Activity-based Therapies in Spinal Cord Injury: Clinical Focus and Empirical Evidence in Three Independent Programs Topics in Spinal Cord Injury Rehabilitation (2012) 18(01): 34-42
Michael L. Jones, PhD1, Eric Harness, CSCS, CSRS III2, Paula Denison, PT, OMPT3, Candy Tefertiller, DPT, ATP, NCS4, Nicholas Evans, MS5, Cathy A. Larson, PT, PhD3
1Virginia C. Crawford Research Institute, Shepherd Center, Atlanta, Georgia
2Project Walk, Spinal Cord Injury Recovery Center, Carlsbad, California
3Center for Spinal Cord Injury Recovery, Rehabilitation Institute of Michigan, Detroit, Michigan
4Craig Hospital, Englewood, Colorado
5Beyond Therapy Program, Shepherd Center, Atlanta, Georgia
Activity-based therapy (ABT) refers to “interventions that target activation of the neuromuscular system below the level of the lesion, with the goal of retraining the nervous system to recover a specific motor task.”1 Intense physical activity has been shown to improve physiological function and health outcomes in individuals with chronic (> 1 year postinjury) spinal cord injury (SCI). The effects of intense activity on neurological and functional recovery, however, have not been fully investigated nor verified.
This article summarizes presentations of a symposium examining the potential impact of ABT in promoting neurological and functional recovery after SCI. The symposium addressed 3 key questions concerning ABT in SCI: (1) What clinical approaches are used? Principles and techniques used in 3 independent programs – Project Walk, the Center for SCI Recovery at the Rehabilitation Institute of Michigan, and Shepherd Center’s Beyond Therapy program – are compared and contrasted. (2) Is there empirical evidence supporting efficacy of ABT in promoting neurological recovery and improving overall function, health, and quality of life? Preliminary findings from each program are presented. (3) What are the issues related to long-term viability
of ABT? Discussion focused on determining who benefits from ABT, gauging the point of diminishing return with respect to functional recovery, and strategies for maintaining any gains achieved from therapy.
Acute energy cost of multi-modal activity based therapy in persons with spinal cord injury
J. Spinal Cord Med (2011) 34(5): 495-500
Eric Turner Harness1, Todd A. Astorino2
1Project Walk Spinal Cord Injury Recovery Center, Carlsbad, CA, USA
2Department of Kinesiology, California State University San Marcos, CA, USA
Objective: To examine acute energy costs of multi-modal activity-based therapy (ABT) in men and women with spinal cord injury (SCI).
Study design: Descriptive case series.
Setting: An outpatient center in California.
Participants: Seven men and women (age = 28.3 ± 11.6 years; duration of injury = 4.3 ± 2.5 years) with injury levels ranging from C5 to T8.
Intervention: Activity-based therapy.
Outcome measures: Oxygen uptake (VO2), energy expenditure (kcal/minute), SCI Metabolic Equivalent of Task (MET) (1 MET = 2.7 ml/kg/minute).
Results: Oxygen uptake (VO2) during ABT ranged from 5.10 to 8.62 ml/kg/minute, with VO2 consistently higher during modalities involving load bearing versus non-load bearing (P = 0.08). SCI MET values ranged from 1.89 to 3.24 and were significantly higher in subjects with mid-thoracic injury versus low-cervical injury (P = 0.01).
Conclusion: Data reveal that multi-modal ABT increases VO2 in persons with SCI, but energy expenditure is relatively low. Strategies must be identified to optimize energy expenditure in the SCI to reduce health risks. Modalities involving load bearing seem to be superior to non-load-bearing activities. VO2 was greater in response to load-bearing modalities than non-load-bearing modalities. It remains to be determined whether chronic ABT enhances cardiovascular fitness and reduces disease risks in this population.
A tele-assessment system for monitoring treatment effects in subjects with spinal cord injury
J. TelemedTelecare. (2010) 16: 152-157
Nuray Yozbatiran1,2, Eric T Harness3, Vu Le1,2, Daniel Luu1,2, Crista V Lopes4 and Steven C Cramer1,2
1Departments of Neurology and Anatomy & Neurobiology, University of California, Irvine, California
2Reeve-Irvine Research Center, Irvine, California
3Project Walk Spinal Cord Injury Recovery Center, Department of Research and Development, Carlsbad, California;
4Department of Informatics, University of California, Irvine, California, USA
We developed a method for remote measurement of balance and leg force in patients with spinal cord injury (SCI). In a group of 21 patients, both telemedicine and conventional clinical assessments were conducted at baseline and six months later. Telemedicine assessments were successfully acquired and transmitted at first attempt. The time required to set up the telemedicine equipment, position the subject, perform the measurements, and then send the data to the university laboratory was approximately 30 minutes. After six months, several motor and sensory functions showed significant changes. There were significant correlations between changes in remotely-measured leg force and changes in several of the American Spinal Injury Association (ASIA) sensory and motor scores. Changes in balance did not show any significant correlations with changes in the ASIA scores. Intra-rater reliability was better than inter-rater reliability. Use of telemedicine to remotely monitor changes in patients with SCI appears promising.
Substrate metabolism during exercise in the spinal cord injured
Eur J Appl Physiol. (2009) 106:187-193
Astorino TA1, Harness ET2.
1 California State University San Marcos, Department of Kinesiology, San Marcos, CA, USA.
2 Project Walk Spinal Cord Injury Recovery, Department of Research and Development, Carlsbad, CA, USA
The primary aim of the study was to examine substrate metabolism during combined passive and active exercise in individuals with spinal cord injury (SCI).
Nine men and women with SCI (mean age 40.6 +/- 3.4 years) completed two trials of submaximal exercise one week apart. Two maintained a complete injury and seven had an incomplete injury. Level of injury ranged from thoracic (T4-T6 and T10) to cervical (four C5-C6 and three C6-C7 injuries). During two bouts separated by one week, subjects completed two 30 min sessions of active lower-body and passive upper-body exercise, during which heart rate (HR) and gas exchange data were continuously assessed. One-way analysis of variance with repeated measures was used to examine differences in all variables over time.
Results demonstrated significant increases (P < 0.05) in HR and oxygen uptake (VO(2)) from rest to exercise. Respiratory exchange ratio (RER) significantly increased (P < 0.05) during exercise from 0.85 +/- 0.02 at rest to 0.95 +/- 0.01 at the highest cadence, reflecting increasing reliance on carbohydrate from 50.0 to 83.0% of energy metabolism.
Data demonstrate a large reliance on carbohydrate utilization during 30 min of exercise in persons with SCI, with reduced contribution of lipid as exercise intensity was increased. Strategies to reduce carbohydrate utilization and increase lipid oxidation in this population should be addressed.
Effects of intense exercise in chronic spinal cord injury
Spinal Cord (2008) 46: 733–737
1Project Walk Spinal Cord Injury Recovery, Department of Research and Development, Carlsbad, CA, USA
2Department of Neurology, University of California, Irvine, CA, USA
3Department of Anatomy and Neurobiology, and the Reeve-Irvine Research Center, University of California, Irvine, CA, USA
Exercise has beneficial effects on muscle and motor function after spinal cord injury (SCI). Little is known regarding effects of prolonged intense exercise (IE) in humans with chronic SCI.
Prospective, non-randomized, controlled observational study. The intervention was either a multimodal IE program (n=21) or a control (CTL) intervention consisting of self-regulated exercise (n=8).
Measure sensorimotor function over 6 months in relation to an IE program.
Single outpatient center.
Subjects with chronic SCI (n=29 total), mainly ASIA Impairment Scale A and B, injury levels C4-T11.
Baseline neurological assessments (for example, ASIA motor score, 393 vs 425, IE vs CTL, P>0.5, means.e.m.) did not differ between the two groups. During the 6 months, IE subjects averaged 7.30.7 h per week exercise, not significantly different from CTL subjects (5.21.3 h per week, P>0.1). However, after 6 months, IE subjects showed significantly greater motor gains than CTL subjects in the main outcome measure, ASIA motor score (change of 4.81.0 vs -0.10.5 points, P=0.0001). The main outcome measure was calculated by ASIA motor score. These IE subject ASIA motor gains correlated with number of exercise hours per week (r=0.53, P<0.02), and with type of specific IE components, particularly load bearing.
Multimodal IE can significantly improve motor function in subjects with chronic SCI. An organized program may provide greater motor benefits than a self-regulated program; load bearing might be of particular value. IE might have therapeutic value in chronic SCI, and as an adjunct to other restorative therapies.
Efficacy of a new rehabilitative device for individuals with spinal cord injury
J Spinal Cord Med (2008) 31(5): 586-91
T A Astorino1, N Tyerman1, K Wong1, E Harness2.
1California State University San Marcos, Department of Kinesiology, San Marcos, CA, USA.
2Project Walk Spinal Cord Injury Recovery, Department of Research and Development, Carlsbad, CA, USA
Regular exercise is required in persons with spinal cord injury (SCI) to reduce the deleterious effects of chronic paralysis. The primary aims of the study were to examine responses to passive and active exercise on a new rehabilitative device for persons with SCI and to examine reliability of these responses over 2 days of testing.
Nine men and women with chronic SCI completed the study, 2 with a complete injury and 7 with an incomplete injury. The level of injury ranged from thoracic (T4-T6 and T10) to cervical (4 with C5-C6 and 3 with C6-C7 injuries). They completed 2 30-minute sessions of active lower-body and passive upper-body exercise, during which heart rate (HR), blood pressure (BP), gas exchange data, rating of perceived exertion (RPE), and oxygen-hemoglobin saturation were continuously assessed. Data Analysis: One-way ANOVA with repeated measures was used to examine differences in all variables over time.
Results demonstrated significant increases (P < 0.05) in HR, systolic BP, RPE, and oxygen uptake (V(O2)) from rest to exercise. No change (P > 0.05) in diastolic BP or oxygen-hemoglobin saturation was evident. Cronbach’s alpha values for HR, systolic BP, and V(O2) recorded over both days of testing ranged from 0.79 to 0.97, indicating adequate consistency.
Data demonstrated that exercise on this device significantly increases HR, V(O2), and systolic BP compared to rest. However, its efficacy for long-term rehabilitation, especially in regular exercisers with SCI, is unknown.
Efficacy of Multimodal Training to Alter Bone Mineral Density and Body Composition in Persons with Spinal Cord Injury: A Case Study.
Presented at the 2009 Southwest Chapter Meeting of the American College of Sports Medicine
Todd A. Astorino1, Kara A. Witzke1, Eric T. Harness2
1Department of Kinesiology, California State University San Marcos
2Project Walk Spinal Cord Injury Recovery Center, Carlsbad, CA
Approximately 12,000 spinal cord injuries (SCI) occur annually, with 80 % of injuries occurring in men. A severe complication of acute SCI is osteoporosis, which is localized at the proximal tibia and distal femur that typically receive loading. Bone loss enhances fracture occurrence at the knee and hip in everyday activities involving little to no trauma. Because bone loss and subsequent fractures elicit severe clinical, psychological, and financial complications, early intervention to slow rate of bone loss in persons with SCI is essential. Efficacy of exercise training to slow bone loss or promote new bone formation in this population is equivocal, as many studies have failed to provide a sufficient ‘mechanostat’ threshold to promote bone growth.
In this study, one subject participated in a preliminary investigation in which DXA scans were performed at baseline and after 6 mo to assess bone mineral density (BMD). A 21 year-old woman two months post-SCI (ASIA A complete injury at C5) underwent 6 mo of intense training 2 – 3 d/wk, 2 – 3 h/d, consisting of vibration training, body weight support treadmill training, resistance training, electrical stimulation, and load-bearing exercise. Her training program was developed and supervised by experienced personnel certified in activity-based recovery of persons with SCI.
Results demonstrated that distal femur BMD was increased by 10 % with training, yet proximal tibia (- 14 %) and total body leg BMD (- 10 %) were reduced. Dramatic losses in BMD were observed for the right/left femoral neck (6.8 – 11.4 %) and greater trochanter (19.2 – 21.9 %). Body mass was increased by 6.4 kg, with the excess mass attributed to a 35 % increase in fat mass (FM) and minimal decrement (- 1.5 %) in lean body mass (LBM). Percent body fat increased from 33.5 – 41.2 %, with increased FM revealed in the arms (10 %), legs (27 %), and trunk (52 %). LBM was increased in the legs (11 %), although attenuated in the arm (- 14 %) and trunk (- 7 %).
Leg LBM is typically decreased soon after SCI, and total-body and regional depots of fat mass are typically increased. The observed increase in leg LBM highlights the benefits of intense, multi-modal training to preserve muscle mass. The marked bone loss at the hip has inspired modification of her current training to increase loading at this site to potentially slow bone loss and reduce fracture risk.