Author: zingleader

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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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Can Using Standers Increase Bone Density In Non-Ambulatory Children?

date: 10/01/2006
author: Katz, Danielle,MD, Snyder, Bryan MD, PhD, Dodek, Anton MD, Holm, Ingrid MD Miller, Claire BS
publication: Abstract as published in the American Academy of Cerebral Palsy and Developmental Medicine (AACPDM) 2006 Conference Proceedings

Purpose: Pathologic fractures are a significant source of morbidity for non-ambulatory children with neuromuscular dysfunction. We hypothesize that increasing weight-bearing in non-ambulatory children will increase bone material density (BMD) and decrease fracture risk. The aim of this pilot study was to demonstrate that non-ambulatory children participating in a standing program for at least two hours a day will experience an increase in BMD in the weight bearing bones. We also evaluate the reliability of measuring BMD at the calcaneous (weight bearing bones) and distal forearm (non-weight bearing bone) using peripheral DXA in delayed, non-ambulatory children.

Methods: After receiving IRB approval, 12 non-ambulatory, quadriplegic children (ages 12-21) consented to participate in a 2 hour/day, 5 day/week standing program. A history, orthopaedic exam, determination of bone age, laboratory tests for metabolic bone disease and BMD at the calcaneal tuberosity and distal forearm metaphyses were obtained. Compliance with the prescribed standing program was monitored for 6 months. BMD was measured using peripheral DXA at baseline and every 3 months. Using Jan. 2003 BMD data as a baseline, the ratio of change in BMD at the calcaneous and distal forearm was evaluated as a function of percent compliance with standing program.

Results: Intrarater reliability for BMD measured by peripheral DXA was good: Pearson correlation for the calcaneous = 0.90 (p=0.01) and for the forearm = 0.96 (p=0.01). Paired t test between two sets of data measured at each site on the same day were not different for calcaneous (t=0.92, df=15, p=0.37) or forearm (t=0.05, df=15, p=0.96). Compliance with the standing program was inconsistent. No patients were 100% compliant. Patients tended to stand longer at the initiation of the study Jan.-April (Jan vs Apr, p = 0.018; Jan vs Jul, p = 0.89; Apr vs Jul, p = 0.063). Compliance (%) was positively correlated (r = -0.62) with increased calcaneous BMD measured in April. This is in contrast to forearm BMD measured at the same time; which was negatively correlated (r = -0.44) with standing compliance. This support the notion that standing preferentially increases bone mass in the weight-bearing bones. However the BMD at the calcaneous measured in July was decreased, perhaps reflecting the decreased compliance the with standing program over the succeeding interval April-July.

Conclusion: It is feasible to have non-ambulatory children participate in a rigorous standing program. The weight bearing ?dose? affects BMD at the calcaneous but the benefit appears to be transient if the intensive standing program is not sustained.

Significance: The intensive use of standers (10 hours/wk) may have a beneficial effect on BMD of weight bearing bones in non-ambulatory children.

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Neural coupling between upper and lower limbs during recumbent stepping.

date: 10/01/2004
author: Huang HJ, Ferris DP.
publication: J Appl Physiol. 2004 Oct;97(4):1299-308. Epub 2004 Jun 4.
pubmed_ID: 15180979
Outside_URL: http://www.ncbi.nlm.nih.gov/pubmed/15180979
During gait rehabilitation, therapists or robotic devices often supply physical assistance to a patient’s lower limbs to aid stepping. The expensive equipment and intensive manual labor required for these therapies limit their availability to patients. One alternative solution is to design devices where patients could use their upper limbs to provide physical assistance to their lower limbs (i.e., self-assistance). To explore potential neural effects of coupling upper and lower limbs, we investigated neuromuscular recruitment during self-driven and externally driven lower limb motion. Healthy subjects exercised on a recumbent stepper using different combinations of upper and lower limb exertions. The recumbent stepper mechanically coupled the upper and lower limbs, allowing users to drive the stepping motion with upper and/or lower limbs. We instructed subjects to step with 1) active upper and lower limbs at an easy resistance level (active arms and legs); 2) active upper limbs and relaxed lower limbs at easy, medium, and hard resistance levels (self-driven); and 3) relaxed upper and lower limbs while another person drove the stepping motion (externally driven). We recorded surface electromyography (EMG) from six lower limb muscles. Self-driven EMG amplitudes were always higher than externally driven EMG amplitudes (P < 0.05). As resistance and upper limb exertion increased, self-driven EMG amplitudes also increased. EMG bursts during self-driven and active arms and legs stepping occurred at similar times. These results indicate that active upper limb movement increases neuromuscular activation of the lower limbs during cyclic stepping motions. Neurologically impaired humans that actively engage their upper limbs during gait rehabilitation may increase neuromuscular activation and enhance activity-dependent plasticity.

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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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Standing and its importance in spinal cord injury management.

date: 01/01/1987
author: Axelson P, Gurski D, Lasko-Harvill A.
publication: RESNA 10th Annual Conference San Jose, California 1987
pubmed_ID:
Outside_URL:
A broad spectrum of physiological problems are associated with lack of gravitational stress in the individual with spinal cord injury. Prolonged immobilization results in systemic de-adaptations which include cardiovascular changes, the alteration of calcium homeostasis which leads to bone de-mineralization and risk of urinary calculi.

Weight bearing in the standing posture has been shown to ameliorate many of these problems and offers physiological advantages for the individual with spinal card injury.

There are also significant psychological and social benefits to standing, including improved self-image, and eye-to-eye interpersonal contact. Increased vocational, recreational and daily living independence are additional benefits of standing.

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Follow-up assessment of standing mobility device users.

date: 10/01/1998
author: Dunn RB, Walter JS, Lucero Y, Weaver F, Langbein E, Fehr L, Johnson P, Riedy L.
publication: Assistive Technology. 1998;10(2):84-93.
pubmed_ID: 10339284

The use of standing devices by spinal cord-injured subjects was investigated through a national survey of a sample of individuals who returned their manufacturer’s warranty card to two companies. We obtained a 32% response rate (99/310). The majority of respondents were male (87%) with a median age between 41 and 50 years. Seventy-seven percent were paraplegic and 21% were quadriplegic. Forty percent had between 1 and 5 years experience with their device, and 84% of those responding were currently using their standing device. Forty-one percent used their standing device one to six times a week; two-thirds stood between 30 minutes and 1 hour for each use. Less than 10% of subjects experienced any side effects, such as nausea or headaches, from standing. Twenty-one percent of subjects reported being able to empty their bladder more completely. There was also a favorable response by some individuals on the effects of the standing devices on bowel regularity, reduction of urinary tract infections, leg spasticity, and number of bedsores. Finally, 79% of subjects highly recommended use of standing devices to other people with spinal cord injury. The positive responses of individuals using standing devices is a strong recommendation for the assistive technology community to make these devices more available to individuals with spinal cord injury.

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Indications for a home standing program for individuals with spinal cord injury.

date: 09/01/1999
author: Walter JS, Sola PG, Sacks J, Lucero Y, Langbein E, Weaver F.
publication: J Spinal Cord Med. 1999 Fall;22(3):152-8.
pubmed_ID: 10685379

Additional analyses were conducted on a recently published survey of persons with spinal cord injury (SCI) who used standing mobility devices. Frequency and duration of standing were examined in relation to outcomes using chi square analyses. Respondents (n = 99) who stood 30 minutes or more per day had significantly improved quality of life, fewer bed sores, fewer bladder infections, improved bowel regularity, and improved ability to straighten their legs compared with those who stood less time. Compliance with regular home standing (at least once per week) was high (74%). The data also suggest that individuals with SCI could benefit from standing even if they were to begin several years after injury. The observation of patient benefits and high compliance rates suggest that mobile standing devices should be more strongly considered as a major intervention for relief from secondary medical complications and improvement in overall quality of life of individuals with SCI.

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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.

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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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Extent and direction of joint motion limitation after prolonged immobility: an experimental study in the rat.

date: 12/01/1999
author: Trudel G, Uhthoff HK, Brown M.
publication: Arch Phys Med Rehabilitation. 1999 Dec;80(12):1542-7.
pubmed_ID: 10597804

OBJECTIVES: To test the hypotheses that contractures progress at different rates in relation to the time after immobilization, that immobilization in flexion leads to loss of extension range of motion, and that joints of sham-operated animals are better controls than the contralateral joint of experimental animals. STUDY DESIGN: Experimental, controlled study in which 40 adult rats had one knee joint immobilized at 135 degrees of flexion for up to 32 weeks and 20 animals underwent a sham procedure. At intervals of 2, 4, 8, 16, and 32 weeks, 8 experimental and 4 sham-operated animals were killed and their knee motion measured in flexion and extension. RESULTS: In the experimental group, the range of motion decreased in the first 16 weeks of immobility at an average rate of 3.8 degrees per week (p<.0001) to reach 61.1 degrees of restriction. A plateau was then observed from which the contracture did not progress further. The loss in range of motion occurred in extension, not in flexion. CONCLUSION: This study defined an acute stage of contractures starting at the onset of immobility and lasting 16 weeks, during which the range of motion was progressively restricted, and a chronic stage during which no additional limitation was detected. The loss in motion was attributed to posterior knee structures not under tension during immobilization in flexion. Contrary to the hypothesis, the contralateral joint was validated as a control choice for range-of-motion experiments.