Physical Activity and Functional Improvement Including Activities of Daily Living
As demonstrated in the previous section, appropriately configured exercise has been demonstrated to increase muscle strength and reduce atrophy. Most rehabilitation professionals presume there is also a clear link between therapeutic exercise and functional improvement that might manifest in enhanced performance of activities of daily living (ADLs). The present section examines the literature that assesses the functional consequences of physical activity programming. As described in our chapter, Rehabilitation Practices (Wolfe et al. 2010), there are numerous reports of substantial gains achieved over the period of inpatient rehabilitation for outcome measures associated with functional independence (e.g., Functional Independence Measure (FIM) but the definitive attribution of these gains to specific aspects of rehabilitation programming remains to be fully elucidated.
Discussion
Of the interventional studies noted in Table 2, eight studies could be described as examining functionally-based outcome measures as a primary measure. Of note, Klose et al. (1990) used an RCT design to examine the effect of four different combinations of conventional physical exercise therapy (PET i.e., strengthening, mat mobility, and transfer, self-care and wheelchair skills training), neuromuscular stimulation (NMS)-assisted exercise or EMG biofeedback training focused on the upper limbs of males and females with tetraplegia (C4-C6) who were at least 1 year post-injury (n=43, 39 completing). Treatment subgroups received one of the following: 1) 8 weeks each of EMG biofeedback followed by PET, 2) 8 weeks each of EMG biofeedback followed by NMS, 3) 8 weeks each of NMS followed by PET, 4) 16 weeks of PET. All four of these treatment groups showed significant improvement in mobility and self-care scores (p<0.05) although there were no differences between groups with each method was equally beneficial in terms of functional improvement.
Bjekefors et al. (2006b) and Bjekefors et al. (2007) implemented kayak ergometer training sessions for 60 minutes, 3/week for 10 weeks. The functional movements that were tested included sit-and-reach, propelling, and transfers as well as anterior-posterior angular and linear displacement, medio-lateral angular and linear displacement and trunk twisting to determine postural stability. There was a statistically significant improvement in the sit-and-reach test, mounting-a-platform, propelling 15m on a level surface and propelling 50m on an incline from pre-to post-training (p<0.05). The results of the transfer test showed a 10% mean increase after training. In the 2007 study, there were significantly smaller AP angular trunk displacements during lateral translations when comparing post-training with pre-training (p=0.038) although there were no differences in FWD or BWD translations. Results also demonstrated significantly smaller AP linear trunk displacements post-training compared to pre-training for all translations (LAT, FWD and BWD) (p<0.05). There was an effect of training on ML angular trunk displacement during lateral translations for kinematic response IV (trunk position 1s after the end of platform deceleration) (p<0.05). There were no significant effects of training on ML linear displacement during lateral translations. There were statistically significant improvements in trunk twisting post-training (p<0.05). Overall, patients’ postural stability was improved; patients showed smaller rotational and linear displacements of the trunk post-training.
In the study by Hetz et al. (2009), participants completed the Physical Activity Assessment for People with Spinal Cord Injury (PARA-SCI). The authors’ objective was to examine participation in activities of daily living (ADLs) and fitness-related factors (i.e., VO2max). Although there were no statistically significant differences in terms of ADL participation between men and women and between individuals with paraplegia and tetraplegia, when compared to men, women spent more time with domestic and personal care activities and those with paraplegia spent more time transferring, cleaning, and preparing food, while individuals with tetraplegia spent more time engaging in dressing, toileting, and wheeling. VO2max was significantly associated with increased participation in cleaning and wheeling (p<0.05). Wheeling, dressing, and toileting were positively correlated with moderate- and heavy-intensity LTPA (p<0.05).
da Silva et al. (2005) conducted a prospective controlled trial (n=16) examining the effect of a 4 month swimming program (45 minute 2x/week) on persons with complete SCI (14 with paraplegia) who had just been discharged from inpatient SCI rehabilitation. The primary outcome measure was the FIM and significant differences were noted for the FIM transfer subscale score (p=0.02), overall motor subscale score (p=0.01) and overall score (p=0.01) between those participating in the swimming program as compared to those in the control group who performed only their routine daily activities.
Duran et al. (2001) also incorporated the FIM in assessing the effects of a mixed exercise program involving three 120 minute sessions/week over 16 weeks. Participants were outpatients with paraplegia and 12 of 13 were ≥ 5 months post-injury (median 10 months). This structured program consisted of activities that were focused on mobility, aerobic resistance, strength, coordination, recreation and relaxation. Significant increases were seen in total FIM score relative to baseline (p<0.001) and time was reduced for all nine wheelchair skills tested (p<0.04 or less) associated with the exercise program. These benefits along with increases in strength and exercise capacity were seen in the absence of statistically significant changes in various physiological parameters (i.e., lipid profile, body composition) although each of these variables did approach significance (p=0.076 to 0.2). Harness et al. (2008) also incorporated a multimodal intense exercise (IE) program that included active assistive, resistance training, load bearing, cycle ergometry, gait training/supported ambulation, and vibration training. The training occurred over 6 months with participants engaging in the exercise program for 56 ± 6 days. Post-training, ASIA motor scores demonstrated a statistically significant improvement in the IE group compared with the control group (p=0.001). Lower extremity scores accounted for most of the ASIA motor score changes and were statistically significant (p<0.05).
Alexeeva et al. (2011) also used the FIM (motor domain component only) as well as the Tinetti scale as secondary measures in a body-weight supported treadmill or fixed track program compared with conventional physical therapy. Participants in all groups engaged in therapy for 1 hour/day, 3 days/week for 13 weeks. They found a slight increase in FIM motor scores post-intervention, but it was not significant. However, they did find significant improvements in balance from pre- to post-testing in both the PT and Track group, but no significant difference for the Treadmill group.
Other investigations incorporated measures associated with the performance of ADLs or other functional measures as secondary objectives. Subjective self-reports of improved walking (with an aid), transferring, dressing and other tasks of daily living along with concomitant strength improvements associated with a FES cycling program were reported by Sloan et al. (1994) for all the incomplete study participants with chronic SCI (n=11 of 12). Hjeltnes and Wallberg-Henriksson (1998) demonstrated significant improvements in the Sunnaas ADL index and muscle strength in persons with tetraplegia in response to a 6-8 week program of 3 days/week 30 minute arm ergometry sessions. This latter investigation was conducted in persons with sub-acute SCI as part of inpatient rehabilitation. Without a suitable control condition, it was uncertain if these benefits were due to the arm ergometry intervention or other aspects of the rehabilitation program or were associated with natural recovery.
Conclusion
There is level 2 evidence from a low quality RCT that either 16 weeks of physical exercise therapy alone or a combination of 2, 8 week blocks of physical exercise therapy, neuromuscular stimulation or EMG biofeedback may enhance self-care and mobility scores.
There is level 2 evidence from a single prospective, controlled trial that a twice weekly swimming program conducted over 4 months immediately following rehabilitation discharge may enhance motor FIM scores. This finding of exercise-related enhancement of functional outcomes is generally supported by 6 additional level 4 studies that employ different modes of physical activity associated with either increases to overall FIM scores or improved performance of ADLs.
Prospective, controlled trials are required to better determine the relationship of physical activity programming and functional benefits. There is no evidence for a relationship between specific program parameters (e.g., mode, intensity, frequency, duration) that might be necessary to achieve particular benefits.
