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Locomotor training after human spinal cord injury: a series of case studies.

date: 07/01/2000
author: Behrman AL, Harkema SJ.
publication: Phys Ther. 2000 Jul;80(7):688-700.
pubmed_ID: 10869131

Many individuals with spinal cord injury (SCI) do not regain their ability to walk, even though it is a primary goal of rehabilitation. Mammals with thoracic spinal cord transection can relearn to step with their hind limbs on a treadmill when trained with sensory input associated with stepping. If humans have similar neural mechanisms for locomotion, then providing comparable training may promote locomotor recovery after SCI. We used locomotor training designed to provide sensory information associated with locomotion to improve stepping and walking in adults after SCI. Four adults with SCIs, with a mean postinjury time of 6 months, received locomotor training. Based on the American Spinal Injury Association (ASIA) Impairment Scale and neurological classification standards, subject 1 had a T5 injury classified as ASIA A, subject 2 had a T5 injury classified as ASIA C, subject 3 had a C6 injury classified as ASIA D, and subject 4 had a T9 injury classified as ASIA D. All subjects improved their stepping on a treadmill. One subject achieved overground walking, and 2 subjects improved their overground walking. Locomotor training using the response of the human spinal cord to sensory information related to locomotion may improve the potential recovery of walking after SCI.

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Physiologic responses to electrically assisted and frame-supported standing in persons with paraplegia.

date: 12/01/2003
author: Jacobs PL, Johnson B, Mahoney ET.
publication: J Spinal Cord Med. 2003 Winter;26(4):384-9.
pubmed_ID: 14992341

BACKGROUND: Systems of functional electrical stimulation (FES) have been demonstrated to enable some persons with paraplegia to stand and ambulate limited distances. However, the energy costs and acute physiologic responses associated with FES standing activities have not been well investigated. OBJECTIVE: To compare the physiologic responses of persons with paraplegia to active FES-assisted standing (AS) and frame-supported passive standing (PS). METHODS: Fifteen persons with paraplegia (T6-T11) previously habituated to FES ambulation, completed physiologic testing of PS and AS. The AS assessments were performed using a commercial FES system (Parastep-1; Altimed, Fresno, Calif); the PS tests used a commercial standing frame (Easy Stand 5000; Altimed, Fresno, Calif). Participants also performed a peak arm-cranking exercise (ACE) test using a progressive graded protocol in 3-minute stages and 10-watt power output increments to exhaustion. During all assessments, metabolic activity and heart rate (HR) were measured via open-circuit spirometry and 12-lead electrocardiography, respectively. Absolute physiologic responses to PS and AS were averaged over 1-minute periods at 5-minute intervals (5, 10, 15, 20, 25, and 30 minutes) and adjusted relative to peak values displayed during ACE to determine percentage of peak (%pk) values. Absolute and relative responses were compared between test conditions (AS and PS) and across time using two-way analysis of variance. RESULTS: The AS produced significantly greater values of VO2 (43%pk) than did PS (20%pk). The mean HR responses to PS (100-102 beats per minute [bpm] throughout) were significantly lower than during AS, which ranged from 108 bpm at 5 minutes to 132 bpm at test termination. CONCLUSION: Standing with FES requires significantly more energy than does AS and may provide a cardiorespiratory stress sufficient to meet minimal requirements for exercise conditioning.

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Shaping appropriate locomotive motor output through interlimb neural pathway within spinal cord in humans.

date: 06/01/2008
author: Kawashima N, Nozaki D, Abe MO, Nakazawa K.
publication: J Neurophysiol. 2008 Jun;99(6):2946-55. Epub 2008 Apr 30.
pubmed_ID: 18450579

Direct evidence supporting the contribution of upper limb motion on the generation of locomotive motor output in humans is still limited. Here, we aimed to examine the effect of upper limb motion on locomotor-like muscle activities in the lower limb in persons with spinal cord injury (SCI). By imposing passive locomotion-like leg movements, all cervical incomplete (n = 7) and thoracic complete SCI subjects (n = 5) exhibited locomotor-like muscle activity in their paralyzed soleus muscles. Upper limb movements in thoracic complete SCI subjects did not affect the electromyographic (EMG) pattern of the muscle activities. This is quite natural since neural connections in the spinal cord between regions controlling upper and lower limbs were completely lost in these subjects. On the other hand, in cervical incomplete SCI subjects, in whom such neural connections were at least partially preserved, the locomotor-like muscle activity was significantly affected by passively imposed upper limb movements. Specifically, the upper limb movements generally increased the soleus EMG activity during the backward swing phase, which corresponds to the stance phase in normal gait. Although some subjects showed a reduction of the EMG magnitude when arm motion was imposed, this was still consistent with locomotor-like motor output because the reduction of the EMG occurred during the forward swing phase corresponding to the swing phase. The present results indicate that the neural signal induced by the upper limb movements contributes not merely to enhance but also to shape the lower limb locomotive motor output, possibly through interlimb neural pathways. Such neural interaction between upper and lower limb motions could be an underlying neural mechanism of human bipedal locomotion.

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Alternate leg movement amplifies locomotor-like muscle activity in spinal cord injured persons.

date: 02/01/2005
author: Kawashima N, Nozaki D, Abe MO, Akai M, Nakazawa K.
publication: J Neurophysiol. 2005 Feb;93(2):777-85. Epub 2004 Sep 22.
pubmed_ID: 15385590

It is now well recognized that muscle activity can be induced even in the paralyzed lower limb muscles of persons with spinal cord injury (SCI) by imposing locomotion-like movements on both of their legs. Although the significant role of the afferent input related to hip joint movement and body load has been emphasized considerably in previous studies, the contribution of the “alternate” leg movement pattern has not been fully investigated. This study was designed to investigate to what extent the alternate leg movement influenced this “locomotor-like” muscle activity. The knee-locked leg swing movement was imposed on 10 complete SCI subjects using a gait training apparatus. The following three different experimental conditions were adopted: 1) bilateral alternate leg movement, 2) unilateral leg movement, and 3) bilateral synchronous (in-phase) leg movement. In all experimental conditions, the passive leg movement induced EMG activity in the soleus and medial head of the gastrocnemius muscles in all SCI subjects and in the biceps femoris muscle in 8 of 10 SCI subjects. On the other hand, the EMG activity was not observed in the tibialis anterior and rectus femoris muscles. The EMG level of these activated muscles, as quantified by integrating the rectified EMG activity recorded from the right leg, was significantly larger for bilateral alternate leg movement than for unilateral and bilateral synchronous movements, although the right hip and ankle joint movements were identical in all experimental conditions. In addition, the difference in the pattern of the load applied to the leg among conditions was unable to explain the enhancement of EMG activity in the bilateral alternate leg movement condition. These results suggest that the sensory information generated by alternate leg movements plays a substantial role in amplifying the induced locomotor-like muscle activity in the lower limbs.

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Femoral loads during passive, active, and active-resistive stance after spinal cord injury: a mathematical model.

date: 03/19/2004
author: Frey Law LA, Shields RK.
publication: Clin Biomech (Bristol, Avon). 2004 Mar;19(3):313-21.
pubmed_ID: 15003348

OBJECTIVE: The purpose of this study was to estimate the loading environment for the distal femur during a novel standing exercise paradigm for people with spinal cord injury. DESIGN: A mathematical model based on experimentally derived parameters. BACKGROUND: Musculoskeletal deterioration is common after spinal cord injury, often resulting in osteoporotic bone and increased risk of lower extremity fracture. Potential mechanical treatments have yet to be shown to be efficacious; however, no previous attempts have been made to quantify the lower extremity loading during passive, active, and active-resistive stance. METHODS: A static, 2-D model was developed to estimate the external forces; the activated quadriceps forces; and the overall bone compression and shear forces in the distal femur during passive (total support of frame), active (quadriceps activated minimally), and active-resistive (quadriceps activated against a resistance) stance. RESULTS: Passive, active, and active-resistive stance resulted in maximal distal femur compression estimates of approximately 45%, approximately 75%, and approximately 240% of body weight, respectively. Quadriceps force estimates peaked at 190% of body weight with active-resistive stance. The distal femur shear force estimates never exceeded 24% of body weight with any form of stance. CONCLUSIONS: These results support our hypothesis that active-resistive stance induces the highest lower extremity loads of the three stance paradigms, while keeping shear to a minimum. RELEVANCE: This model allows clinicians to better understand the lower extremity forces resulting from passive, active, and active-resistive stance in individuals with spinal cord injury.

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Moving the arms to activate the legs.

date: 07/01/2006
author: Ferris DP, Huang HJ, Kao PC.
publication: Exerc Sport Sci Rev. 2006 Jul;34(3):113-20.
pubmed_ID: 16829738

Recent studies on neurologically intact individuals and individuals with spinal cord injury indicate that rhythmic upper limb muscle activation has an excitatory effect on lower limb muscle activation during locomotor-like tasks. This finding suggests that gait rehabilitation therapy after neurological injury should incorporate simultaneous upper limb and lower limb rhythmic exercise to take advantage of neural coupling.

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Reduction of muscular hypertonus by long-term muscle stretch.

date: 01/01/1981
author: Odeen I.
publication: Scand J Rehabilitation Medicine. 1981;13(2-3):93-9.
pubmed_ID: 7345572

In 10 patients with spastic paraparesis, the effect of long-term stretch on hip adductor muscle tone was studied. Stretch was accomplished by using a mechanical leg-abductor device giving individually adjusted adductor muscle stretch in single or repeated 30 min periods. The effect on muscle tone was estimated from surface EMG activity and by range of voluntary and passive hip abduction. The passive movements were obtained by an individually adjusted constant pulling force. After a single session of stretch, range of voluntary hip abduction increased 3 to 16 degrees (average 85%). Range of passive movement increased 1 to 9 degrees (average 23%). After repeated stretch periods in a home program (4 patients), range of voluntary hip abduction increased 5 to 22 degrees (average 255%). Range of passive movements increased 6 to 12 degrees (average 48%). In all patients studied the co-activation of the antagonists in voluntary hip abduction was reduced after a stretch session.

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Evaluation of the effects of muscle stretch and weight load in patients with spastic paraplegia.

date: 01/01/1981
author: Odeen I, Knutsson E.
publication: Scand J Rehabilitation Medicine. 1981;13(4):117-21.
pubmed_ID: 7347432
Clinical observations on patients with spastic paraplegia have indicated that a training regime including weight load on the lower limbs may reduce the muscular hypertonus. Due to the spontaneous fluctuations and great variability in muscle tone it is difficult to judge from clinical findings how the effects may be related to muscle stretch and weight load. Therefore, quantitative determination of the effects on muscle tone by stretch and loading was made in 9 paraplegic patients. Muscle tone was measured before and after 30 min of stretch or weight load in 8 sessions on 4 consecutive days. Stretch was obtained by bracing the foot in maximal dorsal flexion with patient in supine position. For weight load on the lower limbs, the patient stood on a tilt-table at an angle of 85 degrees with feet in 15 degrees dorsal or plantar flexion. Resistance to passive movements was determined during a series of sinusoidal ankle joint movements at three different speeds. After weight load in standing with the feet in dorsal or plantar flexion, the average reduction was 32 and 26%, respectively. After stretch in supine, the average reduction was 17%. Thus, the three procedures tested all resulted in reduction of muscle tone. The largest reductions were obtained by weight load with stretch imposed upon the calf muscles.

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Case study to evaluate a standing table for managing constipation.

date: 06/01/2001
author: Hoenig H, Murphy T, Galbraith J, Zolkewitz M.
publication: SCI Nurse 2001 Summer;18(2):74-7.
pubmed_ID: 12035465

Standing devices have been advocated as a potentially beneficial treatment for constipation in persons with spinal cord injury (SCI); however, definitive data are lacking. A case of a patient who requested a standing table to treat chronic constipation is presented as an illustration of a method to address this problem on an individual patient level. The patient was a 62-year-old male with T12-L1 ASIA B paraplegia who was injured in 1965. The patient was on chronic narcotics for severe, nonoperable shoulder pain. His bowel program had been inadequate to prevent impactions. A systematic approach was used to measure the effects of a standing table on frequency of bowel movements (BMs) and on length of bowel care episodes. There was a significant (p < 0.05) increase in frequency of BMs and a decrease in bowel care time with the use of the standing table 5 times/week versus baseline. For this patient, the use of the standing table was a clinically useful addition to his bowel care program.

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Use of prolonged standing for individuals with spinal cord injuries.

date: 08/01/2001
author: Eng JJ, Levins SM, Townson AF, Mah-Jones D, Bremner J, Huston G.
publication: Phys Ther. 2001 Aug;81(8):1392-9.
pubmed_ID: 11509069

BACKGROUND AND PURPOSE: Prolonged standing in people with spinal cord injuries (SCIs) has the potential to affect a number of health-related areas such as reflex activity, joint range of motion, or well-being. The purpose of this study was to document the patterns of use of prolonged standing and their perceived effects in subjects with SCIs. SUBJECTS: The subjects were 152 adults with SCIs (103 male, 49 female; mean age=34 years, SD=8, range=18-55) who returned mailed survey questionnaires. METHODS: A 17-item self-report survey questionnaire was sent to the 463 members of a provincial spinal cord support organization. RESULTS: Survey responses for 26 of the 152 respondents were eliminated from the analysis because they had minimal effects from their injuries and did not need prolonged standing as an extra activity. Of the 126 remaining respondents, 38 respondents (30%) reported that they engaged in prolonged standing for an average of 40 minutes per session, 3 to 4 times a week, as a method to improve or maintain their health. The perceived benefits included improvements in several health-related areas such as well-being, circulation, skin integrity, reflex activity, bowel and bladder function, digestion, sleep, pain, and fatigue. The most common reason that prevented the respondents from standing was the cost of equipment to enable standing. DISCUSSION AND CONCLUSION: Considering the many reported benefits of standing, this activity may be useful for people with SCI. This study identified a number of body systems and functions that may need to be investigated if clinical trials of prolonged standing in people with SCI are undertaken.