortical excitability using transcranial magnetic stimulation. Younger adults showed reduced corticospinal excitability and enhanced intracortical inhibition after balance training. Two studies on older adults reported mixed results after training. No conclusions could be drawn for corticospinal and intracortical plasticity given the small number of studies. Overall, balance training induced measurable change in spinal excitability, with different changes seen in younger compared to older adults.

Early, Intensive, Lower Extremity Rehabilitation Shows Preliminary Efficacy After Perinatal Stroke: Results of a Pilot Randomized Controlled Trial.

BACKGROUND: Perinatal stroke injures motor regions of the brain, compromising movement for life. Early, intensive, active interventions for the upper extremity are efficacious, but interventions for the lower extremity remain understudied. OBJECTIVE: To determine the feasibility and potential efficacy of ELEVATE-Engaging the Lower Extremity Via Active Therapy Early-on gross motor function. METHODS: We conducted a single-blind, two-arm, randomized controlled trial (RCT), with the Immediate Group receiving the intervention while the Delay Group served as a 3-month waitlist control. A separate cohort living beyond commuting distance was trained by their parents with guidance from physical therapists. Participants were 8 months to 3 years old, with MRI-confirmed perinatal ischemic stroke and early signs of hemiparesis. The intervention was play-based, focused on weight-bearing, balance and walking for 1 hour/day, 4 days/week for 12 weeks. The primary outcome was the Gross Motor Function Measure-66 (GMFM-66). Secondary outcomes included steps and gait analyses. Final follow-up occurred at age 4. RESULTS: Thirty-four children participated (25 RCT, 9 Parent-trained). The improvement in GMFM-66 over 12 weeks was greater for the Immediate than the Delay Group in the RCT (average change 3.4 units higher) and greater in younger children. Average step counts reached 1370-3750 steps/session in the last week of training for all children. Parent-trained children also improved but with greater variability. CONCLUSIONS: Early, activity-intensive lower extremity therapy for young children with perinatal stroke is feasible and improves gross motor function in the short term. Longer term improvement may require additional bouts of intervention. CLINICAL TRIAL REGISTRATION: This study was registered at ClinicalTrials.gov (NCT01773369).

Unique characteristics of motor adaptation during walking in young children.

Children show precocious ability in the learning of languages; is this the case with motor learning? We used split-belt walking to probe motor adaptation (a form of motor learning) in children. Data from 27 children (ages 8-36 mo) were compared with those from 10 adults. Children walked with the treadmill belts at the same speed (tied belt), followed by walking with the belts moving at different speeds (split belt) for 8-10 min, followed again by tied-belt walking (postsplit). Initial asymmetries in temporal coordination (i.e., double support time) induced by split-belt walking were slowly reduced, with most children showing an aftereffect (i.e., asymmetry in the opposite direction to the initial) in the early postsplit period, indicative of learning. In contrast, asymmetries in spatial coordination (i.e., center of oscillation) persisted during split-belt walking and no aftereffect was seen. Step length, a measure of both spatial and temporal coordination, showed intermediate effects. The time course of learning in double support and step length was slower in children than in adults. Moreover, there was a significant negative correlation between the size of the initial asymmetry during early split-belt walking (called error) and the aftereffect for step length. Hence, children may have more difficulty learning when the errors are large. The findings further suggest that the mechanisms controlling temporal and spatial adaptation are different and mature at different times.

Afferent regulation of leg motor cortex excitability after incomplete spinal cord injury.

An incomplete spinal cord injury (SCI) impairs neural conduction along spared ascending sensory pathways to disrupt the control of residual motor movements. To characterize how SCI affects the activation of the motor cortex by spared ascending sensory pathways, we examined how stimulation of leg afferents facilitates the excitability of the motor cortex in subjects with incomplete SCI. Homo- and heteronymous afferents to the tibialis anterior (TA) representation in the motor cortex were electrically stimulated, and the responses were compared with uninjured controls. In addition, we examined if cortical excitability could be transiently increased by repetitively pairing stimulation of spared ascending sensory pathways with transcranial magnetic stimulation (TMS), an intervention termed paired associative stimulation (PAS). In uninjured subjects, activating the tibial nerve at the ankle 45-50 ms before a TMS pulse in a conditioning-test paradigm facilitated the motor-evoked potential (MEP) in the heteronymous TA muscle by twofold on average. In contrast, prior tibial nerve stimulation did not facilitate the TA MEP in individuals with incomplete SCI (n = 8 SCI subjects), even in subjects with less severe injuries. However, we provide evidence that ascending sensory inputs from the homonymous common peroneal nerve (CPN) can, unlike the heteronymous pathways, facilitate the motor cortex to modulate the TA MEP (n = 16 SCI subjects) but only in subjects with less severe injuries. Finally, by repetitively coupling CPN stimulation with coincident TA motor cortex activation during PAS, we show that 7 of 13 SCI subjects produced appreciable (>20%) facilitation of the MEP following the intervention. The increase in corticospinal tract excitability by PAS was transient (<20 min) and tended to be more prevalent in SCI subjects with stronger functional ascending sensory pathways.

Validating Accelerometry as a Measure of Arm Movement for Children With Hemiplegic Cerebral Palsy.

BACKGROUND: For children with hemiplegic cerebral palsy (HCP), rehabilitation aims to increase movement of the affected arm. However, no validated measure objectively examines this construct in pediatric practice or daily life. OBJECTIVE: The objective of this study was to evaluate the criterion and known-groups validity of accelerometry as a measure of arm movement in children and adolescents with HCP. DESIGN: This was a prospective cross-sectional study. METHODS: Twenty-seven children and adolescents with typical development (3.4-13.9 years old) and 11 children and adolescents with HCP (4.7-14.7 years old; Manual Ability Classification System rating I or II) wore accelerometers on their wrists while engaged in 20 minutes of play, which included intermittent intervals of stillness and vigorous movement of the arms. Vector magnitude (VM) values identified the presence (VM > 2.0 counts per epoch) and absence (VM ≤ 2.0 counts per epoch) of arm movement for every 2-second epoch. Video was simultaneously recorded; each 2-second interval of footage was scored as "movement" or "no movement" for each arm. RESULTS: Agreement between accelerometry and video observation was greater than or equal to 81%, and the prevalence-adjusted and bias-adjusted κ value was greater than or equal to 0.69 for both groups of participants; these results supported the criterion validity of accelerometry. The ratio of nondominant arm movement to dominant arm movement measured by accelerometry was significantly greater in participants with typical development (mean [SD] = 0.87 [0.09]) than in participants with HCP (mean = 0.78 [0.07]) on the basis of 10 age- and sex-matched pairs; these results supported known-groups validity. LIMITATIONS: The small sample size of the group with HCP prevented the stratification of data by age. Participants with HCP had high or moderately high function of the affected arm; hence, the findings do not apply to children and adolescents with more significant hemiparesis. CONCLUSIONS: Accelerometry is a valid measure of arm movement in children with HCP and children without HCP. These findings contribute to the development of innovative upper limb assessments for children with hemiparesis.

Development of Walking indicators to advance the quality of spinal cord injury rehabilitation: SCI-High Project.

Objective: To describe the development of structure, process and outcome indicators that will advance the quality of walking rehabilitation for Canadians with spinal cord injury or disease (SCI/D) by 2020. Method: A framework for the evaluation of the quality of walking rehabilitation was developed by experts in walking after SCI/D. A systematic literature review identified factors influencing walking outcomes and potential walking indicators. A Driver diagram analysis summarized the factors affecting walking outcomes and subsequently informed the selection of structure and process indicators. Psychometric properties and clinical utility of potential walking indicators were considered during the selection of outcome indicators. Results: The structure indicator is the number of physical therapists using evidence-based walking interventions per number of ambulatory individuals with SCI/D. The process indicator is the number of received hours of walking interventions during inpatient rehabilitation per number of ambulatory individuals with SCI/D. The intermediary outcome indicator, which is collected at discharge from inpatient rehabilitation, is either the modified Timed Up and Go or the 10-Meter Walk Test, the choice of measure is dictated by the stage of walking recovery, as defined by the Standing and Walking Assessment Tool. The final outcome indicator, collected at 18 months post-discharge, is the Spinal Cord Independence Measure III-Mobility subscale. Conclusion: The selected indicators align with current clinical practice in Canada. The indicators will direct the timing and enhance the volume of walking therapy delivered, to ultimately increase the proportion of patients who achieve their walking potential by 18 months post-rehabilitation.

Walking tasks encountered by urban-dwelling adults and persons with incomplete spinal cord injuries.

OBJECTIVE: Gait retraining should target the walking skills most needed for independence in the home and community. The main objective of this study was to document the walking tasks most commonly encountered in daily life by able-bodied adults. The study also compared participation in walking tasks between able-bodied adults and persons with incomplete spinal cord injuries. PARTICIPANTS: Convenience sample of 50 able-bodied adults and 16 ambulatory, community-dwelling persons with incomplete spinal cord injuries. METHODS: A walking survey was developed, and its content validity and concurrent validity confirmed. Participants used the survey to document the frequency with which walking tasks were encountered during a full waking day. RESULTS: Frequently encountered tasks included walking on smooth and rough surfaces, opening/closing doors and carrying objects. Tasks encountered more than once per day by the majority of able-bodied participants included negotiating obstacles, walking on uneven and sloped surfaces, in crowded environments, narrow spaces, and on steps and stairs. Participants with spinal cord injuries encountered fewer tasks, including many of those frequently encountered by able-bodied participants. CONCLUSION: The findings identify the important walking tasks for ambulation in the home and community. These tasks should be included in therapy programs aiming to retrain functional walking.