Recovery of walking and balance can occur even years after injury in people with incomplete spinal cord injury who participate in locomotor training
Additional study shows patients reduced expenses up to 25% after locomotor training intervention
SHORT HILLS, N.J. (Sept. 4, 2012) – For the first time, new research demonstrates that innovative rehabilitative treatments for individuals with spinal cord injuries can lead to significant functional improvements in patients and a higher quality of life. These treatments are provided through the Christopher & Dana Reeve Foundation NeuroRecovery Network (NRN), a national network of activity-based rehabilitation centers for spinal cord injury. The findings suggest that a shift in both protocol and policy is needed to standardize rehabilitation across multiple centers. The studies were funded by the Reeve Foundation the nation's leading nonprofit dedicated to curing spinal cord injury and improving quality of life for people living with paralysis
The NRN is a national network of rehabilitative centers established by the Christopher & Dana Reeve Foundation to translate scientific advances into activity-based rehabilitation treatment for individuals with neurological disorders, and is funded by a cooperative agreement between the Foundation and the U.S. Centers for Disease Control and Prevention (CDC).
Eleven peer-reviewed studies published in the September 2012 issue of Archives of Physical Medicine & Rehabilitation conclude that establishing a network of rehab centers for spinal cord injuries that standardizes treatment can lead to significant functional improvements for chronically injured patients. Using data from a total of 296 patients living with spinal cord injury (SCI) at seven centers across the country, researchers found that the NRN succeeds because of overarching conditions, including:
- The deployment of standardized activity-based rehabilitation based on and supported by scientific and clinical evidence across the seven centers.
- The rigorous evaluation of all NRN interventions across the seven centers using measures of function, health, and quality of life. These rehabilitation interventions are continually assessed in light of newly emerging knowledge from basic science laboratories.
- The creation of NRN teams that include scientists, physicians, physical and occupational therapists, and hospital administrators. Their varied perspectives enable the most effective and cost-efficient clinical model for the NRN.
In addition, one NRN study published in the September issue of Journal of Neurological Physical Therapy found that expenses associated with equipment, home renovations, and transportation decreased by up to 25 percent for both children and adult patients with motor incomplete spinal cord injury due to the function gained following intensive locomotor training intervention.
Locomotor training is an intensive, activity-based intervention therapy that seeks to re-train the nervous system by simulating stepping and walking for those with spinal cord injuries. More than one million people in the U.S. are living with paralysis due to a spinal cord injury according to the Reeve Foundation.
“These results support the concept that there exists an intrinsic capacity of the human spinal cord circuitry that responds to task-specific sensory cues and can result in recovery in walking,” said Susan J. Harkema, Ph.D., Director of the NRN, University of Louisville professor of neurosurgery and rehabilitation, and research director of the University of Kentucky’s Spinal Cord Research Center and Frazier Rehab Institute. “The existence of the NRN and standardization of locomotor training protocols are crucial to determining the outcomes of these and future studies. By standardizing protocols across all NRN centers, we have an improved ability to understand the capacity for recovery in a chronic SCI population,” she explained.
“The research speaks for itself—the science shows that locomotor training is beneficial to people living with spinal cord injury, even in those who have been injured for quite some time,” said Susan Howley, Executive Vice President of Research at the Christopher & Dana Reeve Foundation. “For the first time, conclusive evidence has proven that standardized rehabilitation across multiple centers can result in positive patient recovery. Policies are needed to ensure that access to these centers is provided to all patients living with spinal cord injury and that new sites are continuously added to the NeuroRecovery Network,” she added.
Locomotor Training Shows Great Value, Promise
Taken together, the Archives papers suggest that locomotor training can be part of the reparative process after spinal cord injury and promotes improvements in the neuromuscular system. Rehabilitation is more than just compensatory—it is part of the repair process.
Locomotor training is used for people with brain and spinal cord injury, stroke, and other neurological disorders. Many people living with SCI, regardless of time elapsed since their injury, have improved their ability to walk after receiving locomotor training in research programs and clinics in Germany, Canada, Switzerland, and the United States.
Locomotor training consists of a continuum of training principles that are applied across the three training environments: step training using body weight support on a treadmill (BWST) and manual assistance; over-ground walking training; and community ambulation training. Sensory information from the legs and trunk during walking is repetitively sent to the spinal cord using BWST. The sensory input comes from the actual stepping, from the manual contact of the therapist on the patient, and from the contact of the sole of the foot on the ground. The therapist ensures that the patient is optimizing standing and walking—although as the patient improves, the assistance of the therapist is reduced.
The Reeve Foundation is accelerating the pace of scientific progress and translating the most promising research into leading-edge treatments and therapies that are changing the lives of people living with spinal cord injury. Thanks to the progress the Reeve Foundation has made possible, NRN patients living with spinal cord injury are regaining motion, improving their balance as well as bowel, bladder and sexual function. As such, the NeuroRecovery Network is helping to improve individuals’ overall health and quality of life.
Multiple research teams headed by Dr. Harkema published the papers described in this press release in the September 2012 issues of leading peer-reviewed medical journals. Participating medical centers included: the Frazier Rehab Institute in Louisville, KY; Boston Medical Center in Boston, MA; Kessler Medical Rehabilitation Research and Education Center/Kessler Institute for Rehabilitation in West Orange, NJ; Magee Rehabilitation Hospital in Philadelphia, PA; Ohio State University Medical Center in Columbus, OH; Shepherd Center in Atlanta, GA; and The Institute for Rehabilitation and Research in Houston, TX.
Key findings from the 11 papers published in Archives of Physical Medicine & Rehabilitation and the study that appeared in the Journal of Neurological Physical Therapy are available upon request or by visiting each journal’s respective website.
ABOUT THE NEURO RECOVERY NETWORK
The NeuroRecovery Network (NRN) is a cooperative network of leading-edge rehabilitation centers designed to provide and develop therapies to promote functional recovery and improve the health and quality of life for people living with paralysis. Funded by the Christopher & Dana Reeve Foundation through a cooperative agreement with the Centers for Disease Control and Prevention (Award No. 1U59DD000838), the NRN translates the latest scientific advances into effective, activity-based rehabilitation treatments.
Each center is staffed with a group of dedicated professionals who have received specialized training in order to deliver the NRN’s therapies. The staff includes center directors, physicians, administrative and clinical supervisors, data managers, physical therapists, and rehab technicians.
ABOUT THE CHRISTOPHER & DANA REEVE FOUNDATION
The Christopher & Dana Reeve Foundation is dedicated to curing spinal cord injury by funding
innovative research, and improving the quality of life for people living with paralysis through
grants, information, and advocacy. For more information or to make a donation to the Christopher & Dana Reeve Foundation, please call (800) 225-0292 or visit www.ChristopherReeve.org.
Maggie Goldberg at Christopher & Dana Reeve Foundation at (973) 379-2690 or firstname.lastname@example.org.
LauraLee Harding, Coyne PR at (973) 588-2000 or email@example.com.
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September 2012: Christopher & Dana Reeve Foundation NeuroRecovery Network Study Highlights
Key findings from the 11 papers published in Archives of Physical Medicine & Rehabilitation are:
Basic Concepts of Activity-Based Interventions for Improved Recovery of Motor Function After Spinal Cord Injury (Roy, RR, Harkema SJ, Edgerton, VR)
- The automaticity within the neural networks that control locomotion and the degree to which it can occur without conscious input from the brain is striking.
- This is possible in large part by the sensory input from the periphery providing a precise representation of the neuromechanical state of the locomotor apparatus to the spinal cord circuitry.
- This neural substrate provides the bases for step training therapy designed to facilitate recovery of locomotor function after a severe spinal cord injury.
Establishing the NeuroRecovery Network: Multisite Rehabilitation Centers That Provide Activity-Based Therapies and Assessments for Neurologic Disorders (Harkema SJ, Schmidt-Read M, Behrman AL, Bratta A, Sisto SA, Edgerton VR.)
- The NRN comprises seven clinical centers that provide standardized activity-based rehabilitation that is supported by scientific and clinical evidence. The therapies are robustly evaluated by taking measures related to function, health and quality of life.
- The NRN brings together scientists, physicians, physical and occupational therapists and hospital administrators to design the most effective and cost efficient clinical model.
Balance and Ambulation Improvements in Individuals With Chronic Incomplete Spinal Cord Injury Using Locomotor Training–Based Rehabilitation (Harkema SJ, Schmidt-Read M, Lorenz D, Edgerton VR, Behrman AL.)
- Recovery of walking and balance can occur even years after injury in people with incomplete spinal cord injury with rigorous locomotor training. Improvements occurred in 88% of the patients evaluated
- Even those with more severe injuries who are classified as AIS C made improvements.
Locomotor training is a rehabilitation strategy that activates the nerves and muscles below the injury level with the goal of recovering the ability to do tasks as close to before the injury as possible.
- The walking and balance measures vary widely in people with incomplete spinal cord injury so better patient stratification and more sensitive outcomes are needed for proper evaluation of new interventions.
Assessment of Functional Improvement without Compensation Reduces Variability of Outcome Measures After Human Spinal Cord Injury (Behrman AL, Ardolino E, VanHiel L, Kern M, Atkinson D, Lorenz DJ, Harkema SJ)
- The Neuromuscular Recovery Scale (NRS) is a new and unique measure of the degree a person who has sustained a spinal cord injury (SCI) has recovered the ability to perform functional tasks relative to how the individual performed these tasks prior to injury (i.e. the same movement pattern and without compensation such as assistive device or substitution by another muscle).
- NRS is more effective than other measures (of balance, walking or sensorimotor impairments) to classify SCI patients into functionally similar groups.
- The NRS may thus be a more sensitive instrument for assessing the therapeutic effect of an intervention tested in clinical trials and studies with the aim of achieving recovery after SCI.
- The NRS can provide the therapist and patient an effective means to quantify recovery, set goals, and assess progress.
Relationship Between ASIA Examination and Functional Outcomes in the NeuroRecovery Network Locomotor Training Program (Buehner J, Forrest G, Schmidt Read M, White S, Tansey K, Basso DM)
- Completing locomotor training in the NRN produced large improvements in walking speed for 70% of participants with incomplete spinal cord injury. Only 22% of participants remained non-ambulatory after completing the program. For many of the participants, the walking speed improved to levels thought to support community ambulation.
- Locomotor Training benefitted people with spinal cord injury by increasing muscle strength in the legs by almost 25% and strength in the arms by 8%. Surprisingly, the strength of the legs was not associated with the amount of locomotor recovery a person attained but it did relate to better balance.
- Improvement in walking speed with locomotor training may depend on several factors including the number of key muscles in the legs that are paralyzed and the number that have near normal strength when training begins. While most leg muscles tested show increased strength, the ankle muscles continue to be weaker than other muscles at the end of the training program.
- Surprisingly the ASIA exam did not predict those individuals that would recover balance and walking function.
Longitudinal Patterns of Functional Recovery in Patients with Incomplete Spinal Cord Injury Receiving Activity-based Rehabilitation (Lorenz DJ, Datta S, Harkema SJ)
- Individuals receiving NRN locomotor training recovered significant balance and walking function at a rate that plateaued over time.
- The Neuromuscular Recovery Scale (NRS), developed by NRN researchers, classifies patients into distinct groups of different functional ability and rates of recovery.
- Individuals with chronic incomplete SCI experienced recovery, but at a slower rate and magnitude than patients enrolled into the NRN sooner after their injuries.
- NRS classification, severity of injury, and time since spinal cord injury combined to create an accurate model for expected recovery with NRN locomotor training.
Ambulation and Balance Outcomes Measure Different Aspects of Recovery in Individuals with Chronic Incomplete Spinal Cord Injury (Forrest GF, Lorenz DJ, Hutchinson K, VanHiel L, Basso DM, Datta S, Sisto SA, Harkema SJ
- Scientists use outcome measures to document changes in patients’ functional performance. These measurements help determine efficacy of interventions like locomotor training, guide decisions about which patients are likely to benefit, and support efforts to gain third-party reimbursement.
- This study of 182 outpatients with clinically incomplete spinal cord injury measured the impact of intensive standardized locomotor training on balance and walking ability using four clinical outcome measures (6-Minute Walk, 10-Meter Walk, Berg Balance Scale and Modified Functional Reach).
- Results show that these measures yield important information about different aspects of recovery of mobility, and that recovery of function during locomotor training can occur at different rates.
- Most importantly, these data underscore the importance of using more than one measure to evaluate the continuum of recovery after spinal cord injury. This is an important consideration for clinicians assessing the progress of their patients during locomotor training, as well as for researchers designing clinical trials for new rehabilitative interventions.
Dynamic Longitudinal Evaluation of the Utility of the Berg Balance Scale in Individuals with Motor Incomplete Spinal Cord Injury (Datta S, Lorenz DJ, Harkema SJ)
- In the general incomplete SCI population, the Berg Balance Scale provides an adequate measure of balance that effectively distinguishes patients with poor, moderate, and strong balance function.
- The Berg Balance Scale performs poorly as a measure of balance in subgroups of patients with poor and strong balance function. New or adapted scales are needed to adequately measure balance in these subgroups.
- The ability of the Berg Balance Scale to measure balance function changes with time and as rehabilitation progresses. Patients with initially poor balance function regain the ability to perform tasks on the scale and it becomes a better measure of balance. Patients with initially strong balance function begin to score perfectly on all or nearly all tasks on the scale, further limiting its utility.
NeuroRecovery Network Provides Standardization of Locomotor Training for Persons with Incomplete Spinal Cord Injury (Morrison SA, Forrest G, VanHiel L, Dave M, DeLorenzo D)
- This case study is of a 25-year old man with a motor incomplete spinal cord injury who received locomotor training for 100 sessions across two different NeuroRecovery Network centers.
- Walking endurance and walking speed showed consistent improvements during overground walking throughout the continuum of training.
- Within the treatment parameters of the body weight supported environment, consistent improvements were observed in average treadmill training speed, maximal training speed and amount of body weight support necessary.
- Overall, the results supported that the NRN standardized protocol provided a mechanism of delivering consistent and reproducible locomotor training across 2 geographically different sites.
Cardiovascular Status of Individuals with Incomplete Spinal Cord Injury from Seven NeuroRecovery Network Rehabilitation Centers (Sisto SA, Lorenz DJ, Hutchinson K, Wenzel L, Harkema SJ, Krassioukov A)
- The purpose of this study was to examine cardiovascular health in a large cohort of individuals with incomplete spinal cord injury.
- Cardiovascular (CV) parameters, including blood pressure (BP) and heart
rate (HR), were examined in 350 people with incomplete SCI at rest and
after an orthostatic challenge involving an abrupt change from lying to
- The cardiovascular health parameters of patients were compared based on Spinal Injury Association Impairment Scores (AIS), neurological level, gender, central cord syndrome, age, time since injury, Neurological Recovery Scale, and total AIS motor score.
- Researchers concluded that resting cardiovascular parameters of blood pressure and heart rate are affected by position, age and neurological level. 21% of the patients had defined orthostatic hypotension (fall in blood pressure with a sudden position change from lying to sitting). Results from this study provide reference for CV parameters for individuals with incomplete SCI.
- Clinical screening and treatments should be considered for cardiovascular dysfunction and orthostatic hypotension given the prevalence and persistence over months to years.
Locomotor Training: As a Treatment of Spinal Cord Injury and in the Progression of Neurological Rehabilitation (Harkema SJ, Hillyer J, Schmidt Read M, Ardolino E, Sisto SA, Behrman AL)
- This article is a review of the current state of understanding of locomotor training and summarizes the findings of the NRN published in this focus issue.
- The evidence from these articles suggests that there is a paradigm shift in rehabilitation where recovery is expected and the therapy prioritizes recovery with compensation minimized to only what is necessary, with the intent of removing it as improvement in the neuromuscular systems continues.
- The most successful approach for evidence-based medicine may be to evaluate all levels of evidence based on their strengths and weaknesses.
- Rehabilitation, especially in the spinal cord injury population, seems to benefit from a comprehensive program, especially in the challenging financial environment we now face within the health care system.
For the full articles, please visit http://www.archives-pmr.org/article/S0003-9993%2812%2900559-X/fulltext#sec1.
Key findings from the study that appeared in the Journal of Neurological Physical Therapy:
Life Care Planning Projections for Individuals With Motor Incomplete Spinal Cord Injury Before and After Locomotor Training Intervention: A Case Series (Morrison SA, Pomeranz J, Yu N, Schmidt Read M, Westcott C, Sisto SA, Behrman AL)
- This study presented case series of two individuals (four year old male and 61 year old female) with motor incomplete spinal cord injury to examine the differences in life cost estimates before and after participation in an intensive locomotor training program. A life care plan was used to project the lifetime costs before and after the intense locomotor training intervention.
- In both cases, the lifetime expenses associated with equipment, home renovations and transportation decreased.
- After 76 sessions, the four year old male had a decrease of expected lifetime expenses between $437,790 and $571,618 due to the gained function following the intense locomotor training intervention.
- After 198 sessions, the 61 year old female had a decrease of expected lifetime expenses between $148,237 and $197,208 due to the gained function following the intense locomotor training intervention.
For the full article, please visit http://journals.lww.com/jnpt/pages/default.aspx.