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Pediatric-Onset Rehabilitation

Lower Extremity

Cervical, thoracic, and/or lumbo-sacral SCI, regardless of age at injury, often results in trunk and lower extremity paralysis and/or weakness. The resulting functional impacts include a spectrum of limitations of trunk control and balance, standing, transferring and walking. The approach to these impairments and their functional impact has primarily involved the introduction of braces and assistive devices to compensate for paralysis/weakness, achieving functional alternatives for the tasks of upright trunk posture, standing, and walking. This treatment approach is consistent with the assumption that the impairments and functional impact of SCI are permanent. Recent evidence, however, points towards some potential for partial functional recovery below the level of the spinal cord lesion. From this vantage point, physical rehabilitation extends to recovery-based strategies tapping into the intrinsic biology of the neuromuscular system to partially restore its capacity for motor control.

The ‘Lower Extremity and Trunk’ evidence for Spinal Cord Injury Research Evidence is presented relative to three therapeutic goals: 1) Trunk control, 2) Standing, and 3) Walking. The literature is further presented within the context of two rehabilitation approaches: 1) compensation (i.e., development of new adaptive behaviours, use of devices/equipment) and 2) restoration (or recovery). Both perspectives have guided the development and use of outcome measures and therapeutic interventions to achieve the goal of improved function. Accordingly, the tables of evidence for lower extremity and trunk outcome measures and interventions for the goals of standing, walking, and trunk upright posture are organized to differentiate the ‘solutions’ as either 1) compensation strategies to achieve functional alternatives or 2) restorative interventions to achieve neuromuscular capacity supporting typical functional behaviors to stand, walk, and maintain an upright trunk posture. Defining the parameters of performance for each goal is critical to compare the intervention strategies.

Main Outcomes Author, Year

Country

Study Design

Sample Size

Study Characteristics Results
 

TRUNK

Cobb Angle Mulcahey et al. (2013)

USA

Observational

N=217

Population: 13.2±4.9yr.; Gender: males=127, females=90; Level of injury: Not reported; Level of severity: AIS A=105, B=45, C=30, D=21, Missing=16; Time since injury=4.2±3.7 yr.

Intervention: None – observational, participants evaluated using the testing guidelines of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) to determine predictors of worse curve and spinal fusion in neurological scoliosis.

*All participants had neuromuscular scoliosis and 24 of the 217 participants underwent spinal fusion due to their progressive neuromuscular scoliosis.

Outcome Measures: ISNCSCI classification, Cobb angle, motor score.

1.         Age of injury (p<0.0001) and AIS classification (p<0.0095) were the only significant predictors of worse curve when grouped as an entire sample

2.        Risk of spinal fusion increased by 11% for every yr. decrease in age at injury

3.        Sex, motor score, and neurological level were not predictors of worse curve of spinal fusion

4.        Subjects injured before the age of 12 were 3.7 times more likely to require a spinal fusion than those injured after age 12 (95% CI, 0.31-44.64)

ISNCSCI Mulcahey et al. (2011)

USA

Repeated Measures

N=236

Population: Mean age=14.5±4.2yr.; Gender: males=109, females=72; Level of injury: Not reported; Level of severity: Complete=97, Incomplete=84; Time since injury=5.0±4.4yr.

Intervention: None – observational, participants given the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) to test interrater reliability. Subjects underwent 4 examinations by 2 raters: sensory tests (in prick (PP) and light touch (LT)), a motor test (upper and lower extremity motor test (UEM and LEM respectively), and a test of anal sensation (AS) and anal contraction (AC).

Outcome Measures: 2-way general linear model analysis of variance, interclass correlation coefficients (ICCs) and 95% confidence intervals.

1.         No child under 6 was able to complete the INSCSCI in its entirety.

2.        3 of the 18 participants in the 0-5-yr. age group the PP(n=2) and motor examinations (n=3).

3.        9 of the 42 participants in the 6-11-yr. age group were unable to complete the entire examination, thus most children 6 yr and older can comprehend the directions for, and participate in the INSCSCI examinations.

4.        Interrater reliability for each variable (PP, LT, TM, UEM, LEM, AS and AC) in all 3 age groups was high (ICC: 0.93-0.99) except for AC in the 12-15-yr. age group which showed moderate reliability (ICC=0.88).

5.        ICC values for S4-5 dermatome PP and LT were all higher than 0.75, indicating moderate interrater reliability across each age group when examined as a function of age.

6.        When analyzed as a function of type of injury (tetraplegia/paraplegia), interrater reliability at each age group was moderate to high (ICC: 0.89-0.99).

7.        Interrater reliability for classification of severity and type of injury was high (ICC≥0.92 and ICC≥0.92 respectively).

 

STAND

PEDI

SCIM

(Altizer et al., 2017)

USA

Case Report

N=1

Population: 23 mo, female, T10 AIS A SCI.

Intervention: Overground supported stepping intervention using a dynamic gait trainer.

Outcome Measures: Paediatric Evaluation of Disability Inventory (PEDI), Spinal Cord Independence Measure (SCIM), Gross Motor Function Measure (GMFM-66), Developmental Profile (DP-3), Support Walker Assessment Ambulation Performance Scale (SWAPS), 6-Minute Walk Test (6MWT).

1.         PEDI score improved by 6 points (60%) from age 36-54mo. and by 18 points (75%) from age 54-72mo.

2.        SCIM score improved over the 3 yr. of intervention (36mo. – 19; 54mo. – 31; 72mo. – 43) but remained well below the median adult score for those with injury at T10 of 63

3.        GDFM-66 score improved minimally over 3 yr of intervention

4.        DP-3 score demonstrated a continued motor deficit in comparison to age, but also shows progress in physical skills

5.        6MWT change from 54-72mo. was double what was expected from documentation in literature for her age and level of SCI.

PEDI (Choksi et al., 2010)

Observational

USA

N=32

Population: Mean age 10.6±6.2 (1-19) yr; Injury Etiology: Traumatic=24, Non-traumatic=8; Level of Injury: Cervical=18, Thoracolumbar=14.

Intervention: Inpatient rehabilitation physiotherapy and occupational therapy (3 hr/day).

Outcome Measures: Pediatric Evaluation of Disability Inventory (mobility and self-care) via Functional Skills and Caregiver Assistance scales).

1.         PEDI mobility (functional skills): ↑24.0±14.7

2.        PEDI mobility (caregiver assistance): ↑26.1+21.5

3.        All children improved or showed no change on walking-related PEDI items:

·          Indoor locomotion methods: 8/21 ↑

·          Indoor locomotion distance/speed: 11/21 ↑

·          Indoor locomotion pulls/carries: 13/21 ↑

·          Outdoor locomotion methods: 1/21 ↑

·          Outdoor locomotion distance/speed: 12/21↑

·          Outdoor locomotion surfaces: 12/21↑

Time using FES (Moynahan, Mullin, et al., 1996)

USA

Observational

N=5

Population: Age: 18.4±1.1 yr; Gender: males=2, females=3; Level of Injury: T4 (n=2), T5 (n=1), T8 (n=1), T11 (n=1); Severity of Injury: AIS A; Orthotics Use: Molded Shoe Insert=4, Ankle Foot Orthosis [AFO]=1.

Intervention: Hybrid system of implanted Functional Electrical Stimulation [FES] (pulse duration 0-150µsec, frequency 0-50 Hz) with wearable AFO. After implantation, participants completed training for standing and mobility.

Outcome Measures: Patterns of home and community FES use; barriers and facilitators of use. Assessed every 1-4 wk for 1 yr.

1.         The frequency of donning the system ranged 23%-34% of the days surveyed; this is equivalent to donning the system once every 3 to 4 days.

2.        The two most common standing activities were “one-handed activities (e.g., painting furniture, changing a car’s air filter, pushing a sibling on a swing-set) or reaching” and “standing for exercise or to stretch,” accounting for 62% of all reported standing activities across subjects.

3.        Maneuvering” was typically performed in areas of the house that were easily accessed by wheelchair.

4.        The FES system was used to perform swing-to gait with their walkers around the house, sometimes transferring to other seats.

5.        “Standing with others” included showing friends or family standing ability, to take pictures or for hugging.

6.        “Transfers” (e.g., for weighing or to transfer into a car) were not widely performed.

7.        “Motivators” for FES use included: being able to do things that would be difficult/impossible otherwise, perceiving a healthful benefit from exercise/standing, having a sense of well-being, and feeling an obligation to stand as a member of the research study.

8.        “Barriers” included: not having time to stand or exercise, having difficulty seeing opportunities and reluctant to wear it all day.

Time to complete tasks (Betz et al., 2002)

USA

Case Report

N=1

Population: 13 yr, male, T8 SCI.

Intervention: Lower extremity implanted Functional Electrical Stimulation (FES) with a Knee Ankle Foot Orthoses (KAFO).

Outcome Measures: Completion of eight upright mobility activities, scored based on completion time and level of independence: donning, stand and reach, high transfer, bathroom, floor to stand, 6-meter walk test (6MWT), stair ascent, stair descent.

1.         Across all time periods, the subject required less time to don the FES system (P<0.0001) and to complete the high reach (P<0.0001), high transfer (P<0.0001), and 6MWT (P=.006) compared with KAFO

2.        More time was needed to complete the floor-to-stand activity for FES compared to KAFO (P=0.0001)

3.        No time differences were seen between FES and KAFO for the inaccessible bathroom transfer (P=0.507) and ascending (P=0.753) and descending stairs (P=0.164)

4.        Subject was able to more quickly complete the sit-to-stand transition (P<0.0001), reach for a videotape on a high shelf (P<0.0001), and return to sitting in the wheelchair (P<0.0001) when using FES

5.        Subject preferred FES to KAFO for all activities but floor-to-stand at 2-yr. follow-up

FIM (Bonaroti et al., 1999b)

USA

Pre-Post

N=5

Population: Age: 9 yr.(n=2), 10 (n=1), 18 yr.(n=2); Gender: males=4, females=1; Etiology: Traumatic SCI=4, Non-Traumatic SCI=1; Level of Injury: cervical=2, thoracic=3; Severity of Injury: Paraplegia=5. Bracing for Standing & Therapy: Knee Ankle Foot Orthoses [KAFO]=5.

Intervention: Hybrid system of implanted Functional Electrical Stimulation [FES] (pulse duration 0-150µsec, frequency 0-50 Hz) with wearable Ankle Foot Orthoses (AFO). After implantation, participants completed FES strengthening followed by sit/stand exercise, and then upright mobility training for 4 weeks.

Outcome Measures: Completion of eight upright mobility activities, scored based on completion time and level of independence with FES versus Long Leg Braces (LLB): donning, stand and reach, high transfer, floor to stand, 6-meter walk test (6MWT), toilet transfer.

1.         When comparing the upright mobility activities between using FES versus LLB, subjects required equal (70%) or less (24%) assistance when using FES compared with using LLB

2.        One subject had greater independence using LLB for the floor to stand transfer

3.        One subject had greater independence using LLB for the 6MWT

4.        For each activity in which FES provided greater independence, subjects improved from requiring contact assistance (3 or 4) while using LLB to not needing contact assistance (5 or 6) while using FES

5.        There were two subjects who required minimal contact assist (4) with LLB but were independent with FES (6), both for the stand and reach activity, and six instances in which minimal (4) or moderate (3) contact assistance was required with LLB and no contact assistance (5) was required using FES

6.        Two activities, stand and reach and high transfer, were performed significantly faster with FES

7.        When subjects were asked which mode of standing, they preferred:

·          FES 62% of the time

·          LLB 27% of the time

·          No preference 11% of the time

FIM,

FST

(Bonaroti et al., 1999a)

USA
Case Report

N=1

Population: 11 yr, T10 AIS A SCI

Intervention: Functional electrical stimulation, Knee Ankle Foot Orthoses

Outcome Measures: Functional Independence Measure (FIM) and time to completion during upright mobility activities: donning, high transfer, toilet transfer, floor-to-standing transfer, ascend/descend stairs.

1.         FIM measurements of bathroom transfer and descending stairs completed significantly faster with KAFO (p<0.001 and p=0.04 respectively)

2.        For the remaining activities there was a trend towards faster completion times with FES, but this was not statistically significant (donning: p=0.28; high transfer: p=0.36; floor transfer: p=0.67; ascending stairs: p=0.32)

3.        While performing the 10 subset activities of the FST, the subject displayed no significant differences in completion times between the 2 modes

4.        Subject was significantly more stable in the static position using KAFO (p=0.03) whereas in dynamic testing subject was slightly more stable using FES, but was not statistically significant (p=0.7)

5.        Ambulation velocity was significantly faster using FES during the 100 feet ambulation (p<0.001) and maximum ambulation (p<0.001) test but not during energy expenditure testing (p=0.13)

 

GAIT

Gait Speed (Behrman et al., 2008)

USA

Case Report

N=1

Population: 4.5 yr, male, C8 AIS C traumatic SCI, 16 mo post-injury.

Intervention: Body weight support, overground walking.

Outcome Measures: American Spinal Injury Association Impairment Scale (AIS), Lower extremity motor score (LEMS), gait speed, walking independence, walking index for spinal cord injury II (WISCI-II), number of steps.

1.         AIS score remained the same after session 74

2.        LEMS score remained at 4/50 at session 74

3.        From session 51 to 76 gait speed increased from 0.19m/s to 0.29m/s

4.        From session 51 to 76 fastest walking speed increased from 0.3m/s to 0.48m/s

5.        WISCI score increased from 0/20 to 13/20

6.        At session 33 the child showed multiple non-cued steps

7.        From session 49 to 74 the child increased from 926 steps per day to 2488 steps per day

Gait Speed (Betz et al., 2002)

USA

Case Report

N=1

Population: 13 yr, male, T8 SCI.

Intervention: Lower extremity implanted Functional Electrical Stimulation (FES) with a Knee Ankle Foot Orthoses (KAFO).

Outcome Measures: Completion of eight upright mobility activities, scored based on completion time and level of independence: donning, stand and reach, high transfer, bathroom, floor to stand, 6-meter walk test (6MWT), stair ascent, stair descent.

1.         Across all time periods, the subject required less time to don the FES system (P<0.0001) and to complete the high reach (P<0.0001), high transfer (P<0.0001), and 6MWT (P=.006) compared with KAFO

2.        More time was needed to complete the floor-to-stand activity for FES compared to KAFO (P=0.0001)

3.        No time differences were seen between FES and KAFO for the inaccessible bathroom transfer (P=0.507) and ascending (P=0.753) and descending stairs (P=0.164)

4.        Subject was able to more quickly complete the sit-to-stand transition (P<0.0001), reach for a videotape on a high shelf (P<0.0001), and return to sitting in the wheelchair (P<0.0001) when using FES

5.        Subject preferred FES to KAFO for all activities but floor-to-stand at 2-yr. follow-up

Gait Speed (Johnston et al., 2005)

USA

Post Test

N=3

Population: Age: 17-21; Gender: males=3; Level and Severity of Injury: Motor complete T3-T8; Time since injury: 1.0-1.5 yr;

Intervention: Functional electrical stimulation (FES) consisting of 22-channel implant stimulator, extension leads and epineural electrodes. Leads emanating from the stimulator include two tresses of nine leads each for stimulation of lower extremity muscles and one tress of four leads for stimulation for bladder and bowel function (parameters: 0.2–8 mA amplitude, 25–600 ms pulse

duration, 2–500 Hz pulse frequency per channel). After implantation and immobilization participants completed exercise phase (FES strengthening) followed by lower extremity conditioning, standing and upright mobility training (13 wk).

Outcome Measures: Completion of eight upright mobility activities, scored based on completion time and level of independence: donning, stand and reach, high transfer, bathroom, floor to stand, 6-minute walk test (6MWT), stair ascent, stair descent.

1.         Three of the 52 electrodes placed for lower extremity stimulation experienced changes in the responses of the muscles.

2.        Two subjects used a walker with wheels to perform the mobility activities and one subject used forearm crutches.

3.        None of the subjects required physical assistance to complete the activities but two required supervision.

4.        One individual could not ascend/descend stairs as it was felt to be unsafe for him; several activities could not be performed by another subject secondary to complaints of shoulder pain related to poor scapular muscle control.

5.        All subjects reported preferring a swing through pattern for walking as they felt it was faster; two subjects could ambulate up to 20 feet and the third subject up to 75 feet.

6.        Just one subject demonstrated positive neuromodulation effects of the bladder; stimulation suppressed reflex bladder contractions acutely thereby reducing vesical pressure.

7.        For one subject, low frequency stimulation significantly increased rectal and anal sphincter pressure which reduced time to defecate; compared to bowel management without stimulation, the patient reported greater satisfaction with stimulation.

Gait Speed, TUG, WISCI II (O’Donnell & Harvey, 2013)

Australia

Case Report

N=1

Population: 17 yr, male, T6 AIS C traumatic SCI, 16 mo post injury.

Intervention: Body weight support treadmill training, overground walking

Outcome Measures: Lower extremity motor score (LEMS), Walking index for spinal cord injury (WISCI II), 6-minute walk test (6MWT), 10-meter walk test (10MWT), Timed up and go (TUG), Pediatric Quality of Life Inventory (PedsQL).

1.         LEMS score improved from 16 to 17 from pre- to post-training and from 17 to 18 from post-training to follow-up

2.        WISCI score improved from 6 to 9 from pre- to post-training and remained at 9 at follow-up

3.        6MWT score improved from 67m (1 rest) at pre-training to 76m (no rests) at post-training and further improved to 80m (no rests) at follow-up

4.        10MWT score improved from 32.2s at pre-training to 30.3s at post-training but declined to 33.6s at follow-up

5.        TUG score improved from 44.6s at pre-training to 40.1s at post-training but declined to 42.0s at follow-up, remaining improved compared to pre-training

6.        Overall PedsQL score improved from 38/92 at pre-training to 23/92 at post-training and remained at 23/92 at follow-up

Years using device (Vogel & Lubicky, 1995)

USA

Observational

N=39

N(Parapodium)=26

N(RGO)=13

RGO – Reciprocating Gait Orthoses

Population: (Parapodium) Age (at injury)=3.2yr. (range birth-9yr.); Gender: males=15, females=11; Level and severity of injury: T1-T4 paraplegia=7, Tetraplegia=6, Not reported=13; Time since injury: Not reported.

(RGO) Age at injury= 8.1yr. (range birth-15yr.); Gender: males=5, females=8; Level and severity of injury: T4 paraplegia=1, Tetraplegia=0, Not reported=12; Time since injury: Not reported.

Intervention: Chart review of parapodium and RGO users.

Outcome Measures: Post-orthotic use outcomes.

1.         No patients in either group were community ambulators

2.        Among the 20 children that began using parapodia at less than 6yr., 12 were household ambulators

3.        All 6 children who began using parapodia after 6yr. old were therapeutic ambulators

4.        Among children that initially used RGOs, 2 were household ambulators and the remaining 11 were all therapeutic ambulators

5.        Of the 26 children in the parapodium group, four were lost to follow-up or died after a mean of 3.7 yr. of orthotic use, 12 continued to use their parapodia with a mean follow-up of 3.4 yr., and 10 stopped using their parapodia after 2.2 vr. on average

6.        12 children who continued to use their parapodium. the mean age at injury was 2 1/2 yr., mean age at initiation of parapodium use was 3.7 yr., and their mean age at current follow-up was 7.1 yr.

7.        For the 10 children who had discontinued use of their parapodium, the mean age at injury was 5 yr., mean age at initiation of orthotic use was 5.7 yr., and mean age at discontinuation of parapodium use was 7.9 yr.

8.        Among the 13 children who initiated their orthotic use with RGOS, three were lost to follow-up after using their RGOs for an average of 2 1/2 yr., two are still using RGOs and 8 have stopped using them

9.        The two children still using them were approximately 2 1/2 yr. old when injured and began orthotic use at three and 3 1/2 yr. of age, each has been followed for 1 1/2 yr.

10.      The eight individuals who discontinued RGO use were on average 10.8 yr. old at the time of their injury, began using the RGO at a mean age of 12 1/2 yr. and stopped using their RGOs at a mean age of 16.7 yr.

11.       Of the eight individuals who discontinued RGO use seven did not progress to another orthotic device and one teenager with T10 paraplegia progressed to a knee ankle foot orthosis (KAFO) which she used sporadically for 1 1/2 yr.

Time to complete task, WeeFIM (Johnston et al., 2003)

USA

Pre-Post

N=9

Population: Age: 12.7±5.2 yr (range 7-20 yr); Level and Severity of Injury: C7 tetraplegia (n=1), T1-11 paraplegia (n=8); Long Leg Bracing [LLB] Used: Knee Ankle Foot Orthoses [KAFO] (n=2), Hip Knee Ankle Foot Orthoses [HKAFO] (n=2), Reciprocating Gait Orthoses [RGO] (n=5).

Intervention: Lower extremity Functional Electrical Stimulation (FES) implant which delivered a balanced

asymmetrical biphasic waveform with pulse duration up to 200 msec, 20 Hz frequency, and 20 mA current. Bilateral ankle foot orthoses (AFO) set in zero

degrees of dorsiflexion were worn when ambulating with the FES system. After implantation and immobilization participants did 2-4 wk of FES strengthening followed by standing and walking exercise, and upright mobility training.

Outcomes: Completion of eight upright mobility activities, scored based on completion time and level of independence: donning, stand and reach, high transfer, bathroom, floor to stand, 6-meter walk test (6MWT), stair ascent, stair descent.

1.         Two subjects did not complete training and were not included for analysis.

2.        12/72 originally implanted electrodes required revision primarily due to inadequate force production.

3.        Subjects completed four activities more quickly when using FES as compared to LLB: donning (p=0.0026), stand and reach (p=0.0012), high transfer (p=0.0009), bathroom (p=0.0164).

4.        Subjects completed five activities with less assistance when using FES as compared to LLB: donning (p=0.0001), stand and reach (p=0.0036), high transfer (p=0.0191), bathroom (p=0.0006), and floor to stand (p=0243).

5.        No activity required more time or more assistance to complete with FES as compared to LLB.

6.        Subjects reported preferring FES for 87.5% of the activities, LLB for 3.6% of the activities, and showed no preference for 8.9% of the activities.

Time to complete task, TUG (Johnston et al., 2005)

USA

Post Test

N=3

Population: Age: 17-21; Gender: males=3; Level and Severity of Injury: Motor complete T3-T8; Time since injury: 1.0-1.5 yr;

Intervention: Functional electrical stimulation (FES) consisting of 22-channel implant stimulator, extension leads and epineural electrodes. Leads emanating from the stimulator include two tresses of nine leads each for stimulation of lower extremity muscles and one tress of four leads for stimulation for bladder and bowel function (parameters: 0.2–8 mA amplitude, 25–600 ms pulse

duration, 2–500 Hz pulse frequency per channel). After implantation and immobilization participants completed exercise phase (FES strengthening) followed by lower extremity conditioning, standing and upright mobility training (13 wk).

Outcome Measures: Completion of eight upright mobility activities, scored based on completion time and level of independence: donning, stand and reach, high transfer, bathroom, floor to stand, 6-meter walk test (6, stair ascent, stair descent;

1.         Three of the 52 electrodes placed for lower extremity stimulation experienced changes in the responses of the muscles.

2.        Two subjects used a walker with wheels to perform the mobility activities and one subject used forearm crutches

3.        None of the subjects required physical assistance to complete the activities but two required supervision.

4.        One individual could not ascend/descend stairs as it was felt to be unsafe for him; several activities could not be performed by another subject secondary to complaints of shoulder pain related to poor scapular muscle control.

5.        All subjects reported preferring a swing through pattern for walking as they felt it was faster; two subjects could ambulate up to 20 feet and the third subject up to 75 feet

6.        Just one subject demonstrated positive neuromodulation effects of the bladder; stimulation suppressed reflex bladder contractions acutely thereby reducing vesical pressure

7.        For one subject, low frequency stimulation significantly increased rectal and anal sphincter pressure which reduced time to defecate; compared to bowel management without stimulation, the patient reported greater satisfaction with stimulation.

WeeFIM, WISCI II (Prosser, 2007)

USA

Case Report

N=1

Population: 5 yr.10 mo, female, C4 AIS A SCI and mild traumatic brain injury.

Intervention: Locomotor training including body weight support treadmill training, overground walking, inpatient rehabilitation with aquatic therapy.

Outcome Measures: Functional Independence Measure for Children II (WeeFIMII), Walking Index for Spinal Cord Injury II (WISCI II).

1.         WeeFIM score improved from 5/35 to 21/35 over 5 months of locomotor training

2.        WISCI score improved from 0 to 12 over 5 months of locomotor training

3.        At home, she walked the majority of the time and walked up the stairs to her bedroom with a handrail and minimal assistance

WISCI II (Fox et al., 2010)

USA

Case Report

N=1

Population: 3.5 yr, male, C8 AIS C SCI.

Intervention: Description of child’s walking function and musculoskeletal growth and development during the 2 yr after locomotor training

Outcome Measures: Walking Index for Spinal Cord Injury II (WISCI II), gait speed, cadence, step length, stride length, daily steps activity at home and in the community, musculoskeletal growth and development, gross motor function measure (GMFM-66).

1.         Walking independence remained unchanged with WISCI score staying at 13/20 as he still used a reverse rolling walker to ambulate

2.        Fastest gait speed increased from 0.45m/s at baseline (1 month post LT) to 0.67m/s at 2 yr. follow-up

·          After 2 yr., gait pattern was improved

·          Able to generate reciprocal stepping with noticeable absence of shoulder and trunk compensations, particularly on his left side

·          Despite being able to step reciprocally, he could not walk backwards, side step, or maintain balance without upper-extremity support

3.        Cadence increased from 63.35 steps/min at baseline to 70.75 steps/min at 2 yr follow-up

4.        Step length increased in both legs:

·          Left leg: increased from 42.25 cm at baseline to 51.31 cm at 2 yr follow-up

·          Right leg: increased from 44.07 cm at baseline to 63.55 cm at 2 yr follow-up

5.        Stride length increased in both legs:

·          Left leg: increased from 85.95cm at baseline to 114.79cm at 2 yr follow-up

·          Right leg: increased from 87.19cm at baseline to 114.47cm at 2 yr follow-up

6.        Daily steps increased from about 1600 steps/day at baseline to 3000 steps/day at 2 yr follow-up

7.        Over the 2-yr. period the child was not diagnosed with scoliosis, but mild coxa valga was noted at both hip joints and radiology reports indicated all findings stable

8.        GMFM-66 scores remained stable over the 2-yr period

Main Outcomes

Author, Year

Country

Study Design

Sample Size

Study Characteristics Results
 

TRUNK

TLSO Brace Sison-Williamson et al. (2007)

USA

“With-and-without intervention quasi-experimental”

N=20

Population: Mean age=10.9±2.9; Gender: males=10, females=10; Level of injury: C7-L1; Level of severity: AIS A=18, B=0, C=2, D=0; Time since injury: Not reported.

Intervention: Upper extremity motion analysis – tested in and out of thoracic lumbar sacral orthoses (TLSO) brace.

Outcome Measures: Reach volume (in and out of TLSO brace)

1.         Reachable workspace volumes were significantly greater for the non-TLSO brace condition compared to the TLSO condition (p=0.0002)

2.        Anterior posterior and medial lateral ranges of reach were statistically greater in the non-TLSO condition (p=0.002 and p=0.01, respectively).

3.        Nondominant hand medial lateral reaches were statistically greater in the non-TLSO brace condition (p=0.03)

4.        Dominant hand anterior posterior reaches were statistically greater in the non-TLSO condition (p=0.009).

Scoliosis/ Spinal Fusion Mehta et al. (2004)

USA

Case Control

N=123

Population: Mean age=7.4yr; Gender: males=69, females=54; Level of injury: cervical=69, thoracic=54; Severity of Injury: AIS A=71, B=49, C=1, D=2; Mean time since injury=2.1yr.

Intervention: Patient records from January 1996 to December 2001 from the Shriners Hospitals for Children-Philadelphia were

retrospectively reviewed. Patients were divided into 5 groups based on their radiographic curve severity at presentation (group I: patients with < 1 Ü0 of scoliosis; group II: 11 ° to 20°; group III: 21 ° to 40°; group IV: 4 1 ° to 50°; group V: > 5 1° of

curvature). Each group was then subdivided into a group that

was managed with prophylactic bracing and a group that was not braced.

Outcome Measures: Completion of bracing regimen, surgery, or cessation of growth.

At follow-up (range 2-13 yr), 95% of patients had developed scoliosis; surgical stabilization was required in 65% of the total sample.

Group I (initial curve <10°; n=42)

1.         29 of the patients in this group were braced, and 13 who were not.

2.        Of the braced group, 13 (45%) went on to surgery, whereas 10 (77%) of the non-braced group had surgical correction (p=0.03).

3.        Of the patients who were initially braced, the average time to surgery was 8.5 yr, whereas that for the non-braced group was 4.2 yr (p=0.002).

4.        There was no significant difference between time to surgery for the braced and non-braced patient groups at higher (>20°) initial curve presentations.

Group II (Initial curve 11 ° to 20°; n=25)

1.         Eighteen (72%) patients in this group were braced and 72 8%) were not braced.

2.        Nine of the 18 children in the braced group (50%) required surgery at 6.8 years after initial presentation, whereas 6 of 7 of the nonbraced group (86%) required surgery at 3.7 years after presentation.

3.        The difference between the rate of surgery (p=0.04) and the length of time to surgery (p=0.008) in the braced vs nonbraced group was statistically significant, whereas the curve at the time of surgery was not (p=0.52).

Group III (Initial curve 21 ° to 40°; n=28)

1.         Of the 20 (61%) children initially braced in this group, 1 2 (60%) went on to have surgery at 4.2 years after presentation, whereas 8 (40’7’o) did not require surgery.

2.        Of the 8 children (3 9%) who were not braced, 6 (7 5%) went on to surgical correction at 3.2 years after presentation.

3.        While there was no statistical difference for time to surgery between the braced and nonbraced patients in group III (p=0.3 6), there was a trend toward less surgical intervention in the braced patients (p=0.08).

Group IV (Initial curve > 41 ° but < 50°; n=16) & Group V (curves > 51 ° at presentation; n=12)

1.         In Group IV, one patient (6%) was not braced and proceeded to surgery, whereas 15 (94%) were braced, of which 12 (80%) went on to have surgical correction of their deformity.

2.        In Group V, ten patients (83%) were braced and 2 (17%) were not braced; surgical correction of the spine was performed on 8 children (80%) in the braced group and both children (100%) in the nonbraced group.

3.        In group IV and V, There was no significant difference between time to surgery for the braced and non-braced patient groups.

TLSO Brace Chafetz et al. (2007)

USA

Prospective Controlled Trial

N=14

Population: Mean age:10.8±2.4yr; Gender: males=7, females=7; Level of injury: C1-C7=1, T1-T12=13; Severity of injury: Not reported; Time since injury: Not reported.

Intervention: Children with spinal cord injuries (SCI) completed the activities of the functional activities scale (FAS) and repetitive timed motor tests (TMT) while wearing a thoracolumbosacral orthosis (TLSO) and without a TLSO. Subjects were asked their preference for wearing or not wearing the TLSO during each of the activities.

Outcome Measures: Timed motor test (TMT), functional activities scale (FAS).

1.       For each of the activities of the TMT, subjects were slower when wearing the TLSO. For those wearing a TLSO, there was a noticeable 26% increase in time for donning a shirt (13.6±4.3s to 17.1±8.0s), and a 21% increase in time for donning pants (40.0±8.6s to 48.2±12.8s) (p<0.01)

2.      For FAS, wearing a TLSO did not impact the activities of eating, grooming, wheelchair propulsion, curb management, or transitioning from sitting at the edge of a bed to a supine position

3.      The only statistically significant difference was for upper-body dressing, with the activity scoring lower when the subject was wearing a TLSO (p<0.01)

4.      Preference for not wearing a TLSO was significantly different (p<0.05) for lower-body dressing, reaching for the floor, and transitioning from a supine position to sitting at the edge of the bed

Scoliosis/ Spinal Fusion Mulcahey et al. (2013)

USA

Cross-Sectional

N=217

Population: 13.2±4.9yr.; Gender: males=127, females=90; Level of injury: Not reported; Level of severity: AIS A=105, B=45, C=30, D=21, Missing=16; Time since injury=4.2±3.7yr.

Intervention: None – observational, participants evaluated using the testing guidelines of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) to determine predictors of worse curve and spinal fusion in neurological scoliosis.

*All participants had neuromuscular scoliosis and 24 of the 217 participants underwent spinal fusion due to their progressive neuromuscular scoliosis.

Outcome Measures: ISNCSCI classification, Cobb angles, motor score.

1.         Age of injury (p<0.0001) and AIS classification (p<0.0095) were the only significant predictors of worse curve when grouped as an entire sample

2.        Risk of spinal fusion increased by 11% for every yr. decrease in age at injury

3.        Sex, motor score, and neurological level were not predictors of worse curve of spinal fusion

4.        Subjects injured before the age of 12 were 3.7 times more likely to require a spinal fusion than those injured after age 12 (95% CI, 0.31-44.64)

Scoliosis/ Spinal Fusion Schottler et al. 2012

USA

Cross-Sectional

N=159

Population: Median Age: 2yr (age range: 0-5yr); Gender: males=92, females=67; Level of severity: Paraplegia=100 (incomplete=33, complete=64, unknown=3), Tetraplegia=52 (incomplete=23, complete=24, unknown=5), Not reported=7; Time Since Injury=Not reported

Interventions:

Outcome Measures: Complications (i.e., scoliosis, hip dysplasia, latex allergies, autonomic dysreflexia, pressure ulcers, spasticity, deep venous thrombosis, and kidney stones), demographic and injury-related factors (i.e., age at injury, etiology, level of injury, American Spinal Injury Association Impairment Scale (AIS), and SCIs without radiological abnormalities (SCIWORA))

1.         Ninety-six percent of participants developed scoliosis, 57% had hip dysplasia, and 7% had latex allergy.

2.        Median age of initiating wheelchair use was 3 years 4 months (range 1y 2mo–12y 5mo).

3.        Twenty-four participants were community ambulators, and they were more likely to have AIS D lesions and less likely to have skeletal complications.

 

STAND

FES (Johnston et al., 2003)

USA

Pre-Post

N=9

Population: Age: 12.7±5.2 yr (range 7-20 yr); Level and Severity of Injury: C7 tetraplegia (n=1), T1-11 paraplegia (n=8); Long Leg Bracing [LLB] Used: Knee Ankle Foot Orthoses [KAFO] (n=2), Hip Knee Ankle Foot Orthoses [HKAFO] (n=2), Reciprocating Gait Orthoses [RGO] (n=5).

Intervention: Lower extremity Functional Electrical Stimulation (FES) implant which delivered a balanced

asymmetrical biphasic waveform with pulse duration up to 200 msec, 20 Hz frequency, and 20 mA current. Bilateral ankle foot orthoses (AFO) set in zero

degrees of dorsiflexion were worn when ambulating with the FES system. After implantation and immobilization participants did 2-4 wk of FES strengthening followed by standing and walking exercise, and upright mobility training.

Outcomes: Completion of eight upright mobility activities, scored based on completion time and level of independence: donning, stand and reach, high transfer, bathroom, floor to stand, 6-meter walk test(6MWT), stair ascent, stair descent.

1.         Two subjects did not complete training and were not included for analysis

2.        12/72 originally implanted electrodes required revision primarily due to inadequate force production

3.        Subjects completed four activities more quickly when using FES as compared to LLB: donning (p=0.0026), stand and reach (p=0.0012), high transfer (p=0.0009), bathroom (p=0.0164)

4.        Subjects completed five activities with less assistance when using FES as compared to LLB: donning (p=0.0001), stand and reach (p=0.0036), high transfer (p=0.0191), bathroom (p=0.0006), and floor to stand (p=0243)

5.        No activity required more time or more assistance to complete with FES as compared to LLB

6.        Subjects reported preferring FES for 87.5% of the activities, LLB for 3.6% of the activities, and showed no preference for 8.9% of the activities

FES (Johnston et al., 2005)

USA

Post Test

N=3

Population: Age: 17-21; Gender: males=3; Level and Severity of Injury: Motor complete T3-T8; Time since injury: 1.0-1.5 yr;

Intervention: Functional electrical stimulation (FES) consisting of 22-channel implant stimulator, extension leads and epineural electrodes. Leads emanating from the stimulator include two tresses of nine leads each for stimulation of lower extremity muscles and one tress of four leads for stimulation for bladder and bowel function (parameters: 0.2–8 mA amplitude, 25–600 ms pulse

duration, 2–500 Hz pulse frequency per channel). After implantation and immobilization participants completed exercise phase (FES strengthening) followed by lower extremity conditioning, standing and upright mobility training (13 wk).

Outcome Measures: Completion of eight upright mobility activities, scored based on completion time and level of independence: donning, stand and reach, high transfer, bathroom, floor to stand, 6-meter walk test (6MWT), stair ascent, stair descent.

1.         Three of the 52 electrodes placed for lower extremity stimulation experienced changes in the responses of the muscles

2.        Two subjects used a walker with wheels to perform the mobility activities and one subject used forearm crutches.

3.        None of the subjects required physical assistance to complete the activities but two required supervision

4.        One individual could not ascend/descend stairs as it was felt to be unsafe for him; several activities could not be performed by another subject secondary to complaints of shoulder pain related to poor scapular muscle control

5.        All subjects reported preferring a swing through pattern for walking as they felt it was faster; two subjects could ambulate up to 20 feet and the third subject up to 75 feet

6.        Just one subject demonstrated positive neuromodulation effects of the bladder; stimulation suppressed reflex bladder contractions acutely thereby reducing vesical pressure

7.        For one subject, low frequency stimulation significantly increased rectal and anal sphincter pressure which reduced time to defecate; compared to bowel management without stimulation, the patient reported greater satisfaction with stimulation.

FES (Moynahan, Mullin, et al., 1996)

USA

Observational

N=5

Population: Age: 18.4±1.1 yr; Gender: males=2, females=3; Level of Injury: T4 (n=2), T5 (n=1), T8 (n=1), T11 (n=1); Severity of Injury: AIS A; Orthotics Use: Molded Shoe Insert=4, Ankle Foot Orthosis [AFO]=1.

Intervention: Hybrid system of implanted Functional Electrical Stimulation [FES] (pulse duration 0-150µsec, frequency 0-50 Hz) with wearable AFO. After implantation, participants completed training for standing and mobility.

Outcome Measures: Patterns of home and community FES use; barriers and facilitators of use. Assessed every 1-4 wk for 1 yr.

1.         The frequency of donning the system ranged 23%-34% of the days surveyed; this is equivalent to donning the system once every 3 to 4 days.

2.        The two most common standing activities were “one-handed activities (e.g., painting furniture, changing a car’s air filter, pushing a sibling on a swing-set) or reaching” and “standing for exercise or to stretch,” accounting for 62% of all reported standing activities across subjects.

3.        Maneuvering” was typically performed in areas of the house that were easily accessed by wheelchair.

4.        The FES system was used to perform swing-to gait with their walkers around the house, sometimes transferring to other seats.

5.        “Standing with others” included showing friends or family standing ability, to take pictures or for hugging.

6.        “Transfers” (e.g., for weighing or to transfer into a car) were not widely performed.

7.        “Motivators” for FES use included: being able to do things that would be difficult/impossible otherwise, perceiving a healthful benefit from exercise/standing, having a sense of well-being, and feeling an obligation to stand as a member of the research study.

8.        “Barriers” included: not having time to stand or exercise, having difficulty seeing opportunities and reluctant to wear it all day.

FES (Bonaroti et al., 1999a)

USA
Case Report

N=1

Population: 11 yr, T10 AIS A SCI

Intervention: Functional electrical stimulation, Knee Ankle Foot Orthoses

Outcome Measures: Functional Independence Measure (FIM) and time to completion during upright mobility activities: donning, high transfer, toilet transfer, floor-to-standing transfer, ascend/descend stairs.

1.         FIM measurements of bathroom transfer and descending stairs completed significantly faster with KAFO (p<0.001 and p=0.04 respectively)

2.        For the remaining activities there was a trend towards faster completion times with FES, but this was not statistically significant (donning: p=0.28; high transfer: p=0.36; floor transfer: p=0.67; ascending stairs: p=0.32)

3.        While performing the 10 subset activities of the FST, the subject displayed no significant differences in completion times between the 2 modes

4.        Subject was significantly more stable in the static position using KAFO (p=0.03) whereas in dynamic testing subject was slightly more stable using FES, but was not statistically significant (p=0.7)

5.        Ambulation velocity was significantly faster using FES during the 100 feet ambulation (p<0.001) and maximum ambulation (p<0.001) test but not during energy expenditure testing (p=0.13)

FES (Bonaroti et al., 1999b)

USA

Pre-Post

N=5

Population: Age: 9 yr (n=2), 10 (n=1), 18 yr (n=2); Gender: males=4, females=1; Etiology: Traumatic SCI=4, Non-Traumatic SCI=1; Level of Injury: cervical=2, thoracic=3; Severity of Injury: Paraplegia=5. Bracing for Standing & Therapy: Knee Ankle Foot Orthoses [KAFO]=5.

Intervention: Hybrid system of implanted Functional Electrical Stimulation [FES] (pulse duration 0-150µsec, frequency 0-50 Hz) with wearable Ankle Foot Orthoses (AFO). After implantation, participants completed FES strengthening followed by sit/stand exercise, and then upright mobility training for 4 weeks.

Outcome Measures: Completion of eight upright mobility activities, scored based on completion time and level of independence with FES versus Long Leg Braces (LLB): donning, stand and reach, high transfer, floor to stand, 6-meter walk test (6MWT), toilet transfer.

1.         When comparing the upright mobility activities between using FES versus LLB, subjects required equal (70%) or less (24%) assistance when using FES compared with using LLB

2.        One subject had greater independence using LLB for the floor to stand transfer

3.        One subject had greater independence using LLB for the 6MWT

4.        For each activity in which FES provided greater independence, subjects improved from requiring contact assistance (3 or 4) while using LLB to not needing contact assistance (5 or 6) while using FES

5.        There were two subjects who required minimal contact assist (4) with LLB but were independent with FES (6), both for the stand and reach activity, and six instances in which minimal (4) or moderate (3) contact assistance was required with LLB and no contact assistance (5) was required using FES

6.        Two activities, stand and reach and high transfer, were performed significantly faster with FES

7.        When subjects were asked which mode of standing they preferred, FES was preferred in 62% of the cases, LLB were preferred 27% of the time, and there was no preference 11% of the time.

FES (Betz et al., 2002)

USA

Case Report

N=1

Population: 13 yr, male, T8 SCI.

Intervention: Lower extremity implanted Functional Electrical Stimulation (FES) with a Knee Ankle Foot Orthoses (KAFO).

Outcome Measures: Completion of eight upright mobility activities, scored based on completion time and level of independence: donning, stand and reach, high transfer, bathroom, floor to stand, 6-meter walk test (6MWT), stair ascent, stair descent.

1.         Across all time periods, the subject required less time to don the FES system (P<0.0001) and to complete the high reach (P<0.0001), high transfer (P<0.0001), and 6MWT (P=.006) compared with KAFO

2.        More time was needed to complete the floor-to-stand activity for FES compared to KAFO (P=0.0001)

3.        No time differences were seen between FES and KAFO for the inaccessible bathroom transfer (P=0.507) and ascending (P=0.753) and descending stairs (P=0.164)

4.        Subject was able to more quickly complete the sit-to-stand transition (P<0.0001), reach for a videotape on a high shelf (P<0.0001), and return to sitting in the wheelchair (P<0.0001) when using FES

5.        Subject preferred FES to KAFO for all activities but floor-to-stand at 2-yr. follow-up

Dynamic gait trainer (Altizer et al., 2017)

USA

Case Report

N=1

Population: 23 mo, female, T10 AIS A SCI.

Intervention: Overground supported stepping intervention using a dynamic gait trainer.

Outcome Measures: Paediatric Evaluation of Disability Inventory (PEDI), Spinal Cord Independence Measure (SCIM), Gross Motor Function Measure (GMFM-66), Developmental Profile (DP-3), Support Walker Assessment Ambulation Performance Scale (SWAPS), 6-Minunte Walk Test (6MWT).

1.         PEDI score improved by 6 points (60%) from age 36-54mo. and by 18 points (75%) from age 54-72mo

2.        SCIM score improved over the 3 yr of intervention (36mo. – 19; 54mo. – 31; 72mo. – 43) but remained well below the median adult score for those with injury at T10 of 63

3.        GDFM-66 score improved minimally over 3 yr of intervention

4.        DP-3 score demonstrated a continued motor deficit in comparison to age, but also shows progress in physical skills

5.        6MWT change from 54-72mo. was double what was expected from documentation in literature for her age and level of SCI.

Dynamic Gait Trainer (Choksi et al., 2010)

Observational

USA

N=32

Population: Mean age 10.6±6.2 (1-19) yr; Injury Etiology: Traumatic=24, Non-traumatic=8; Level of Injury: Cervical=18, Thoracolumbar=14.

Intervention: Inpatient rehabilitation physiotherapy and occupational therapy (3 hr/day).

Outcome Measures: Pediatric Evaluation of Disability Inventory (mobility and self-care) via Functional Skills and Caregiver Assistance scales).

1.         PEDI mobility (functional skills): ↑24.0±14.7

2.        PEDI mobility (caregiver assistance): ↑26.1+21.5

3.        All children improved or showed no change on walking-related PEDI items:

·          Indoor locomotion methods: 8/21 ↑

·          Indoor locomotion distance/speed: 11/21 ↑

·          Indoor locomotion pulls/carries: 13/21 ↑

·          Outdoor locomotion methods: 1/21 ↑

·          Outdoor locomotion distance/speed: 12/21↑

·          Outdoor locomotion surfaces: 12/21↑

 

GAIT

Orthoses (Vogel & Lubicky, 1995)

USA

Observational

N=39

N(Parapodium)=26

N(RGO)=13

RGO – Reciprocating Gait Orthoses

Population: (Parapodium) Age at injury=3.2yr. (range birth-9yr.); Gender: males=15, females=11; Level and severity of injury: T1-T4 paraplegia=7, Tetraplegia=6, Not reported=13; Time since injury: Not reported.

(RGO) Age at injury= 8.1yr. (range birth-15yr.); Gender: males=5, females=8; Level and severity of injury: T4 paraplegia=1, Tetraplegia=0, Not reported=12; Time since injury: Not reported.

Intervention: Chart review of parapodium and RGO users.

Outcome Measures: Post-orthotic use outcomes.

1.         No patients in either group were community ambulators

2.        Among the 20 children that began using parapodia at less than 6yr., 12 were household ambulators

3.        All 6 children who began using parapodia after 6yr. old were therapeutic ambulators

4.        Among children that initially used RGOs, 2 were household ambulators and the remaining 11 were all therapeutic ambulators

5.        Of the 26 children in the parapodium group, four were lost to follow-up or died after a mean of 3.7 yr. of orthotic use, 12 continued to use their parapodia with a mean follow-up of 3.4 yr., and 10 stopped using their parapodia after 2.2 vr on average

6.        12 children who continued to use their parapodium. the mean age at injury was 2 1/2 yr., mean age at initiation of parapodium use was 3.7 yr., and their mean age at current follow-up was 7.1 yr.

7.        For the 10 children who had discontinued use of their parapodium, the mean age at injury was 5 yr., mean age at initiation of orthotic use was 5.7 yr., and mean age at discontinuation of parapodium use was 7.9 yr.

8.        Among the 13 children who initiated their orthotic use with RGOS, three were lost to follow-up after using their RGOs for an average of 2 1/2 yr., two are still using RGOs and 8 have stopped using them

9.        The two children still using them were approximately 2 1/2 yr. old when injured and began orthotic use at three and 3 1/2 yr. of age, each has been followed for 1 1/2 yr.

10.      The eight individuals who discontinued RGO use were on average 10.8 yr. old at the time of their injury, began using the RGO at a mean age of 12 1/2 yr. and stopped using their RGOs at a mean age of 16.7 yr.

11.       Of the eight individuals who discontinued RGO use seven did not progress to another orthotic device and one teenager with T10 paraplegia progressed to a knee ankle foot orthosis (KAFO) which she used sporadically for 1 1/2 yr.

FES (Johnston et al., 2003)

USA

Pre-Post

N=9

Population: Age: 12.7±5.2 yr (range 7-20 yr); Level and Severity of Injury: C7 tetraplegia (n=1), T1-11 paraplegia (n=8); Long Leg Bracing [LLB] Used: Knee Ankle Foot Orthoses [KAFO] (n=2), Hip Knee Ankle Foot Orthoses [HKAFO] (n=2), Reciprocating Gait Orthoses [RGO] (n=5).

Intervention: Lower extremity Functional Electrical Stimulation (FES) implant which delivered a balanced

asymmetrical biphasic waveform with pulse duration up to 200 msec, 20 Hz frequency, and 20 mA current. Bilateral ankle foot orthoses (AFO) set in zero

degrees of dorsiflexion were worn when ambulating with the FES system. After implantation and immobilization participants did 2-4 wk of FES strengthening followed by standing and walking exercise, and upright mobility training.

Outcomes: Completion of eight upright mobility activities, scored based on completion time and level of independence: donning, stand and reach, high transfer, bathroom, floor to stand, 6-meter walk test(6MWT), stair ascent, stair descent.

1.         Two subjects did not complete training and were not included for analysis

2.        12/72 originally implanted electrodes required revision primarily due to inadequate force production

3.        Subjects completed four activities more quickly when using FES as compared to LLB: donning (p=0.0026), stand and reach (p=0.0012), high transfer (p=0.0009), bathroom (p=0.0164)

4.        Subjects completed five activities with less assistance when using FES as compared to LLB: donning (p=0.0001), stand and reach (p=0.0036), high transfer (p=0.0191), bathroom (p=0.0006), and floor to stand (p=0243)

5.        No activity required more time or more assistance to complete with FES as compared to LLB

6.        Subjects reported preferring FES for 87.5% of the activities, LLB for 3.6% of the activities, and showed no preference for 8.9% of the activities

FES (Johnston et al., 2005)

USA

Post Test

N=3

Population: Age: 17-21; Gender: males=3; Level and Severity of Injury: Motor complete T3-T8; Time since injury: 1.0-1.5 yr;

Intervention: Functional electrical stimulation (FES) consisting of 22-channel implant stimulator, extension leads and epineural electrodes. Leads emanating from the stimulator include two tresses of nine leads each for stimulation of lower extremity muscles and one tress of four leads for stimulation for bladder and bowel function (parameters: 0.2–8 mA amplitude, 25–600 ms pulse

duration, 2–500 Hz pulse frequency per channel). After implantation and immobilization participants completed exercise phase (FES strengthening) followed by lower extremity conditioning, standing and upright mobility training (13 wk).

Outcome Measures: Completion of eight upright mobility activities, scored based on completion time and level of independence: donning, stand and reach, high transfer, bathroom, floor to stand, 6-meter walk test(6MWT), stair ascent, stair descent;

1.         Three of the 52 electrodes placed for lower extremity stimulation experienced changes in the responses of the muscles

2.        Two subjects used a walker with wheels to perform the mobility activities and one subject used forearm crutches

3.        None of the subjects required physical assistance to complete the activities but two required supervision

4.        One individual could not ascend/descend stairs as it was felt to be unsafe for him; several activities could not be performed by another subject secondary to complaints of shoulder pain related to poor scapular muscle control

5.        All subjects reported preferring a swing through pattern for walking as they felt it was faster; two subjects could ambulate up to 20 feet and the third subject up to 75 feet

6.        Just one subject demonstrated positive neuromodulation effects of the bladder; stimulation suppressed reflex bladder contractions acutely thereby reducing vesical pressure

7.        For one subject, low frequency stimulation significantly increased rectal and anal sphincter pressure which reduced time to defecate; compared to bowel management without stimulation, the patient reported greater satisfaction with stimulation

Main Outcomes

Author, Year

Country

Study Design

Sample Size

Study Characteristics

Results

 

TRUNK

SATCo (Singh et al., 2020)

USA

Not Reported

N=36 (SCI=26)

N(TD)=10

Population: SCI: Mean age=5.0±2.0yr; Gender: males=17, females=9; Level of injury: C2-L2; Level of severity: AIS A=4, B=3, C=2, D=1, N/A=16 (younger than 6yr.); Time since injury=2.7±2.0yr. Typically Developing (TD): Mean age=6.0±2.0 yr; Gender: males=5, females=5.

Intervention: Trunk Control Assessment SCI vs TD groups.

Outcome Measures: Trunk Control Assessment (SATCo), Surface Electromyography (EMG), EMG Normalization

1.         SCI group scored significantly lower on the SATCo compared to the TD group (p<0.001)

2.        Every participant in the TD group completed all levels of the SATCo test, where 21 of the 26 individuals in the SCI group did not complete all levels

3.        SCI group had significantly higher thoracic paraspinal (PST) muscle activation than the TD group over lower ribs (p=0.01), below ribs (p=0.001) and pelvis (p=0.03)

4.        SCI group produced significantly lower PST muscle activation at inferior scapula (p=0.03), and significantly higher EMG magnitude at no support (p=0.004) level compared to the TD group

SATCo Argetsinger et al. (2020)

USA

Case Study

N=1

Population: Age=35mo; Gender: males=0, females=1; Level of injury: C5-C7; Level of severity: tetraplegia; Time since injury=32mo. Intervention: Activity-based therapy (ABT) for 8 months

Outcome Measures: Neuromuscular capacity (Segmental Assessment of Trunk Control (SATCo))

5.        Neuromuscular capacity improved significantly, especially for head and trunk control – allowed for major improvements in respiratory health, novel engagement with her environment, and improved physical abilities
SATCo (Argetsinger et al., 2019)

USA

Prospective Study

N=21

Population: Mean age=63.3±27.2mo.; Gender: males=10, females=11; Level of injury: cervical=9, thoracic=12; Level of severity: Not reported; Time since injury=18.3±18mo.

Intervention: Activity-based locomotor training (AB-LT) with outcomes reported with regards to chronicity, initial score, ad injury level

Outcome Measures: Segmental Assessment of Trunk Control (SATCo); Pediatric Balance Scale; Modified Functional Reach (MRF-Forward-Right-Left); Timed Short Sit; Timed Long Sit; Timed Stand.

1.         SATCo scores increased significantly (p<0.05) regardless of chronicity, injury level, or initial score

2.        Significant difference from first to last evaluations for MRF-Forward-Right-Left, Timed Short Sit, Timed Long Sit and Timed stand scores

3.        No significant change in Pediatric Balance Scale from first to last evaluation

ABT (Goode-Roberts et al., 2021)

Switzerland

Case Report

N=1

Population: Age:2.7yr; Gender: males=1; Level of injury: C1-Sacrum; Severity of injury: Not reported; Time since injury=2.7 yr.

Intervention: The patient received 144 sessions of Activity-Based Locomotor Training (AB-LT) and 90 sessions of Activity-Based Neuromuscular Electrical Stimulation (AB-NMES) over a seven-month period. AB-LT was provided for 1.5h/day, 5 days per week, followed by 1h/day, 5 days per week of AB-NMES.

Outcome Measures: Resting respiratory rate, Segmental Assessment of Trunk Control (SATCo), Bayley-III Assessment.

1.       The patient’s resting respiratory rate steadily declined over a 4-month period from 60 to 30 BPM

2.      The number of times the patient required to be suctioned during therapy sessions declined overall, with the exception of periods of viral respiratory illness

3.      The patient’s SATCo score increased from 0/20 to 5/20

4.      Bayley-III assessment at discharge revealed dramatic developmental changes; non-verbal cognitive abilities improved from that of a 16-day old to a 9-month developmental level and social/emotional skills from 0-3 month to 15-18 developmental level

SATCo (A. L. Behrman et al., 2019)

USA

Pre-Post

N=26

Population: Age: 5.0±3.0 yr; Gender: 15 males, 11 females; Etiology: 12 traumatic, 14 non-traumatic; Time since injury: 1.4±1.3 yr; Level of Injury: cervical=9, thoracic=15, lumbar=2; AIS: A (n=6), B 9 (n=4), C (n=3), D (n=1); Chronicity: 13 acute, 13 chronic.

Intervention: Activity-based locomotor training (AB-LT), 5 times per week for 60 sessions, 1.5 hr per session. Body weight support (1 hr) followed by overground walking with supports, as necessary. Integration of training principles encouraged in daily activities. Neuromuscular electrical stimulation (40-100 Hz) provided 1-1.5 hr per week, 5 days per week, for 4 participants only.

Outcome Measures: Segmental Assessment of Trunk Control (SATCo), Pediatric Neuromuscular Recovery Scale (Pediatric NRS) at baseline, sessions 20, 40, and 60 and/or discharge.

1.         Pediatric NRS scores improved significantly from baseline to session 20 (p<0.05), from session 20 to 40 (p<0.05); while scores improved from session 40 to 60 they were not significant

2.        On average, the inter-evaluation change in Pediatric NRS score was 3.7 (p<0.05)

3.        SATCo scores improved significantly from baseline to session 20 (p<0.05), from session 20 to 40 (p<0.05); while scores improved from session 40 to 60 they were not significant

4.        On average, the inter-evaluation change in SATCo score was 1.7 (p<0.05)

5.        There was no significant difference in Pediatric NRS or SATCo scores by chronicity of SCI.

Supine Functional Neurophysiological Assessment Atkinson et al. (2019)

USA

Observational

N=43

N=43 (SCI=24)

Population: SCI: Mean age=7.5±3.4yr.; Gender: males=12, females=12; Level of injury: C1-T12; Level of severity: AIS N/A=10 (younger than 6 yr.), A=4, B=1, C=8, D=0, Not reported=1; Time since injury=4.6±3.6 yr. Typically Developing (TD): Mean age=6.9±2.8yr.; Gender: males=12, females=12; Level of injury: N/A; Level of severity: N/A; Time since injury: N/A.

Intervention: None – observational, SCI were split into 2 groups – Voluntary Movements (IMA) and Non-voluntary Movements (NMA).

Outcome Measures: Left Ankle Dorsiflexion (LADF), Right Ankle Dorsiflexion (RADF); Left Knee Flexion (LKF); Right Knee Flexion (RKF), Bilateral Hip and Knee Flexion (BHKF), Bilateral Hip and Knee Extension (BHKE); Bilateral Hip Adduction (BHA); Neck Flexion (NF); Sit-up.

1.         SCI participants in both the IMA and NMA groups had significantly lower magnitudes and SI values in comparison with TD children (p < 0.01)

2.        Magnitude significantly different between the NMA and IMA groups for all tasks (p < 0.05), with little variability in magnitude or SI values in the NMA group due to lack of EMG activity in these participants

3.        In TD children, SI values were close to one for each task, and were not significantly correlated with age. In contrast, significantly greater variability in SI values was observed for IMA participants (p < 0.0001)

4.        Across all tasks, SI values were significantly larger in TD group as compared with either the NMA or the IMA groups (p < 0.01), however no significant differences were observed between SCI groups

5.        With regard to magnitude, significant differences were found for all events and all groups, with the exception of NF (IMA vs. TD) (p < 0.05), wherein NMA magnitude values were significantly lower than all other groups

6.        IMA magnitudes were significantly larger than the NMA group, and significantly smaller than the TD group. A positive correlation was found between SI and qualitative scores across all tasks (CC = 0.67, p <0.0001)

 

STAND

NMRS Ardolino et al. 2016

USA

Observational

N=12

Population: Children with SCI=5: Age Range: 48mo-143mo; Gender: males=3, females=2; Level of severity: Not reported; Time since injury: Not reported

Children without SCI=7: Age Range: 22mo-126mo; Gender: males=4, females=3

Intervention: None – observational

Outcome Measures: draft Pediatric NRS, revised draft Pediatric NRS, clarity of wording and scoring

1.         After the Delphi process and field testing, the final Pediatric NRS consists of 13 items scored on a 12-point scale.

2.        All items, except 1, achieved 80% agreement by experts, in terms of clarity of wording and scoring.

NMRS (Andrea L Behrman et al., 2019)

USA

Observational

N(HCP)=14

N(SCI–P)=32

HCP – Healthcare Professional

SCI-P – Spinal Cord Injury – Pediatric

Population: (SCI-P) Mean age=6.0±3.0yr.; Gender: males=17, females=15; Level of injury: C1-L5; Level of severity: AIS A=6, B=5, C=2, D=5, N/A=14 (younger than 6yr.); Time since injury: Not reported.

Intervention: None – observational.

Outcome Measures: Interrater reliability.

1.         Interrater reliability coefficient was determined to be near 1 overall for Pediatric NRS score (ICC=0.966; 95% CI, 0.89-0.98)

2.        12 of 16 individual items exhibited high concordance coefficients (Kendall’s W ≥0.8)

3.        4 items were found to have concordance coefficients <0.8 and >0.69.

4.        Interrater reliability was equal among groups defined by neurological level and age, but lower among non-ambulatory individuals.

 

GAIT

LEMS, Home Activities (Behrman et al., 2008)

USA

Case Report

N=1

Population: 4.5 yr, male, C8 AIS C traumatic SCI, 16 mo post-injury.

Intervention: Body weight support, overground walking.

Outcome Measures: Functional Independence Measure for Children II (WeeFIMII), preferred speed, fast speed, community steps

1.         AIS score remained the same after session 74

2.        LEMS score remained at 4/50 at session 74

3.        From session 51 to 76 gait speed increased from 0.19m/s to 0.29m/s

4.        From session 51 to 76 fastest walking speed increased from 0.3m/s to 0.48m/s

5.        WISCI score increased from 0/20 to 13/20

6.        At session 33 the child showed multiple non-cued steps

7.        From session 49 to 74 the child increased from 926 steps per day to 2488 steps per day

LEMS, Berg Balance (Behrman et al., 2012)

USA

Case Reports

N=3

Population: Case 1: 15 yr, male, T5 SCI, AIS D. Case 2: 14 yr, male, T5 AIS C ruptured arteriovenous malformation; Case 3: 14 yr, male, C2 AIS D SCI.

Intervention: Locomotor Training (Body weight support treadmill training, overground walking), community integration.

Outcome Measures: 10-meter walk test (10MWT),6-minute walk test 6MWT, Berg Balance Scale (BBS),

Case 1

1.         10MWT with initial rolling walker (RW) device improved from 0.16m/s at initial evaluation to 1.12m/s at discharge and declined to 1.06m/s at 12mo. follow-up

2.        10MWT with current bilateral single point canes (BSPCs) devices improved from 0.77m/s at session 20 (started use of BSPCs) to 1.22m/s at discharge and declined to 1.01m/s at 12mo. follow-up (use of BSPCs stopped after session 40)

3.        6MWT with initial rolling walker (RW) device improved from 53.07m at initial evaluation to 291.69m at discharge and improved further to 298.4m at 12mo. follow-up

4.        6MWT with current bilateral single point canes (BSPCs) devices improved from 242.32m at session 20 (started use of BSPCs) to 308.15m at discharge and improved further to 316.11m at 12mo. follow-up (use of BSPCs stopped after session 40)

5.        BBS score improved from 8/56 at initial evaluation to 48/56 at discharge and declined to 47/56 at 12mo. follow-up

Case 2

1.         10MWT with initial rolling walker (RW) device improved from 0.12m/s at initial evaluation to 0.22m/s at session 80 and improved further to 0.38m/s at session 200

2.        10MWT with current bilateral loftstand crutches (BLCs) devices remained at 0.1m/s from session 40 (started use of BLCs) session 80 and improved to 0.45m/s at session 200 (use of bilateral single point canes (BSPCs) at session 200)

3.        6MWT with initial rolling walker (RW) device improved from 25.6m at initial evaluation to 44.8m at session 80 and improved further to 117.3m at session 200

4.        6MWT with current bilateral loftstand crutches (BLCs) devices declined from 13.6m at session 40 (started use of BLCs) to 7.6m at session 80 but improved to 123.8m at session 200 (use of bilateral single point canes (BSPCs) at session 200)

5.        BBS score increased from 7/56 at initial evaluation to 23/56 at session 80 and improved further to 31/56 at session 200

Case 3

1.         10MWT increased from 1.3m/s at initial evaluation to 1.5m/s at session 20 and increased further to 1.72m/s at discharge

2.        6MWT increased from 435m at initial evaluation to 467m at session 20 and increased further to 500m at discharge

3.        BBS score increased from 55/56 at initial evaluation to 56/56 at session 20 and sustained a score of 56/56 at discharge

LEMS

·          LEMSs for the three reported cases were 29, 22, and 46, respectively

·          Only the adolescent in Case 1 demonstrated significant change (17 points) in his LEMS post-LT that could also account for improvement in function

·          For the other two instances, the LEMS change was relatively minor

BERG Balance,

NRS

(Behrman et al., 2017)

USA

Not reported

N=Not reported

Population: Not reported

Intervention: Basic scientific findings that legs to locomotor training (LT) and activity-based therapies (ABT).

Outcome Measures: Neuromuscular recovery scale (NRS), Berg Balance Scale (BBS).

1.         BBS over time revealed scores that spanned the entire breadth of the scale and his variation did not reduce when this sample was divided into groups by AIS classification

·          To be able to make comparisons across groups in research studies, or make clinical predictions, a tool that can classify persons according to activity domain, in addition to impairment, is needed

2.        NRS has been found to have strong test-retest reliability (Spearman correlation coefficients of 0.92–0.99) as well as high inter-rater reliability (Kendall coefficient of concordance ≥0.90)

3.        The construct validity of the original NRS was established using Rasch analysis, which revealed that the NRS stratifies individuals with all AIS classifications into 5 distinct strata

4.        No floor or ceiling effects were found for the NRS, and the scale also demonstrated a logical order of item difficulty

5.        NRS was found to be a stronger predictor of recovery than AIS classification when measuring the change in performance of persons with motor-incomplete SCI on the BBS, 6MWT and 10MWT

6.        Pediatric Neuromuscular Recovery Scale (Peds NRS) was developed by clinicians and researchers with pediatric expertise and consists of 13 items graded on a 12-point scale

7.        The use of the adult NRS and Peds NRS in other neurological populations is also being investigated

LEMS (O’Donnell & Harvey, 2013)

Australia

Case Report

N=1

Population: 17 yr, male, T6 AIS C traumatic SCI, 16 mo post injury.

Intervention: Body weight support treadmill training, overground walking

Outcome Measures: Lower extremity motor score (LEMS), Walking index for spinal cord injury (WISCI II), 6-min walk test (6MWT), 10-m walk test (10MWT), Timed up and go (TUG), Pediatric Quality of Life Inventory (PedsQL).

1.         LEMS score improved from 16 to 17 from pre- to post-training and from 17 to 18 from post-training to follow-up

2.        WISCI score improved from 6 to 9 from pre- to post-training and remained at 9 at follow-up

3.        6MWT score improved from 67m (1 rest) at pre-training to 76m (no rests) at post-training and further improved to 80m (no rests) at follow-up

4.        10MWT score improved from 32.2s at pre-training to 30.3s at post-training but declined to 33.6s at follow-up

5.        TUG score improved from 44.6s at pre-training to 40.1s at post-training but declined to 42.0s at follow-up, remaining improved compared to pre-training

6.        Overall PedsQL score improved from 38/92 at pre-training to 23/92 at post-training and remained at 23/92 at follow-up

Home activities (Prosser, 2007)

USA

Case Report

N=1

Population: 5 yr.10 mo, female, C4 AIS A SCI and mild traumatic brain injury.

Intervention: Locomotor training including body weight support treadmill training, overground walking, inpatient rehabilitation with aquatic therapy.

Outcome Measures: Functional Independence Measure for Children II (WeeFIMII), Walking Index for Spinal Cord Injury II (WISCI II), home activities.

1.         WeeFIM score improved from 5/35 to 21/35 over 5 months of locomotor training

2.        WISCI score improved from 0 to 12 over 5 months of locomotor training

3.        At home, she walked most of the time and walked up the stairs to her bedroom with a handrail and minimal assistance

Home Activities, Observational Gait Analysis (Fox et al., 2010)

USA

Case Report

N=1

Population: 3.5 yr, male, C8 AIS C SCI.

Intervention: Description of child’s walking function and musculoskeletal growth and development during the 2 yr after locomotor training

Outcome Measures: Walking Index for Spinal Cord Injury II (WISCI II), gait speed, cadence, step length, stride length, daily steps activity at home and in the community, musculoskeletal growth and development, gross motor function measure (GMFM-66).

1.         Walking independence remained unchanged with WISCI score staying at 13/20 as he still used a reverse rolling walker to ambulate

2.        Fastest gait speed increased from 0.45m/s at baseline (1 month post LT) to 0.67m/s at 2 yr follow-up

·          After 2 yr., gait pattern was improved

·          Able to generate reciprocal stepping with noticeable absence of shoulder and trunk compensations, particularly on his left side

·          Despite being able to step reciprocally, he could not walk backwards, side step, or maintain balance without upper-extremity support

3.        Cadence increased from 63.35 steps/min at baseline to 70.75 steps/min at 2 yr follow-up

4.        Step length increased in both legs:

·          Left leg: increased from 42.25cm at baseline to 51.31cm at 2 yr follow-up

·          Right leg: increased from 44.07cm at baseline to 63.55cm at 2 yr follow-up

5.        Stride length increased in both legs:

·          Left leg: increased from 85.95cm at baseline to 114.79cm at 2 yr follow-up

·          Right leg: increased from 87.19cm at baseline to 114.47cm at 2 yr follow-up

6.        Daily steps increased from about 1600 steps/day at baseline to 3000 steps/day at 2 yr follow-up

7.        Over the 2-yr. period the child was not diagnosed with scoliosis, but mild coxa valga was noted at both hip joints and radiology reports indicated all findings stable

8.        GMFM-66 scores remained stable over the 2-yr. period

Observational Gait Analysis Fox et al.  (2013)

USA

Pre-Post

N=5

Population: Mean age:8.6±2.7yr; Gender: males=4, females=1; Level of injury: C1-C7=2, T1-T12=3; Time since injury>1yr.

Intervention: Modular control of patients with incomplete spinal cord injury (ISCI) was examined via locomotor tasks including treadmill training, overground walking, pedaling, stair climbing, supine lower extremity flexion/extension, and crawling.

Outcome Measures: Lower extremity motor score (LEMS), variance accounted for (VAF), electromyogram (EMG) recordings.

1.       Fewer modules were needed to account for muscle activation in the lower extremities of children with ISCIs compared with controls (p<0.05)

2.     An average of 2.11±0.71 modules was required to account for the EMG data recorded in lower extremities of children with ISCI

3.     With the use of the muscle weightings from treadmill walking and task-specific timing profiles, the VAF exceeded 86% for all locomotor tasks

4.     The VAF exceeded 90% for all tasks performed by the children with ISCIs

5.     Modularity is constrained in children with ISCI

Observational Gait Analysis (Heathcock et al., 2014)

USA

Case Report

N=1

Population: 15 mo, male, T11-L4 in-utero spinal cord tumour resulting in SCI with subsequent removal at 5.5 wk of age.

Intervention: Treadmill Step Training Program

Outcome Measures: Number and pattern of walking steps, gait speed, observational gait analysis, standing.

1.         An increase in the percentage of alternating steps and a matching decrease in the percentage of single steps over the 20-month intervention period were observed

2.        At 30 months of age, a pattern of alternating stepping on the treadmill occurred more than 80% of the time, in sharp contrast to the initial 6 months of training when alternating steps comprised fewer than 10% of the total steps

3.        Number of steps increased from 1 step at 16mo to 10 steps at 22mo.

4.        At 22mo. of age, steps were measured in distance and increased from 3m at 22mo. to about 6m at 31mo.

5.        Gait speed varied over the 20 mo period (0.48m/s at 31mo. and 0.40m/s at 35mo.)

6.        Only the right leg accounted for most of the stepping rate from 15 through 20 months of age because there were few or no independent steps on the left

7.        Over the 20-month intervention period, stepping with the right and left legs increased, with a greater rate of improvement being observed for the left leg, suggesting improvements in symmetry and bilateral function

8.        Static standing improved from standing with an arm support on the walker for 30s with contact guard assistance (CGA) at 15mo. to static standing for 20s with standby assistance

NRS Ardolino et al. 2016

USA

Observational

N=12

Population: Children with SCI=5: Age Range: 48mo-143mo; Gender: males=3, females=2; Level of severity: Not reported; Time since injury: Not reported

Children without SCI=7: Age Range: 22mo-126mo; Gender: males=4, females=3

Intervention: None – observational

Outcome Measures: draft Pediatric NRS, revised draft Pediatric NRS, clarity of wording and scoring

1.         After the Delphi process and field testing, the final Pediatric NRS consists of 13 items scored on a 12-point scale.

2.        All items, except 1, achieved 80% agreement by experts, in terms of clarity of wording and scoring.

NRS (Andrea L Behrman et al., 2019)

USA

Observational

N(HCP)=14

N(SCI–P)=32

HCP – Healthcare Professional

SCI-P – Spinal Cord Injury – Pediatric

Population: (SCI-P) Mean age=6.0±3.0yr.; Gender: males=17, females=15; Level of injury: C1-L5; Level of severity: AIS A=6, B=5, C=2, D=5, N/A=14 (younger than 6yr.); Time since injury: Not reported.

Intervention: None – observational.

Outcome Measures: Interrater reliability.

1.         Interrater reliability coefficient was determined to be near 1 overall for Pediatric NRS score (ICC=0.966; 95% CI, 0.89-0.98)

2.        12 of 16 individual items exhibited high concordance coefficients (Kendall’s W ≥0.8)

3.        4 items were found to have concordance coefficients <0.8 and >0.69.

4.        Interrater reliability was equal among groups defined by neurological level and age, but lower among non-ambulatory individuals.

Main Outcomes

Author, Year

Country

Study Design

Sample Size

Study Characteristics

Results

 

TRUNK

ABT Argetsinger et al. (2020)

USA

Case Study

N=1

Population: Age=35mo; Gender: males=0, females=1; Level of injury: C5-C7; Level of severity: tetraplegia; Time since injury=32mo.

Intervention: Activity-based therapy (ABT) for 8 months

Outcome Measures: Neuromuscular capacity (Segmental Assessment of Trunk Control (SATCo))

1.         Neuromuscular capacity improved significantly, especially for head and trunk control – allowed for major improvements in respiratory health, novel engagement with her environment, and improved physical abilities
ABT (A. L. Behrman et al., 2019)

USA

Pre-Post

N=26

Population: Age: 5.0±3.0 yr; Gender: 15 males, 11 females; Etiology: 12 traumatic, 14 non-traumatic; Time since injury: 1.4±1.3 yr; Level of Injury: cervical=9, thoracic=15, lumbar=2; AIS: A (n=6), B 9 (n=4), C (n=3), D (n=1); Chronicity: 13 acute, 13 chronic.

Intervention: Activity-based locomotor training (AB-LT), 5 times per week for 60 sessions, 1.5 hr per session. Body weight support (1 hr) followed by overground walking with supports, as necessary. Integration of training principles encouraged in daily activities. Neuromuscular electrical stimulation (40-100 Hz) provided 1-1.5 hr per week, 5 days per week, for 4 participants only.

Outcome Measures: Segmental Assessment of Trunk Control (SATCo), Pediatric Neuromuscular Recovery Scale (Pediatric NRS) at baseline, sessions 20, 40, and 60 and/or discharge.

1.         Pediatric NRS scores improved significantly from baseline to session 20 (p<0.05), from session 20 to 40 (p<0.05); while scores improved from session 40 to 60, they were not significant

2.        On average, the inter-evaluation change in Pediatric NRS score was 3.7 (p<0.05)

3.        SATCo scores improved significantly from baseline to session 20 (p<0.05), from session 20 to 40 (p<0.05); while scores improved from session 40 to 60 they were not significant

4.        On average, the inter-evaluation change in SATCo score was 1.7 (p<0.05)

5.        There was no significant difference in Pediatric NRS or SATCo scores by chronicity of SCI

ABT (Argetsinger et al., 2019)

USA

Prospective Study

N=21

Population: Mean age=63.3±27.2mo.; Gender: males=10, females=11; Level of injury: cervical=9, thoracic=12; Level of severity: Not reported; Time since injury=18.3±18mo.

Intervention: Activity-based locomotor training (AB-LT) with outcomes reported with regards to chronicity, initial score, ad injury level

Outcome Measures: Segmental Assessment of Trunk Control (SATCo); Pediatric Balance Scale; Modified Functional Reach (MRF-Forward-Right-Left); Timed Short Sit; Timed Long Sit; Timed Stand.

1.         SATCo scores increased significantly (p<0.05) regardless of chronicity, injury level, or initial score

2.        Significant difference from first to last evaluations for MRF-Forward-Right-Left, Timed Short Sit, Timed Long Sit and Timed stand scores

3.        No significant change in Pediatric Balance Scale from first to last evaluation.

ABT (Goode-Roberts et al., 2021)

Switzerland

Case Report

N=1

Population: Age:2.7yr; Gender: males=1; Level of injury: C1-Sacrum; Severity of injury: Not reported; Time since injury=2.7 yr.

Intervention: The patient received 144 sessions of Activity-Based Locomotor Training (AB-LT) and 90 sessions of Activity-Based Neuromuscular Electrical Stimulation (AB-NMES) over a seven-month period. AB-LT was provided for 1.5h/day, 5 days per week, followed by 1h/day, 5 days per week of AB-NMES.

Outcome Measures: Resting respiratory rate, Segmental Assessment of Trunk Control (SATCo), Bayley-III Assessment.

1.         The patient’s resting respiratory rate steadily declined over a 4-month period from 60 to 30 BPM

2.        The number of times the patient required to be suctioned during therapy sessions declined overall, with the exception of periods of viral respiratory illness

3.      The patient’s SATCo score increased from 0/20 to 5/20

4.      Bayley-III assessment at discharge revealed dramatic developmental changes; non-verbal cognitive abilities improved from that of a 16-day old to a 9-month developmental level and social/emotional skills from 0-3 month to 15-18 developmental level

ABT (Fox et al., 2010)

USA

Case Report

N=1

Population: 3.5 yr, male, C8 AIS C SCI.

Intervention: Description of child’s walking function and musculoskeletal growth and development during the 2 yr after locomotor training

Outcome Measures: Walking Index for Spinal Cord Injury II (WISCI II), gait speed, cadence, step length, stride length, daily steps activity at home and in the community, musculoskeletal growth and development, gross motor function measure (GMFM-66).

1.         Walking independence remained unchanged with WISCI score staying at 13/20 as he still used a reverse rolling walker to ambulate

2.        Fastest gait speed increased from 0.45m/s at baseline (1 month post LT) to 0.67m/s at 2 yr follow-up

·          After 2 yr., gait pattern was improved

·          Able to generate reciprocal stepping with noticeable absence of shoulder and trunk compensations, particularly on his left side

·          Despite being able to step reciprocally, he could not walk backwards, side step, or maintain balance without upper-extremity support

3.        Cadence increased from 63.35 steps/min at baseline to 70.75 steps/min at 2 yr follow-up

4.        Step length increased in both legs:

·          Left leg: increased from 42.25cm at baseline to 51.31cm at 2 yr follow-up

·          Right leg: increased from 44.07cm at baseline to 63.55cm at 2 yr follow-up

5.        Stride length increased in both legs:

·          Left leg: increased from 85.95cm at baseline to 114.79cm at 2 yr follow-up

·          Right leg: increased from 87.19cm at baseline to 114.47cm at 2 yr follow-up

6.        Daily steps increased from about 1600 steps/day at baseline to 3000 steps/day at 2 yr follow-up

7.        Over the 2-yr. period the child was not diagnosed with scoliosis, but mild coxa valga was noted at both hip joints and radiology reports indicated all findings stable

8.        GMFM-66 scores remained stable over the 2-yr. period

ABT Felter et al. (2018)

USA

Case Report

N=1

Population: Age: 3yr; Gender: female; Level of injury: tetraplegia; Severity of injury: Not reported; Time since injury=3yr.

Intervention: The effectiveness of activity-based therapies (ABT) in a tetraplegic 3-yr.-old girl born with intrauterine spinal cord infarcts (IUSCI).

Outcome Measures: Gross Motor Function Measure-88 (GMFM-88) and Physical Abilities and Mobility Scale (PAMS).

1.         Developmental milestones in functional mobility included rolling supine to side-lying, sitting for five mins wearing a trunk orthosis, social interactions, and upper extremity function

2.        Body weight supported treadmill training combined with transcutaneous spinal cord stimulation improved ambulation and stepping

3.        ABT did not restore function, rather, the neurological and musculoskeletal system were trained to function as intended

 

STAND

ABT (A. L. Behrman et al., 2019)

USA

Pre-Post

N=26

Population: Age: 5.0±3.0 yr; Gender: 15 males, 11 females; Etiology: 12 traumatic, 14 non-traumatic; Time since injury: 1.4±1.3 yr; Level of Injury: cervical=9, thoracic=15, lumbar=2; AIS: A (n=6), B 9 (n=4), C (n=3), D (n=1); Chronicity: 13 acute, 13 chronic.

Intervention: Activity-based locomotor training (AB-LT), 5 times per week for 60 sessions, 1.5 hr per session. Body weight support (1 hr) followed by overground walking with supports, as necessary. Integration of training principles encouraged in daily activities. Neuromuscular electrical stimulation (40-100 Hz) provided 1-1.5 hr per week, 5 days per week, for 4 participants only.

Outcome Measures: Segmental Assessment of Trunk Control (SATCo), Pediatric Neuromuscular Recovery Scale (Pediatric NRS) at baseline, sessions 20, 40, and 60 and/or discharge.

1.         Pediatric NRS scores improved significantly from baseline to session 20 (p<0.05), from session 20 to 40 (p<0.05); while scores improved from session 40 to 60 they were not significant

2.        On average, the inter-evaluation change in Pediatric NRS score was 3.7 (p<0.05)

3.        SATCo scores improved significantly from baseline to session 20 (p<0.05), from session 20 to 40 (p<0.05); while scores improved from session 40 to 60 they were not significant

4.        On average, the inter-evaluation change in SATCo score was 1.7 (p<0.05)

5.        There was no significant difference in Pediatric NRS or SATCo scores by chronicity of SCI.

ABT (McCain, Farrar, & Smith, 2015) USA

Case Report

N=1

Population: 11 yr, female, T4 AIS C non-traumatic ischemic spinal cord stroke, 6 mo post-injury.

Intervention: Strengthening, Standing Activities, Body weight support treadmill training, overground walking, functional electrical stimulation, walking

2 Conditions:

Condition 1: FES on left quads, bilateral ankle foot orthoses (AFOs), back brace, reverse walker, level surfaces and walking independently

Condition 2: Reverse walker, left AFO, back brace, level surfaces and walking independently

Outcome Measures: Walking index for spinal cord injury (WISCI II), Lower extremity motor score (LEMS), myotomes for light touch (LT) and pinprick (PP) scores, 6-minute walk test (6MWT), cadence, step length.

1.         Subjects WISCI score was calculated at her highest possible level at discharge

2.        Total LEMS score increased from 16 at baseline to 22 at 18mo.

3.        LT scores remained at 55 from baseline to 18mo.

4.        PP scores increased from 16 at baseline to 33 at 18mo.

5.        6MWT at 16mo. was 166ft. with 6 brief standing rests in condition 1 and improved to 368ft. with 2 brief standing rests at 18mo. in condition 2

6.        Cadence at 16mo. was 32.4steps/min in condition 1 and improved to 42.3steps/min in condition 2 at 18mo.

7.        Step length was measures in both legs

·          Right leg at 16mo. was 31.1cm in condition 1 and improved to 46.8cm at 18mo. in condition 2

·          Left leg at 16mo. was 39.9cm in condition 1 and improved to 53.9cm at 18mo. in condition 2

ABT (Murillo et al., 2012)

Spain

Case Report

N=1

Population: 15 yr, female, T6 AIS B, traumatic SCI, 24 mo post-injury.

Intervention: Functional Electrical Stimulation-assisted Lokomat, Overground walking with Dynamico walker, with and without Functional Electrical Stimulation.

Outcome Measures: 10-Meter Walk Test (10MWT), cadence, stride length, distance.

10MWT at the end of 3 months of training yielded the following results

1.         Cadence was 29.1 steps/min

2.        Stride length was 0.63m

3.        Walking speed was 0.15m/s

4.        Stance times were 2.94 s (right) and 2.84 s (left).

5.        Energy expenditure not measured, but patient was nearly exhausted after completing a distance of 200m

 

GAIT

ABT (Prosser, 2007)

USA

Case Report

N=1

Population: 5 yr. 10 mo., female, C4 AIS A SCI and mild traumatic brain injury.

Intervention: Activity

Based Restorative Therapy including body weight support treadmill training, overground walking, inpatient rehabilitation with aquatic therapy.

Outcome Measures: Functional Independence Measure for Children II (WeeFIMII), Walking Index for Spinal Cord Injury II (WISCI II), home activities.

1.         WeeFIM score improved from 5/35 to 21/35 over 5 months of locomotor training

2.        WISCI score improved from 0 to 12 over 5 months of locomotor training

3.        At home, she walked most of the time and walked up the stairs to her bedroom with a handrail and minimal assistance

ABT (Behrman et al., 2017)

USA

Not reported

N=Not reported

Population: Not reported

Intervention: Basic scientific findings that legs to locomotor training (LT) and activity-based therapies (ABT).

Outcome Measures: Neuromuscular recovery scale (NRS), Berg Balance Scale (BBS).

1.         BBS over time revealed scores that spanned the entire breadth of the scale and his variation did not reduce when this sample was divided into groups by AIS classification

2.        NRS has been found to have strong test-retest reliability (Spearman correlation coefficients of 0.92–0.99) as well as high inter-rater reliability (Kendall coefficient of concordance ≥0.90)

3.        The construct validity of the original NRS was established using Rasch analysis, which revealed that the NRS stratifies individuals with all AIS classifications into 5 distinct strata

4.        No floor or ceiling effects were found for the NRS, and the scale also demonstrated a logical order of item difficulty

5.        NRS was found to be a stronger predictor of recovery than AIS classification when measuring the change in performance of persons with motor-incomplete SCI on the BBS, 6MWT and 10MWT

6.        Pediatric Neuromuscular Recovery Scale (Peds NRS) was developed by clinicians and researchers with pediatric expertise and consists of 13 items graded on a 12-point scale

7.        The use of the adult NRS and Peds NRS in other neurological populations is also being investigated

ABT (Andrea L Behrman et al., 2019)

USA

Observational

N(HCP)=14

N(SCI–P)=32

HCP – Healthcare Professional

SCI-P – Spinal Cord Injury – Pediatric

Population: (SCI-P) Mean age=6.0±3.0yr.; Gender: males=17, females=15; Level of injury: C1-L5; Level of severity: AIS A=6, B=5, C=2, D=5, N/A=14 (younger than 6yr.); Time since injury: Not reported.

Intervention: None – observational.

Outcome Measures: Interrater reliability.

1.         Interrater reliability coefficient was determined to be near 1 overall for Pediatric NRS score (ICC=0.966; 95% CI, 0.89-0.98)

2.        12 of 16 individual items exhibited high concordance coefficients (Kendall’s W ≥0.8)

3.        4 items were found to have concordance coefficients <0.8 and >0.69.

4.        Interrater reliability was equal among groups defined by neurological level and age, but lower among non-ambulatory individuals.

ABT Melicosta et al. (2019)

USA

Case Series

N=31

Population: Children with acute flaccid myelitis; Age range: 17mo-16yr; Gender: males=17, females=14; Level of injury: Not reported; Severity of injury: Not reported; Time since injury: 0.5-77mo.

Intervention: Participants underwent an intensive Activity

Based Restorative Therapy (ABRT) program between March 2005 and January 2017. Participants completed weight bearing daily through lower and upper limbs as appropriate for their presentation. Locomotor training was completed 3-5x/wk when applicable, including treadmill and over-ground retraining using a body weight supported system. Task-specific practice and massed practice were completed daily with the goal of completing as many repetitions as possible for neurological and daily function restoration. Seventeen of the participants received inpatient treatment, and fourteen received solely outpatient interventions.

Outcome Measures: Spinal Cord Independence Measure (SCIM), Physical Ability and Mobility Scale (PAMS), Functional Independence Measure for Children (WeeFIM), assessment of mobility and transfers, balance, ambulation, activities of daily living (ADLs), hand function (strength and skills), durable medical equipment, and orthotic use.

1.         SCIM scores improved significantly from baseline to post-intervention among participants who had admission and discharge scores (p=0.007).

2.        PAMS improved significantly from baseline to post-intervention (p<0.001)

3.        Significant improvements were observed in the self-care (p<0.001), mobility (p=0.001), cognition domains of WeeFIM (p=0.039), as well as total WeeFIMR developmental quotient (DQ) scores (p<0.001)

ABT Hagen et al. (2020)

USA

Case Series

N=29

Population: Age:6.47±4.14yr; Gender: males=22, females=7; Level of injury: C1-Sacrum; Severity of injury: Not reported; Mean time since injury= 253.59 days.

Intervention: Activity-based restorative therapy (ABRT) was administered to children with acute flaccid myelitis (AFM). The therapy consisted of 1-2h of occupational therapy and 2-3h of physical therapy, which were structured to include interventions of ABRT: functional electrical stimulation (FES), locomotor gait training (LT), massed and task specific practice, and weight loading.

Outcome Measures: Functional Independence Measure for Children (WeeFIM), Manual Muscle Testing (MMT), the Spinal Cord Independence Measure (SCIM), the Physical Abilities and Mobility Scale (PAMS), Modified Rankin Scale for Neurologic Disability (mRS).

1.       On the WeeFIM, significant change was seen from admission to discharge across all subdomains, including self-care (p<0.001), mobility (p<0.001), and cognition (p<0.05)

2.      Significant change from admission to discharge was seen across all muscle groups on the MMT, with effect sizes ranging from p<0.05 (ankle dorsiflexion, knee extension) to p<0.001 (elbow flexion/extension)

3.      Most muscle groups tested showed a moderate effect size

4.      More than a third (39%) of the group improved in mRS rating over the course of admission, with eight individuals improving by 1 point and three individuals improving by 2 points

5.      Overall, children showed significant improvements across all outcome measures, with effect sizes ranging from moderate to large

ABT (Behrman et al., 2008)

USA

Case Report

N=1

Population: 4.5 yr, male, C8 AIS C traumatic SCI, 16 mo post-injury.

Intervention: Body weight support overground walking.

Outcome Measures: American Spinal Injury Association Impairment Scale (AIS), Lower extremity motor score (LEMS), gait speed, walking independence, walking index for spinal cord injury II (WISCI-II), number of steps.

1.         AIS score remained the same after session 74

2.        LEMS score remained at 4/50 at session 74

3.        From session 51 to 76 gait speed increased from 0.19m/s to 0.29m/s

4.        From session 51 to 76 fastest walking speed increased from 0.3m/s to 0.48m/s

5.        WISCI score increased from 0/20 to 13/20

6.        At session 33 the child showed multiple non-cued steps

7.        From session 49 to 74 the child increased from 926 steps per day to 2488 steps per day

ABT (Fox et al., 2010)

USA

Case Report

N=1

Population: 3.5 yr, male, C8 AIS C SCI.

Intervention: Description of child’s walking function and musculoskeletal growth and development during the 2 yr after locomotor training

Outcome Measures: Walking Index for Spinal Cord Injury II (WISCI II), gait speed, cadence, step length, stride length, daily steps activity at home and in the community, musculoskeletal growth and development, gross motor function measure (GMFM-66).

1.         Walking independence remained unchanged with WISCI score staying at 13/20 as he still used a reverse rolling walker to ambulate

2.        Fastest gait speed increased from 0.45m/s at baseline (1 month post LT) to 0.67m/s at 2 yr follow-up

·  After 2 yr., gait pattern was improved

·  Able to generate reciprocal stepping with noticeable absence of shoulder and trunk compensations, particularly on his left side

·  Despite being able to step reciprocally, he could not walk backwards, side step, or maintain balance without upper-extremity support

3.        Cadence increased from 63.35 steps/min at baseline to 70.75 steps/min at 2 yr follow-up

4.        Step length increased in both legs:

·  Left leg: increased from 42.25cm at baseline to 51.31cm at 2 yr follow-up

·  Right leg: increased from 44.07cm at baseline to 63.55cm at 2 yr follow-up

5.        Stride length increased in both legs:

·  Left leg: increased from 85.95cm at baseline to 114.79cm at 2 yr follow-up

·  Right leg: increased from 87.19cm at baseline to 114.47cm at 2 yr follow-up

6.        Daily steps increased from about 1600 steps/day at baseline to 3000 steps/day at 2 yr follow-up

7.        Over the 2-yr. period the child was not diagnosed with scoliosis, but mild coxa valga was noted at both hip joints and radiology reports indicated all findings stable

8.        GMFM-66 scores remained stable over the 2-yr. period

ABT (Behrman et al., 2012)

USA

Case Reports

N=3

Population: Case 1: 15 yr, male, T5 SCI, AIS D. Case 2: 14 yr, male, T5 AIS C ruptured arteriovenous malformation; Case 3: 14 yr, male, C2 AIS D SCI.

Intervention: Locomotor Training (Body weight support treadmill training, overground walking), community integration.

Outcome Measures: 10-meter walk test (10MWT),6-minute walk test (6MWT), Berg Balance Scale (BBS),

Case 1

1.         10MWT with initial rolling walker (RW) device improved from 0.16m/s at initial evaluation to 1.12m/s at discharge and declined to 1.06m/s at 12mo. follow-up

2.        10MWT with current bilateral single point canes (BSPCs) devices improved from 0.77m/s at session 20 (started use of BSPCs) to 1.22m/s at discharge and declined to 1.01m/s at 12mo. follow-up (use of BSPCs stopped after session 40)

3.        6MWT with initial rolling walker (RW) device improved from 53.07m at initial evaluation to 291.69m at discharge and improved further to 298.4m at 12mo. follow-up

4.        6MWT with current bilateral single point canes (BSPCs) devices improved from 242.32m at session 20 (started use of BSPCs) to 308.15m at discharge and improved further to 316.11m at 12mo. follow-up (use of BSPCs stopped after session 40)

5.        BBS score improved from 8/56 at initial evaluation to 48/56 at discharge and declined to 47/56 at 12mo. follow-up

Case 2

1.         10MWT with initial rolling walker (RW) device improved from 0.12m/s at initial evaluation to 0.22m/s at session 80 and improved further to 0.38m/s at session 200

2.        10MWT with current bilateral loftstand crutches (BLCs) devices remained at 0.1m/s from session 40 (started use of BLCs) session 80 and improved to 0.45m/s at session 200 (use of bilateral single point canes (BSPCs) at session 200)

3.        6MWT with initial rolling walker (RW) device improved from 25.6m at initial evaluation to 44.8m at session 80 and improved further to 117.3m at session 200

4.        6MWT with current bilateral loftstand crutches (BLCs) devices declined from 13.6m at session 40 (started use of BLCs) to 7.6m at session 80 but improved to 123.8m at session 200 (use of bilateral single point canes (BSPCs) at session 200)

5.        BBS score increased from 7/56 at initial evaluation to 23/56 at session 80 and improved further to 31/56 at session 200

Case 3

1.         10MWT increased from 1.3m/s at initial evaluation to 1.5m/s at session 20 and increased further to 1.72m/s at discharge

2.        6MWT increased from 435m at initial evaluation to 467m at session 20 and increased further to 500m at discharge

3.        BBS score increased from 55/56 at initial evaluation to 56/56 at session 20 and sustained a score of 56/56 at discharge

LEMS

·  LEMSs for the three reported cases were 29, 22, and 46, respectively

·  Only the adolescent in Case 1 demonstrated significant change (17 points) in his LEMS post-LT that could also account for improvement in function

·  For the other two instances, the LEMS change was relatively minor

ABT (Heathcock et al., 2014)

USA

Case Report

N=1

Population: 15 mo, male, T11-L4 in-utero spinal cord tumour resulting in SCI with subsequent removal at 5.5 wk of age.

Intervention: Treadmill Step Training Program

Outcome Measures: Number and pattern of walking steps, gait speed, observational gait analysis, standing.

1.         An increase in the percentage of alternating steps and a matching decrease in the percentage of single steps over the 20-month intervention period were observed

2.        At 30 months of age, a pattern of alternating stepping on the treadmill occurred more than 80% of the time, in sharp contrast to the initial 6 months of training when alternating steps comprised fewer than 10% of the total steps

3.        Number of steps increased from 1 step at 16mo to 10 steps at 22mo.

4.        At 22mo. of age, steps were measured in distance and increased from 3m at 22mo. to about 6m at 31mo.

5.        Gait speed varied over the 20mo. period (0.48m/s at 31mo. and 0.40m/s at 35mo.)

6.        Only the right leg accounted for most of the stepping rate from 15 through 20 months of age because there were few or no independent steps on the left

7.        Over the 20-month intervention period, stepping with the right and left legs increased, with a greater rate of improvement being observed for the left leg, suggesting improvements in symmetry and bilateral function

8.        Static standing improved from standing with an arm support on the walker for 30s with contact guard assistance (CGA) at 15mo. to static standing for 20s with standby assistance

TM and OG walking (O’Donnell & Harvey, 2013)

Australia

Case Report

N=1

Population: 17 yr, male, T6 AIS C traumatic SCI, 16 mo post injury.

Intervention: Body weight support treadmill training, overground walking

Outcome Measures: Lower extremity motor score (LEMS), Walking index for spinal cord injury (WISCI II), 6-min walk test (6MWT), 10-m walk test (10MWT), Timed up and go (TUG), Pediatric Quality of Life Inventory (PedsQL).

1.         LEMS score improved from 16 to 17 from pre- to post-training and from 17 to 18 from post-training to follow-up

2.        WISCI score improved from 6 to 9 from pre- to post-training and remained at 9 at follow-up

3.        6MWT score improved from 67m (1 rest) at pre-training to 76m (no rests) at post-training and further improved to 80m (no rests) at follow-up

4.        10MWT score improved from 32.2s at pre-training to 30.3s at post-training but declined to 33.6s at follow-up

5.        TUG score improved from 44.6s at pre-training to 40.1s at post-training but declined to 42.0s at follow-up, remaining improved compared to pre-training

6.        Overall PedsQL score improved from 38/92 at pre-training to 23/92 at post-training and remained at 23/92 at follow-up

Compared SCI to non-SCI Fox et al.  (2013)

USA

Pre-Post

N=5

Population: Mean age:8.6±2.7yr; Gender: males=4, females=1; Level of injury: C1-C7=2, T1-T12=3; Time since injury>1yr.

Intervention: Modular control of patients with incomplete spinal cord injury (ISCI) was examined via locomotor tasks including treadmill training, overground walking, pedaling, stair climbing, supine lower extremity flexion/extension, and crawling.

Outcome Measures: Lower extremity motor score (LEMS), variance accounted for (VAF), electromyogram (EMG) recordings.

1.         Fewer modules were needed to account for muscle activation in the lower extremities of children with ISCIs compared with controls (p<0.05)

2.        An average of 2.11±0.71 modules was required to account for the EMG data recorded in lower extremities of children with ISCI

3.        With the use of the muscle weightings from treadmill walking and task-specific timing profiles, the VAF exceeded 86% for all locomotor tasks

4.        The VAF exceeded 90% for all tasks performed by the children with ISCI

5.        Modularity is constrained in children with ISCIs.

BWSTT (Nymark, 1998)

Canada

Case Report

N=1

Population: Mean age=33.2±17.6yr.; Gender: males=3, females=2; Level of injury: C2-T10; Severity of injury: AIS A=0, B=1, C=3, D=1; Time since injury=36.8±7.0d.

Intervention: Body Weight Support Treadmill Training (BWSTT)

Outcome Measures: Clinical Outcome Variables Scale (COVS), treadmill speed, cadence, stride length, Range of Motion (ROM) hip and knee sum, Electromyography (EMG) summed indices.

1.         Mean COVS scores significantly increased from pre- to post-training (p=0.03)

2.        Mean treadmill speed significantly increased from pre- to post-training (p=0.001)

3.        Mean cadence significantly increased from pre- to post-training (p=0.001)

4.        Mean stride length (m) increased from pre- to post-training but not significantly (p=0.16)

5.        Mean ROM (degrees) increased from pre- to post-training but not significantly (p=0.07)

Mean summed indices of ROM increased from pre- to post-training but not significantly (p=0.09)

TMNOG Walking (Hornby et al., 2005)

USA

Case Reports

N=3

Population: Case1: 13 yr., female, C6 AIS B traumatic SCI, 6 mo. post-injury.

Case 2: 40 yr., male, T2 AIS B spinal vascular accident, 5wk. post-injury.

Case 3: 43 yr., male, C6 AIS C, 18 mo. post-injury.

Intervention: Robotic- or therapist-assisted body weight support treadmill training.

Outcome Measures: American Spinal Cord Injury (AIS) classification, Lower Extremity Motor Score (LEMS), Functional Independence Measure Locomotor (FIML) subscale, Walking Index for Spinal Cord Injury II (WISCI II), gait speed, gait endurance, Timed Up and Go (TUG) tests, Standing Functional Reach Test (FRT), Sitting Functional Reach Test (FRT).

Case 1

1.         AIS score improved from class C at initial evaluation to class D at final evaluation

2.        LEMS score increased from 6 at initial evaluation to 48 at final evaluation

3.        FIML subscale increased from 0 at initial evaluation to 6 at final evaluation

4.        WISCI score increased from 0 at initial evaluation to 16 at final evaluation

5.        Gait speed increased from 0.29m/s at transition evaluation to 0.55m/s at final evaluation

6.        Gait endurance increased from 243ft at transition evaluation to 480ft at final evaluation

7.        TUG score not evaluation in case 1

8.        Sitting FRT remained >10in at both transition and final evaluation

9.        Standing FRT increased from 4in at transition evaluation to 7in at final evaluation

Case 2

1.         AIS score improved from class C at initial evaluation to class D at final evaluation

2.        LEMS score increased from 19 at initial evaluation to 50 at final evaluation

3.        FIML subscale increased from 0 at initial evaluation to 6 at final evaluation

4.        WISCI score increased from 0 at initial evaluation to 13 at final evaluation

5.        Gait speed increased from 0.36m/s at transition evaluation to 0.58m/s at final evaluation

6.        Gait endurance increased from 460ft at transition evaluation to 632ft at final evaluation

7.        TUG score improved (decreased) from 30.6s at transition evaluation to 18.5s at final evaluation

8.        Sitting FRT remained >10in at both transition and final evaluation

9.        Standing FRT increased from 6in at transition evaluation to >10in at final evaluation

Case 3:

1.         AIS score remained at class C from initial to final evaluation

2.        LEMS score decreased from 31 at initial evaluation to 30 at transition evaluation, but increase back to 31 at final evaluation

3.        FIML subscale increased from 5 at initial evaluation to 6 at final evaluation

4.        WISCI score remained at 13 from initial to final evaluation

5.        Gait speed increased from 0.11m/s at transition evaluation to 0.21m/s at final evaluation

6.        Gait endurance increased from 100ft at transition evaluation to 204ft at final evaluation

7.        TUG score not evaluation in case 3

8.        Sitting FRT remained at >10in from initial to final evaluation

9.        Standing FRT decreased from 10in at initial evaluation to 6in at final evaluation

Author, Year

Country

Study Design

Number of Studies Included for Review

Method

Databases Search

Level of Evidence

Research Question

Results
Donenberg et al. (2019)

USA

Systematic review of published articles

N=11

Method: Comprehensive literature search of articles discussing the effectiveness of locomotor training (LT) in children following spinal cord injury (SCI). Forms of LT included body-weight supported treadmill or over ground training, functional electrical stimulation, robotics, and virtual reality. Articles were restricted to children between the ages of 15 mo to children 18 yr.

Databases: PubMed, PEDro, CINAHL, Cochrane, PsycINFO, Web of Knowledge.

Level of evidence: Evidence was categorized according to the American Academy for Cerebral Palsy in Developmental Medicine (AACPDM) levels of evidence. Level 4: 2 papers, Level 5: 9 papers.

Questions/ measure/ hypothesis:

Examine the effectiveness of LT in children with SCI through measuring improvements in ambulation.

1.       Outcomes assessed: Gait Speed, TUG, WISCI II, FES, Robotics, LEMS, NRS, ABT

2.      Age, completeness, and level of injury remain the most important prognostic factors to consider with the LT intervention.

3.      There was a greater likelihood for recovery of locomotion for adults with incomplete SCI when training begins closer to the time of injury.

4.     All forms of LT used in studies within this review had positive changes in locomotion. No one form of LT has been determined to be superior.

5.      Children might benefit from LT to develop or restore ambulation following SCI.

Gandhi et al. (2017)

Canada

Systematic Review

N=13 (N=13 pediatric SCI)

“A systematic review to summarize the who, what, when and how of walking interventions in children with SCI”

OMs: Gait Speed, Robotics, TM and OG walking, WeeFIT, TUG, WISCI II, ABT, Observational gait analysis

1.         Outcome Assessed: Training parameters and walking outcomes, total training duration (duration × frequency × number of weeks)

2.        The training durations, frequencies, and modes used with the children varied; however, overground walking practice was included in 10/13 pediatric studies.

3.        Improvements in walking capacity, speed, and distance were comparable between children and adults.

4.        There was a trend for greater gains with greater total training durations.

5.        There is a paucity of high-quality research examining interventions targeting walking after pediatric SCI; however, intensive training, including practice overground, results in notable improvements.

Funderburg et al. (2017)

USA

Scoping Review

N=26 (N=10 pediatric SCI)

“This is a scoping review of the literature on interventions for gait in individuals with pediatric spinal cord impairments.”

OMs: Gait Speed, WeeFIM, TUG, WISCI II, orthoses, FES, ABT

1.         Four categories of interventions were identified:

·          Orthoses/assistive devices

·          Electrical stimulation

·          Treadmill training

·          Infant treadmill stepping

2.        Studies on orthotic intervention, electrical stimulation, and treadmill training reported benefits for various components of gait.

3.        The majority of studies (77%) were classified as levels of evidence III and IV.

Damiano & DeJong (2009)

USA

Systematic Review

N=29 (N=6 pediatric SCI)

“A systematic review was undertaken to explore the strength, quality, and conclusiveness of the scientific evidence supporting the use of treadmill training and body weight support in those with pediatric motor disabilities.”

OMs: ABT, Home activities

1.         A total of 29 studies were identified, 6 of which concern individuals with pediatric SCI.

2.        The studies identified for those with SCI were either individual case reports or individual subject data from a multiple case series.

3.        All six studies included other types of intervention including stretching, overground training or other non-specific physical and/or occupational therapy rehabilitation exercises.

4.        Most outcome results were positive, with some showing large and clearly clinically significant changes such as progression from no ability to step, to walking independently with an assistive device by the end of training.

Discussion

Compensation-Focused Interventions for Standing and Gait/Walking

The evidence for compensation-based approaches to standing and walking in pediatric SCI spans from 1994-2017. The use of functional electrical stimulation (FES) to stand has been tested in small-scale studies and includes examination of the criteria for eligibility for surface lower extremity stimulation (Triolo et al., 1994), study of FES home use for standing/mobility (Moynahan, Mullin, et al., 1996), comparison of percutaneous intramuscular electrodes to leg braces for those with thoracic complete SCI (Bonaroti et al., 1999a; Bonaroti et al., 1999b), a 3-year follow-up study in one subject with percutaneous intramuscular electrodes (Betz et al., 2002), and FES compared to long-leg braces (knee-ankle-foot orthoses, KAFOs)(Betz et al., 2002), and FES for upright mobility (Johnston et al., 2003) and for walking via swing-to gait pattern (Johnston et al., 2005). While able to achieve standing with surface FES, researchers noted significant barriers to use of surface FES, such as the impracticality of application of electrodes for function, and reluctance of the participant to use the system for the entire day (Moynahan, Mullin, et al., 1996). Implanted FES systems showed comparable functional impact when compared to KAFOs and even better performance in accomplishing certain tasks (Betz et al., 2002; Johnston et al., 2005; Johnston et al., 2003). While promising, the most relevant information is that the FES surface and implantable systems did not advance from experimental study to clinical translation for use by children and adolescents with SCI in the home and community.

Standing frames, braces, and assistive devices to achieve upright standing and ‘walking’ (i.e., brace-walking) have also been investigated as compensatory strategies for lower-limb paralysis. Lower limb braces provide external support and joint alignment to achieve the standing position and possibly swing-through gait with a walker or forearm crutches. Vogel and colleagues (1995) provide a thorough description of the pediatric population using braces and devices to achieve standing and walking describing ‘who’ (e.g., age, injury level, time since injury), progress to a different device (e.g., parapodium to reciprocating gait orthosis, RGO), and duration of use (including age at point of change to another device, abandonment or ceasing to ambulate, i.e., approximately age 10 years).  Choksi et al. (2010) reported outcomes of 32 child and adolescent patients with subacute SCI who received inpatient rehabilitation (occupational therapy and physical therapy) using the Pediatric Evaluation of Disability Inventory.  While significant gains in distance and speed were achieved for basic indoor, outdoor locomotion and more complex locomotion (i.e., being able to carry objects and walk independently without devices) did not significantly change. Several case studies addressed the type of assistive device being used during gait training and its potential impact on outcomes (Altizer et al., 2017), thus demonstrating the merits of certain types of equipment. Research concerning the use of braces and assistive devices to achieve ‘brace-walking’ beyond the reports of by Vogel et al. 1995 and 2010 is negligible. This may mean that the use of these strategies remains the standard of care. While robotic devices for ambulation have been introduced to the market for pediatric use, scientifically reported outcomes and follow-up via research are lacking.

Recovery-Focused Interventions for Standing and Gait/Walking

The plethora of research providing foundational rationale and arguments for recovery-based approaches to achieve walking via repair of the neuromuscular system through activity-dependent plasticity (Edgerton et al., 2004) is beyond the scope of this review. This critical new knowledge of the neurobiological control of posture and locomotion, however, provides a physiological and neural basis for training strategies to focus on accessing the ‘smart’ spinal cord below the lesion for practical use. Published research in adults with SCI using activity-based locomotor training or activity-based restorative therapy have preceded research and clinical use of these strategies for children with SCI.  Most literature regarding activity-based locomotor training and activity-based restorative therapy in pediatric SCI are case studies or studies with small sample sizes. Nevertheless, they introduce the potential for a new direction in rehabilitation.

Prosser et al. (2007) and Heathcock et al. (2014) reported the benefits of ‘locomotor training’ in case studies of children during the acute phase post-injury (< 1 year) with the potential for interaction with ‘natural recovery’. In addition, the case study by Heathcock and colleagues (2014) was the first to report use of activity-based locomotor training in a child who had not yet mastered ambulation as a developmental milestone prior to their injury. In comparison, Behrman et al. (2008) and Fox et al. (2010) (follow-up) reported achievement of a reciprocal pattern of walking in a child with chronic, cervical SCI and non-ambulatory (American Spinal Injury Association Impairment Scale C, lower extremity motor score < 10) via locomotor training.  Similarly, Behrman et al. (2012), O’Donnell and Harvey (2013), and Hornby et al. (2005) reported positive outcomes in standing and walking using treadmill training for adolescents with incomplete SCI. Both manually-facilitated stepping and robotic-assisted stepping were reported, though not compared.  Similar to the literature in adult SCI, achievement or improvement in ambulation using activity-based locomotor training/activity-based restorative therapy appears most effective in those with incomplete SCI. The findings for 26 consecutively-enrolled children in a clinical activity-based locomotor training program demonstrate the high percentage of improvements in walking for children with incomplete SCI and the very low percentage of children with complete injuries who achieve even therapeutic or household ambulation (Andrea L Behrman et al., 2019). Clinicians may thus speculate that activity-based locomotor training should be abandoned for those children with complete injuries. Evidence from research with adults with complete SCI, however, may once again point the direction for children with severe SCI and motor paralysis. Recent literature on epidural stimulation combined with activity-based locomotor training to achieve reciprocal walking in adults with SCI (Angeli et al., 2018) and the use of transcutaneous spinal stimulation to enable stepping behavior in adults and a 17-year-old with acute SCI (Baindurashvili et al., 2020) may suggest important future directions (Baindurashvili et al., 2020) may for the rehabilitation of children with severe SCI and motor paralysis. Reporting the findings for adults with SCI is beyond the scope of this chapter.  Pilot work studying the use of transcutaneous spinal stimulation combined with activity-based locomotor training to enable stepping in non-ambulatory children with chronic SCI is ongoing and findings have yet to be published (Clinicaltrials.gov # NCT04077346).

Three reviews are also considered among the body of evidence for achievement of ambulation post pediatric SCI (Damiano & DeJong, 2009; Funderburg et al., 2017; Gandhi et al., 2017), and are each discussed below.

Damiano and DeJong’s (2009) systematic review explored the strength, quality, and conclusiveness evidence on the use of treadmill training and body weight support in those with pediatric motor disabilities. Of the 29 studies identified from the literature search, six involved individuals with pediatric SCI. The outcome results of using treadmill training and/or body-weight support in the pediatric SCI population were positive, with some showing large and clinically significant changes, such as progression from no ability to step, to walking independently with an assistive device by the end of training. However, the authors pointed out that since the studies identified were either individual case reports or individual subject data from a case series, conclusions regarding the efficacy of the use of treadmill training and body-weight support in children with SCI should be drawn with caution, and more controlled studies, especially those utilizing randomized designs, are needed (Damiano & DeJong, 2009).

Funderberg et al. (2017) reported evidence for three approaches: use of orthotics and assistive devices, electrical stimulation (surface and implanted), and ‘treadmill-training.’ It was noted that orthotic studies typically compare one type of orthosis to another for utility, but that the evidence for any orthotic device is not sufficient to warrant development of a clinical guideline. Electrical stimulation, while showing benefit, requires equipment, intensive training, potentially invasive procedures, and lacks long-term assessments for physiological effects and meaningful use. As noted, FES and implantable stimulation has not advanced to a level of clinical application for ambulation goals. Lastly, ‘treadmill training’ leads to use of less restrictive devices and improvements in speed, distance, capacity for walking (number of steps per hour), and community-based activity (number of steps per day) for children with varying impairment levels. Funderberg et al. (2017) recommended this mode of training for functional gains. Infant treadmill training has been reported in the context of spina bifida as potentially beneficial, yet long-term follow-up studies are needed. While not reported in the pediatric SCI literature, Funderberg et al also postulated that early implementation (i.e., at the typical age of cruising, standing, and step initiation) of therapies promoting the sensorimotor experience of walking and activity-dependent plasticity may be advantageous to children injured in utero or under one year of age.

Gandhi et al. (2017) further explored the parameters of training, reporting the many differences across cases and studies with the treadmill being a common thread across studies. In this review, understanding the intent and therapeutic goal in selecting and using specific equipment (e.g., treadmill, partial body weight support), how to perform and deliver the training and make clinical decisions, and progress a child through therapy were highlighted as critical to the success of any training program. It should also be noted that the use of the term ‘treadmill training’ to describe an intervention is felt to be insufficient and likely results in grouping of evidence and outcomes in a way that may lead to misinterpretation and misunderstanding of the therapy and its effect (Behrman et al., 2008). Gandhi et al. (2017) summarized key findings from a review of 13 pediatric studies for walking. First, there was a trend towards greater improvement in studies of greater dosage/duration of training.  Second, 10/13 studies included overground training as a transfer of skill from treadmill to the real-world environment, and this strategy appeared to be beneficial. Third, an argument was made that children with complete SCI should be included in research for walking recovery despite earlier concerns about their potential for recovery. This is based on the likelihood that children have greater potential for recovery relative to those with adult-onset SCI.

Lastly, while advocating for more rigorous studies (e.g., inclusion of blinded assessors) Gandhi et al. (2017) cautioned that the traditional randomized clinical trial may not be feasible with this ‘low-prevalence population’. Thus, the design of studies for pediatric SCI may require alternative methodological design strategies. With the very low incidence of recovery of walking in the chronic stages of SCI, non-ambulatory pediatric subjects serving as their own control should provide optimal ‘controls’, decrease heterogeneity of the sample, and allow for a smaller ‘n’. Understanding ‘who’ benefits beyond the simplistic view of SCI as ‘complete’ or ‘incomplete’ will necessitate more sensitive exploration of predictors and biomarkers for response (Mesbah et al., 2021; Rejc et al., 2020), as well as study of mechanisms for response to interventions.

Measurements: Compensation Focus and Recovery Focus

Outcome measurements for standing/walking are distinct in whether they do or do not take into account the mechanism through which the outcome is achieved (i.e., via compensatory strategies or recovery of function).  Measures that allow the use of compensation strategies emphasize achievement of a ‘functional’ goal regardless of the behavioral strategy or equipment used to accomplish the goal. For instance, a patient may successfully move from sitting to standing using a walker to assist with balance, and strength of the arms to compensate for leg weakness. Achieving standing is the only goal and employed compensation strategies are not “counted against” achievement of the goal. The many outcome measures employed to assess standing/walking in SCI that do allow patients to use compensatory strategies without penalty include:

  • Pediatric Evaluation of Disability Inventory
  • Spinal Cord Independence Measure
  • Time to complete a task
  • Functional Independence Measure
  • Gait speed
  • Years using a device
  • Functional Independence Measure for Children
  • Timed Up and Go
  • Walking Index of SCI I and II – in some instances (e.g., Walking Index of SCI II), the use of equipment is accounted for in the scoring, but equipment and compensation are allowed.

A recovery-focused measure, in comparison, provides a means, even stepwise, to assess the neuromuscular capacity to perform a task without behavioral or device/equipment compensation. Thus, a sit-to-stand is performed and the incremental capacity to perform with a typical, kinematic pattern of trunk and limbs is assessed.  The Neuromuscular Recovery Scale and Pediatric Neuromuscular Recovery Scale (Behrman et al., 2017; Andrea L Behrman et al., 2019; Behrman et al., 2012); observational gait analysis, and the Segmental Assessment of Trunk Control (Argetsinger et al., 2019; Goode-Roberts et al., 2021) are examples of recovery- or restorative-focused measures. Compensations are not ‘allowed’ or are noted with scoring relevant to their presence or absence during task performance.

Interventions and Measurements for Trunk Control:

Trunk control is instrumental to the achievement of a variety of tasks from breathing and coughing to sitting/standing upright to reaching overhead to walking. The knowledge that SCI-induced trunk paralysis is irreversible guides the current clinical decision-making by therapists and the medical field (Schottler et al., 2012). Historically, therapy does not expect to restore function, but to adapt the task or environment to achieve a novel solution to the problem (Chafetz et al., 2007; Mehta et al., 2004; Mulcahey et al., 2013; Sison-Williamson et al., 2007).

Clinically, the Trunk Impairment Scale, the Gross Motor Function Classification System, and the Pediatric Berg Balance Scale have been used to measure trunk control in children with SCI. However, independent sitting and standing by participants is a prerequisite for these tests. Therefore, testing trunk control in children who have not achieved independent sitting and in children with a low functional level is limited. In addition, these tests measure trunk performance as a single unit allowing for a compensatory posture (e.g., kyphotic posture). To determine the motor impairment of trunk function, the International Standards for Neurological Classification of SCI is used by clinicians (Mulcahey et al., 2011). Unfortunately, because function of trunk muscles cannot be tested individually, the scale relies on truncal sensory perception (tested with the patient in supine) as a stand-in for trunk motor function (assuming that motor function is preserved at the truncal levels where sensation is preserved). In addition, the scale is only valid for children 6 years and above (Mulcahey et al., 2011).

A new pediatric measurement instrument, the Segmental Assessment of Trunk Control, was recently introduced and validated to assess and track improvements in trunk control in children with SCI who lack independent sitting or in whom sitting control is impaired (Argetsinger et al., 2019; A. L. Behrman et al., 2019). This evidence demonstrated improved trunk control in children with SCI post-activity-based locomotor training and has set forth a paradigm shift in our expectation of recovery of trunk function after SCI. In recent studies, surface electromyography collected during Segmental Assessment of Trunk Control and active trunk tasks revealed apparent preservation of postural extensor muscle activation after pediatric-onset SCI. This preservation reflects residual supraspinal influence on spinal motor circuits and has important implications for the potential to tap into preserved trunk activation below the lesion level in pediatric-onset SCI (Atkinson et al., 2019; Singh et al., 2020). The implications of this finding (beyond a measurable improvement in a performance score (i.e., improved Segmental Assessment of Trunk Control score) without compensation) are unclear. Further investigation is needed to determine any meaningful impact of preserved and trainable trunk control in the home, school, and community for children with SCI, as well as potential reduction of risk for scoliosis (Argetsinger et al., 2020; Goode-Roberts et al., 2021).

Conclusion

In reviewing the evidence for lower extremity and trunk control rehabilitation across time (i.e., 1994-2021), a paradigm shift in the intended therapeutic end-goal is observed. The original intent was to achieve upright trunk posture, standing, and walking as a functional goal with the implementation of external support (i.e., leg braces and assistive devices). Now, the intent is to achieve upright trunk posture, standing, and walking via the intrinsic neurobiology for the control of posture, standing, and walking. For instance, leg braces (e.g., knee ankle foot orthoses or reciprocating gait orthosis) are meant precisely as an end goal to train the patient to walk with braces. Thus, the braces serve to compensate for paralysis of the lower extremities. The braces are not a therapeutic step towards standing or walking without braces. The goal is to achieve the ‘functional’ ability to stand or walk dependent upon braces (and assistive devices) to provide external support for an extended position of the knees, stable position of the ankles, and in some cases, advance a step with brace-promoted hip flexion during gait. This functional goal for standing and walking is based on the premise that these goals are achieved only in the context of external support, that the voluntary motor control of the lower extremities is insufficient for standing or stepping, and that the functional goal of standing and stepping is meritorious for a child whether practical, developmentally-appropriate or simply desirable. Achieving standing and walking via this strategy is reported as changing with musculoskeletal growth and aging into adolescence and ultimately adulthood when for practical circumstances (e.g., speed of mobility) brace walking is abandoned for wheeled mobility.

Restorative Treatment

After a pediatric SCI, it has been assumed that paralysis is permanent, especially in the chronic period post-SCI (typically considered >1-year post SCI), and the individual will never stand or walk independently again. Upright posture and mobility provide interactions with the child at the same height as their peers, opportunity for participation in school and community. Therefore, children have been encouraged to use wheeled standers or devices such as orthoses, robotics, and FES (Betz et al., 2002; Bonaroti et al., 1999a; Bonaroti et al., 1999b; Johnston et al., 2005; Johnston et al., 2003; Vogel & Lubicky, 1995). Measurements to evaluate the uses of equipment for upright posture and mobility includes gait speed and the speed to perform a task (Betz et al., 2002; O’Donnell & Harvey, 2013). However, these measures ignore the mechanics of how the task was performed and place increased demands on the upper extremities. Furthermore, the devices that passively produce an upright posture and upright mobility are cumbersome and lead to a high rate of user abandonment, especially as the child develops into adolescence.

Edgerton et al. (1991) identified that a restoration approach may have potential for humans after SCI. His findings were based on a decade of animal research, showing the potential of motor recovery and walking after SCI. Since then, there has been a divergence between compensatory interventions (with braces and wheeled standers) and restorative interventions (including locomotor training). Over a decade of research has supported restoration interventions for children with spinal cord injuries to improve motor function below the level of the lesion (Baindurashvili et al., 2020; Behrman et al., 2008; Andrea L Behrman et al., 2019; Behrman et al., 2012; Fox et al., 2010; Heathcock et al., 2014; Hornby et al., 2005; O’Donnell & Harvey, 2013; Prosser, 2007). No intervention, compensatory or restorative-based, however, has consistently resulted in children with motor complete SCI standing or walking reciprocally independently without bracing or assistive devices. Alternatively, children and adolescents with incomplete SCI demonstrate benefits.

Restoration interventions continue to be a “new frontier” of research, with early research based on case studies (Behrman et al., 2008; Behrman et al., 2012; Fox et al., 2010; Heathcock et al., 2014; Prosser, 2007). Outcomes have measured how the movement occurs, including step length, stride length, and stepping patterns (Fox et al., 2010) and modular contributions to movement patterns across motor tasks (Fox et al., 2013). Restoration interventions require maximizing weight bearing on the legs, promoting normal kinematics, optimizing sensory cues, minimizing compensation strategies, and knowledge of the intrinsic biology for motor control: posture and locomotion, particularly contributions of the spinal circuitry and sensory input. The requirements for restoration interventions significantly contrast the approach to compensatory interventions (Behrman et al., 2008; Roy et al., 2012). The future of compensatory intervention models is focused on robotics, or potentially ‘smart orthotics’ but with no evidence to date in the scientific literature to support application in the clinic for children. Research for restorative interventions is focused on altering the state of excitability of the spinal cord via various interventions from those emphasizing the sensorimotor experience/training of posture and walking to spinal stimulation and combining interventions (Angeli et al., 2018; Gerasimenko et al., 2015; Harkema et al., 2011).

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