Locomotor Training: As a Treatment of Spinal Cord Injury and in the Progression of Neurologic Rehabilitation

ArticleinArchives of physical medicine and rehabilitation 93(9):1588-97 · September 2012with40 Reads
DOI: 10.1016/j.apmr.2012.04.032 · Source: PubMed
Abstract
Scientists, clinicians, administrators, individuals with spinal cord injury (SCI), and caregivers seek a common goal: to improve the outlook and general expectations of the adults and children living with neurologic injury. Important strides have already been accomplished; in fact, some have labeled the changes in neurologic rehabilitation a "paradigm shift." Not only do we recognize the potential of the damaged nervous system, but we also see that "recovery" can and should be valued and defined broadly. Quality-of-life measures and the individual's sense of accomplishment and well-being are now considered important factors. The ongoing challenge from research to clinical translation is the fine line between scientific uncertainty (ie, the tenet that nothing is ever proven) and the necessary burden of proof required by the clinical community. We review the current state of a specific SCI rehabilitation intervention (locomotor training), which has been shown to be efficacious although thoroughly debated, and summarize the findings from a multicenter collaboration, the Christopher and Dana Reeve Foundation's NeuroRecovery Network.
    • "Physical therapists are directly engaged in gait training. The rationale for specific gait training following TSCI is to provide the injured nervous system with task-specific sensory input to stimulate the remaining spinal cord networks even when supraspinal input (above the lesion) is compromised [16, 17]. Gait training typically includes some combination of Body Weight Supported Treadmill Training (BWSTT) or robotic-assisted gait training (Fig. 4). "
    [Show abstract] [Hide abstract] ABSTRACT: The impact of traumatic spinal cord injury (TSCI) on function and quality of life (QOL) is substantial, and the incidence of people living with complete TSCI is increasing over time as our emergent and critical care capabilities improve. Much of TSCI treatment and prognosis is based on initial assessment of the neurological level of injury (NLI), which is followed throughout the continuum of rehabilitation. Medical treatment and surveillance of the patient’s vulnerable organs begins in the intensive care unit and continues into acute rehabilitation, with pulmonary, cardiovascular, integumentary, genitourinary, and gastrointestinal as priority systems. The multidisciplinary rehabilitation team collaborates to help patients achieve specific functional goals. Determining outcome and prognosis for ambulation in TSCI is based upon completeness of injury and NLI, as well as other variables. Traditional TSCI rehabilitation techniques when done in concert with new methods, i.e., augmentative motor devices and novel neuromedical treatments such as stem cell work, continues to expand the possibilities for QOL for this challenging patient population.
    Full-text · Article · Sep 2015
    • "In all individuals, EMG activity during attempts to move the lower limbs and during reinforcement maneuvers was similar to the EMG recorded during relaxation. Also, prior to implantation, after 80 sessions of Locomotor Training (combined stand and step training, with stepping comprising the majority of minutes [32]) there were no significant changes in the EMG activity during assisted stepping in any of the four research participants. In summary, without epidural stimulation, no functional motor connectivity between the supraspinal and spinal centers below the level of injury was detected in any of the four research participants. "
    [Show abstract] [Hide abstract] ABSTRACT: Sensory and motor complete spinal cord injury (SCI) has been considered functionally complete resulting in permanent paralysis with no recovery of voluntary movement, standing or walking. Previous findings demonstrated that lumbosacral spinal cord epidural stimulation can activate the spinal neural networks in one individual with motor complete, but sensory incomplete SCI, who achieved full body weight-bearing standing with independent knee extension, minimal self-assistance for balance and minimal external assistance for facilitating hip extension. In this study, we showed that two clinically sensory and motor complete participants were able to stand over-ground bearing full body-weight without any external assistance, using their hands to assist balance. The two clinically motor complete, but sensory incomplete participants also used minimal external assistance for hip extension. Standing with the least amount of assistance was achieved with individual-specific stimulation parameters, which promoted overall continuous EMG patterns in the lower limbs' muscles. Stimulation parameters optimized for one individual resulted in poor standing and additional need of external assistance for hip and knee extension in the other participants. During sitting, little or negligible EMG activity of lower limb muscles was induced by epidural stimulation, showing that the weight-bearing related sensory information was needed to generate sufficient EMG patterns to effectively support full weight-bearing standing. In general, electrode configurations with cathodes selected in the caudal region of the array at relatively higher frequencies (25-60 Hz) resulted in the more effective EMG patterns for standing. These results show that human spinal circuitry can generate motor patterns effective for standing in the absence of functional supraspinal connections; however the appropriate selection of stimulation parameters is critical.
    Full-text · Article · Jul 2015
    • "Rehabilitation in the SCI population would seem to greatly benefit from research conducted in the form of randomized controlled trials to determine the type of training that could lead to the highest degree of recovery after damage to the spinal cord (Mehrholz et al., 2012). The clinician must also consider the nature and etiology of the injury, and continued monitoring of the patient is required in order to implement the best strategy for rehabilitation (Harkema et al., 2012). Treatment of SCI also relies on the use of molecular and cellular approaches, which involve mainly delivering therapeutic agents that could combat secondary injuries following acute trauma. "
    [Show abstract] [Hide abstract] ABSTRACT: Spinal cord injury affects more than 2.5 million people worldwide and can lead to paraplegia and quadriplegia. Anatomical discontinuity in the spinal cord results in disruption of the impulse conduction that causes temporary or permanent changes in the cord's normal functions. Although axonal regeneration is limited, damage to the spinal cord is often accompanied by spontaneous plasticity and axon regeneration that help improve sensory and motor skills. The recovery process depends mainly on synaptic plasticity in the preexisting circuits and on the formation of new pathways through collateral sprouting into neighboring denervated territories. However, spontaneous recovery after spinal cord injury can go on for several years, and the degree of recovery is very limited. Therefore, the development of new approaches that could accelerate the gain of motor function is of high priority to patients with damaged spinal cord. Although there are no fully restorative treatments for spinal injury, various rehabilitative approaches have been tested in animal models and have reached clinical trials. In this paper, a closer look will be given at the potential therapies that could facilitate axonal regeneration and improve locomotor recovery after injury to the spinal cord. This article highlights the application of several interventions including locomotor training, molecular and cellular treatments, and spinal cord stimulation in the field of rehabilitation research. Studies investigating therapeutic approaches in both animal models and individuals with injured spinal cords will be presented.
    Full-text · Article · Apr 2015
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