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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 of SCIRE 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(TM)) but the definitive attribution of these gains to specific aspects of rehabilitation programming remains to be fully elucidated.

Table 2: Physical Activity and Functional Improvement Including ADLs

Author Year

Country
Score
Research Design
Total Sample Size

MethodsOutcome
Alexeeva et al. 2011

USA

PEDro=7

RCT

N=35

Population:

Fixed Track Group: Mean age: 37.3± 13 yrs ; Gender: 12 males, 2 females; Level of injury: ASIA C (17%), ASIA D (83%); Cause of injury: traumatic (100%)

Treadmill Group: Mean age: 36.4±12.9 yrs ; Gender: 8 males, 1 female; Level of injury: ASIA C (36%), ASIA D (64%); Cause of injury: traumatic (100%)

Physical Therapy Group: Mean age: 43.3±15.8 yrs ; Gender: 10 males, 2 females; Level of injury: ASIA C (11%), ASIA D (89%); Cause of injury: traumatic (75%), non-traumatic (25%)

Treatment: Patients participated in a body weight supported training program (Fixed Track or Treadmill) or comprehensive physical therapy for 1hr/d, 3 d/wk for 13 wks.

Outcome Measures: FIM (motor domain component only); Tinetti Scale

1.   There was a slight increase in FIM motor scores after training, but it was not significant.

2.   There were significant improvements in balance pre-to-post in the PT group (p<0.001) and the Track group (p<0.01), but no significant difference for the Treadmill group.

Klose et al. 1990

USA

PEDro=5

RCT

N=43

 

Population: Age (range): 18-45 yrs; Level of injury (range): C4-C6; Severity of injury: incomplete (43); Time post-injury: minimum of one year

Treatment: Training blocks of either supervised physical exercise therapy (PET), neuromuscular stimulation, or electromyographic biofeedback. Group 1 received 8 wks each of EMG biofeedback followed by PET, group 2 received 8 wks each of EMG biofeedback followed by NMS, group 3 received 8 wks each of NMS followed by PET, and group 4 received 16 wks of PET (3d/wk).

Outcome Measures: Manual muscle tests, self-care scores, mobility

1.  Significant improvements were found for measures of mobility, self-care, and left arm manual muscle test scores (p<0.05).

2.  The repeated measures component was significant for all of the outcome measures except the EMGs (p<0.01).

3.  All exercise modes were effective. No difference was found on comparisons between groups.

Harness et al. 2008

USA

Prospective, non-randomized, controlled trial

Initial N=31, Final N=29

Population: Intense Exercise Group: Mean age: 37.8±3.6 yrs; Gender: 18 males, 3 females; Severity of Injury: ASIA A or B (57%), ASIA C or D (43%) Control: Mean age: 34.5±2.9 yrs; Gender: 8 males

Treatment: Treatment group – multi-modal intense exercise program; Control group – self-regulated exercise.

Outcome Measures:Motor gains via ASIA motor score

 

1.   When compared to control participants, intense exercise participants had significantly larger clinical gains as measured by changes in ASIA motor score (p=0.0001).  ASIA motor score changes were mostly attributed to lower extremity motor scores; lower extremity motor scores had a significant group difference (p<0.04), while upper extremity motor scores did not.
Bjekefors et al. 2006

Sweden

Pre-Post

N=10

Population: Mean age: 37.6 yrs (range: 24-60); Gender: 7 males, 3 females; Level of injury: T3-12; Severity of injury: ASIA A (70%), ASIA B (20%), ASIA C (10%)

Treatment: Patients received kayak ergometer training for 60 min, 3d/wk for 10 wks.

Outcome Measures: Sit-and-reach test, propelling tests, and transfer/propelling wheelchair tests.

1.   Sit-and-reach test scores showed a significant improvement from pre- to post-intervention (p<0.05). There was a statistically significant improvement in mounting-a-platform, propelling 15m on a level surface and propelling 50m on an incline from pre-to post-training (p<0.05)

2.   The results of the transfer test showed a 10% mean increase after training.

Bjerkefors et al. 2007

Sweden

Pre-Post

N=10

 

 

 

 

 

 

 

 

 

 

 

 

Population: Mean Age: 38±12 yrs; Level of injury: T3-12; Severity of injury: ASIA A (70%), ASIA B (20%), ASIA C (10%)

Treatment: Patients received kayak ergometer training for 60 min, 3d/wk for 10 wks.

Outcome Measures: Anterior-posterior (AP) angular and linear displacement during forward, backward, and lateral translations; medio-lateral (ML) angular and linear displacement during lateral translations; trunk twisting angular displacement during lateral translation; postural stability.

 

1.   There were significantly smaller AP angular trunk displacements during lateral translations when comparing post-training with pre-training (p=0.038).  There were no differences in FWD or BWD translations.

2.   Results 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).

3.   There were no significant effects of training on ML linear displacement during lateral translations.

4.   There were statistically significant improvements in trunk twisting post-training (p<0.05).

5.   Patients’ postural stability was improved post-training; patients’ showed smaller rotational and linear displacements of the trunk.

Chen et al. 2006

USA

Pre-Post

N=16

Population:  Mean age: 43.8 yrs (range: 21-66); Gender: 9 males, 7 females; Level of injury: tetraplegia (25%) and paraplegia (75%); Severity of injury: ASIA A (56%), C (19%), D (25%); Cause of injury: traumatic (93.75%) and non-traumatic (6.25%);

Treatment: 12 wks of a weight management program (e.g., nutrition, exercise, behaviour modification training) + 1-30 min exercise session for 6 wks.

Outcome Measures: Three self-reported statements measured on a 5-point scale (difficulty transferring difficulty putting on/taking off clothes and time required for a bowel movement.

1.   There was a statistically significant improvement in self-reports of difficulty transferring post-treatment (p=0.004).

2.   There was a statistically significant improvement in self-reports of difficulty putting on/taking off clothes post-treatment (p=0.02).

3.   Time required for a bowel movement improved with a mean change of -27.5 minutes, but this improvement was not statistically significant (p=0.27).

Hetz et al. 2008

Canada

Observational

N=48

Population: Mean age: 39.48; Gender: 35 males, 13 females; Level of injury: tetraplegia (39.6%), paraplegia (60.4%%); Severity of injury: complete (58.3%), incomplete (41.7%); Cause of injury: traumatic (81.3%), non-traumatic (18.8%)

Treatment: Questionnaire

Outcome Measures: Physical Activity Recall Assessment for People with Spinal Cord Injury (PARA-SCI)

 

1.   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.

2.   VO2 Max was significantly associated with increased participation in cleaning and wheeling (p<0.05).

3.   Wheeling, dressing, and toileting were positively correlated with moderate- and heavy-intensity LTPA (p<0.05).

 

 

da Silva et al. 2005

Brazil

Downs & Black score=18

Prospective controlled trial

N=16

 

 

Population: Chronic SCI with AISA A Experimental Group (EG): Age (range): 21-34 yrs; Gender: 7 males, 1 female; Time post-injury (range): 15-40 mo Control Group (CG): Age (range): 21-41 yrs; Gender: 7 males, 1 female; Time post-injury (range):14-30 mo

Treatment: Comparison of swimming program vs. normal daily activities upon discharge from rehabilitation (both groups received orientation class during rehabilitation on numerous SCI related topics including swimming). Experimental group (EG): Swimming program with a Physical Educator professor, 2d/wk, 45 min each, consisting of a warm up, main exercise & cool-down. Outcome Measures: Functional Independence Measure (FIM) at discharge & follow-up (avg 4 mo post-discharge).

1.     Pre vs. post swimming program:

·         Body care: EG -↑ (p=0.01), CG – ↑ (p=0.02)

·         Transference: EG – ↑ (p=0.00), CG – ↑ (p=0.04)

·         Overall motor score= EG – ↑ (p=0.00), CG -↑ (p=0.01)

·         Overall FIM score = EG – ↑ (p=0.00), CG -↑ (p=0.02)

·         Other areas did not have significant changes in either group.

2.     More significant ↑ (difference scores in EG vs. CG for transference (p=0.02), overall motor score (p=0.01) and overall score (p=0.01).

 

Hjeltnes & Wallberg-Henriksson 1998

Norway

Downs & Black score=16

Prospective controlled trial (dissimilar control group)

N=20

 

 

Population: Exercise group: Level of Injury: tetraplegia (10): Severity of injury:  AISA A (70%), ASIA B (30%); Mean time post-injury: 99 d  Control Group: Level of injury: paraplegia (10); AISA A (100%); Mean time post-injury: 78 d

Treatment: Exercise group: standard rehabilitation + arm ergometry (tetraplegia), 30 min/d, 3 d/wk for a 12-16 wk period; Control group: standard rehabilitation (paraplegia).

Outcome Measures: Ability to perform activities of daily living (Sunnaas ADL index), muscle strength (manual muscle testing), physiological assessments (VO2, load) collected pre, mid & post program.

1.     Experimental (tetraplegia) and Control (paraplegia) groups were not compared for functional and strength scores. Otherwise:

a.   ↑ in ADL ability from pre to post program in those with tetraplegia (p<0.001).

b.   ↑ in manual muscle scores from pre to post program in those with tetraplegia (p<0.001).

c.    Peak resistance to cycling increased over cycling program but VO2 did not.

 

 

Durán et al. 2001

Colombia

Downs & Black score=16

Pre-post

N=13

 

 

Population: Age (range): 17-38yrs; Gender: 12 males. 1 female; Time post-injury (range): 2-120 mo; Severity of injury: ASIA A (85%), ASIA B (7.5%), ASIA C (7.5%)

Treatment: 16 wk exercise program (4 wks adaptation, 1 wk enhancement, 11 wks specific program)- 3d/wk, 120 min/session, containing mobility, coordination, strength, aerobic resistance and relaxation exercises.

Outcome Measures: Functional Independence Measure (FIM), Wheelchair skills test and various strength/resistance and physiological measures collected pre & post program.

1.     ↑ FIM from pre to post program, 106 to 113 respectively (p<0.001).

2.     Reduced time for all 9 wheelchair skills from pre to post program, (p<0.04 or less).

3.     ↑ in work capacity (weight lifted and reps) pre to post program.

4.     Generally no sig. diff. in various physiological parameters.

 

 

Sloan et al. 1994

Australia

Downs & Black score=14

Pre-post

N=12

 

 

Population: Age (range): 15-54 yrs; Gender: 7 males, 5 females; Severity of injury: complete (1), incomplete (11); Time post-injury (range): 2 -138 mo

Treatment: Functional electrical stimulation (FES) induced cycling programme: 3d/wk for 3 mo, all programmes were individualized & gradual progressed to 30 min/session.

Outcome Measures: Functional assessment: independence & activities of daily living (ADL) tasks, muscle testing (grade and size) collected pre & post programme.

1.     All incomplete SCI patients had subjective self-reported improvements in well-being & functional independence, namely walking, dressing, transferring and ADL tasks.

2.     Most muscles increased in area and strength.

3.     Variable changes in spasticity (2 people discontinued because of increases in spasticity).

 

 

Dallmeijer et al. 1999

The Netherlands

Downs & Black score=13

Pre-post

Initial N=27, Final N=20

 

Population: Mean age: 40.3 yrs; Gender: 16 males,4 females; Level of injury:  paraplegia (11) tetraplegia (9),; AISA B, C & D; Mean time post-injury: t1=331 d, t2=765 d

Treatment: Described changes in first years post-discharge and examined effect of those participating in ≥1 hr/wk of sport vs. those with no activity on physical capacity.                

Outcome Measures: Standardized ADL tasks physical strain & performance time (ascending ramp, transfer, passing door, washing hands); Sport activity & health status questionnaire; physical capacity (strength, power, VO2 on wheelchair ergometer test) collected @ discharge (t1) & follow-up (t2, mean time=1.2 yrs).

1.     Description of participation, illness, musculoskeletal system complaints:

·          8/20=sedentary, 12 participated in ≥1 hr/wk (Overall group mean= 2.5 hrs/wk).

·         10/20=serious illness during time span (UTI, pressure sores, pain, intestinal problems, pneumonia).

·         9/20 Musculoskeletal system complaints.

2.     Physical strain: was reduced over the year for all ADL tasks, except hand washing.

3.     Performance time: ↓ in transfer & ramp only (p<0.05) between t1 and t2 but not for other ADL tasks.

4.     Participation in sport was correlated with measures of improved physical capacity (no relationship with ADL was assessed).

 

 

Effing et al. 2006

The Netherlands

Downs & Black score=13

Pre-post (Single subject controlled design)

N=3

 

 

Population: Chronic incomplete SCI; Age (range): 45-51 yrs; Gender: 3 males; Severity of injury: AISA C (75%), ASIA D (25%); Time post-injury (range): 29-168 mo

Treatment: Body weight supported treadmill training 5d/wk for 30 min/session for 12 wks personalized to physical abilities.

Outcome Measures: Perceived performance on activities of daily living (ADL) – Canadian Occupational Performance Measure (COPM); Semi-structured interview; Performance based walking – Walking Capacity Scale; Walking Speed – 7 m; Balance & Mobility – Get Up & Go Test. Collected at baseline, 6 wks – treatment, 12 wks – wash-out, 6 wks – follow-up, 6 mo.

1.     Subject 1:

·         Perceived ADL performance: rather stable, ↓ satisfaction during intervention phase (p<0.01).

·         Interview: walked further without rest, felt better overall

·         Walking speed: ↑ speed with ↓ steps (p<0.05)

·         Balance: ↑ (p<0.05).

2.     Subject 2:

·         Perceived ADL performance: ↑ improvement during intervention into washout period (p<0.01)

·         Interview: transfer independently, ↓ pain medications, ↓ spasms, felt better overall

·         Walking performance: ↑ (p<0.01)

·         Could not perform walking speed & balance tests.

3.     Subject 3:

·         Perceived ADL performance: ↑ improvement; however, not in the intervention phase (p<0.05).

·         Interview: sit longer in a wheelchair, more stability, walking ability with a cane, ↓ pressure ulcers, felt better overall

·         Walking performance: ↑ (p<0.05)

·         Balance: ↑ (p<0.01).

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. VO2 Max 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.

Conclusions

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.

  • Generally physical activity programming may be useful in improving functional outcomes such as performance of ADLs, but specific exercise and program parameters are not readily available.