Naaz Kapadia

Game-based Exercises for Dynamic Short-Sitting Balance Rehabilitation of People With Chronic Spinal Cord and Traumatic Brain Injuries

Background and Purpose: Goal-oriented, task-specific training has been shown to improve function; however, it can be difficult to maintain patient interest. This report describes a rehabilitation protocol for the maintenance of balance in a short-sitting position following spinal cord and head injuries by use of a center-of-pressure–controlled video game–based tool. The scientific justification for the selected treatment is discussed. Case Descriptions: Three adults were treated: 1 young adult with spina bifida (T10 and L1–L2), 1 middle-aged adult with complete paraplegia (complete lesion at T11–L1), and 1 middle-aged adult with traumatic brain injury. All patients used wheelchairs full-time. Outcomes: The patients showed increased motivation to perform the game-based exercises and increased dynamic short-sitting balance. Discussion: The patients exhibited increases in practice volume and attention span during training with the game-based tool. In addition, they demonstrated substantial improvements in dynamic balance control. These observations indicate that a video game–based exercise approach can have a substantial positive effect by improving dynamic short-sitting balance.

Functional Electrical Stimulation Therapy of Voluntary Grasping Versus Only Conventional Rehabilitation for Patients With Subacute Incomplete Tetraplegia A Randomized Clinical Trial

Background. Functional electrical stimulation therapy (FET) has a potential to improve voluntary grasping among individuals with tetraplegia secondary to traumatic spinal cord injury (SCI). Objective. This single-site, randomized controlled trial examined the efficacy of 40 hours of FET with conventional occupational therapy (COT) compared with COT alone to improve grasping. Methods. Twenty-four subjects with subacute traumatic incomplete SCI (C4-C7, AIS B-D) consented to participate in 40 hours of therapy over 8 weeks, beyond the conventional rehabilitation program. Subjects were randomized to receive FET + COT (n = 9) or COT (n = 12). The key outcomes were changes in Functional Independence Measure (FIM) self-care subscores, Spinal Cord Independence Measure (SCIM) self-care subscores, and Toronto Rehabilitation Institute Hand Function Test (TRI-HFT) performed at baseline and follow-up. Results. At the end of the treatments, the change in mean FIM self-care subscore for the FET + COT group was 20.1 versus 10 (P = .015) for the COT group. Subjects randomized to FET + COT also had greater improvements in the SCIM and TRI-HFT. No longer term follow-up was feasible. Conclusion. FET significantly reduced disability and improved voluntary grasping beyond the effects of considerable conventional upper extremity therapy in individuals with tetraplegia.

Relationship Between Dynamic Balance Measures and Functional Performance in Community-Dwelling Elderly People

Background Poor balance control, mobility restrictions, and fall injuries are serious problems for many older adults. Objective The purpose of this study was to evaluate a new dynamic standing balance assessment test for identifying individuals at risk for falling in a group of community-dwelling older adults. Design This was a cross-sectional observational study of 72 community-dwelling older adults who were receiving rehabilitation in a geriatric day hospital. Method A Dynamic Balance Assessment (DBA) test protocol was developed based on the concept of the Sensory Organization Test and the Clinical Test of Sensory Interaction and Balance. The DBA consists of 6 tasks performed on a normal floor surface and repeated on a sponge surface. A flexible pressure mat was used to record the foots center of pressure (COP) on both surfaces, and loss of balance was recorded. Balance performance also was evaluated using the Berg Balance Scale, the Timed “Up & Go” Test, gait speed, and the Six-Minute Walk Test. Participants were classified as “fallers” or “nonfallers” based on a self-report. Results No significant differences were noted between the faller group (n=47) and the nonfaller group (n=25) for demographic variables or medications. The DBA composite scores, which were derived from analysis of COP excursions of the 6 tasks performed on the sponge surface, were able to distinguish between fallers and nonfallers. Of the clinical tests, only the Timed “Up & Go” Test was able to differentiate between the faller and nonfaller groups. Limitations A prospective study is needed to confirm the current findings and to expand testing to a larger and more diverse sample. Conclusions The findings indicate that analysis of the extent and amount of COP displacements during selected tasks and under different surface conditions is an appropriate method to assess dynamic standing balance controls and can discriminate between fallers and nonfallers among community-dwelling elderly people.

Task-Specific Rehabilitation of Finger-Hand Function Using Interactive Computer Gaming

The present case study assessed the feasibility of using an interactive gaming system, coupled with the manipulation of common objects, as a form of repetitive, task-specific movement therapy. Three adults with moderate chronic motor impairments of the fingers and hand participated: one 36-year-old man with an incomplete cervical spinal cord injury, one 60-year-old man with a left cortical cerebro-vascular accident, and one 38-year-old woman with left hemiplegic cerebral palsy. Each subject received an intervention of 15 one-hour sessions, which consisted solely of interactive exercise gaming using a diverse range of objects. The objects provided graded and challenging training levels, which emulated the functional properties of objects used in daily life. This in turn produced positive effects on the recovery of active finger range of motion and hand function.

Relationship Between Clinical Assessments of Function and Measurements From an Upper-Limb Robotic Rehabilitation Device in Cervical Spinal Cord Injury

Upper limb robotic rehabilitation devices can collect quantitative data about the users movements. Identifying relationships between robotic sensor data and manual clinical assessment scores would enable more precise tracking of the time course of recovery after injury and reduce the need for time-consuming manual assessments by skilled personnel. This study used measurements from robotic rehabilitation sessions to predict clinical scores in a traumatic cervical spinal cord injury (SCI) population. A retrospective analysis was conducted on data collected from subjects using the Armeo Spring (Hocoma, AG) in three rehabilitation centers. Fourteen predictive variables were explored, relating to range-of-motion, movement smoothness, and grip ability. Regression models using up to four predictors were developed to describe the following clinical scores: the GRASSP (consisting of four sub-scores), the ARAT, and the SCIM. The resulting adjusted R^2 value was highest for the GRASSP “Quantitative Prehension” component (0.78), and lowest for the GRASSP “Sensibility” component (0.54). In contrast to comparable studies in stroke survivors, movement smoothness was least beneficial for predicting clinical scores in SCI. Prediction of upper-limb clinical scores in SCI is feasible using measurements from a robotic rehabilitation device, without the need for dedicated assessment procedures.

Functional Electrical Stimulation Therapy for Grasping in Traumatic Incomplete Spinal Cord Injury: Randomized Control Trial

The purpose of this single-site randomized control trial was to assess the short-term and long-term efficacy of functional electrical stimulation (FES) therapy over conventional occupational therapy in improving voluntary hand function in incomplete C4-C7 spinal cord injury individuals. All 22 participants recruited in this randomized control trial received treatment for both the left and right upper extremities. Every participant, irrespective of group allocation, received one dose (60 min per day, 5 days per week for the duration of 8 weeks) of conventional occupational therapy for hand function. Of the 22 participants, 12 individuals received an additional dose of conventional occupational therapy, while the remaining 10 participants received a dose of FES hand therapy. The primary outcome measure was Functional Independence Measure (FIM) self-care subscore. The secondary outcome measures were Spinal Cord Independence Measure (SCIM) self-care subscore and Toronto Rehabilitation Institute Hand Function Test (TRI-HFT). The participants who received FES therapy showed significantly greater improvements in hand function at discharge, and were able to maintain their gains at long-term follow-up as assessed using FIM self-care subscore, SCIM self-care subscore, and TRI-HFT. The FES therapy effectively increased independence and thereby improved quality of life of individuals with tetraplegia when compared with conventional occupational therapy.

A randomized trial of functional electrical stimulation for walking in incomplete spinal cord injury: Effects on body composition

Abstract Objective To evaluate the effects of functional electrical stimulation (FES)-assisted walking on body composition, compared to a non-FES exercise program in individuals with a spinal cord injury (SCI). Design Parallel-group randomized controlled trial. Methods Individuals with chronic (≥18 months) incomplete SCI (level C2 to T12, AIS C or D) were recruited and randomized to FES-assisted walking (intervention), or aerobic and resistance training (control) sessions thrice-weekly for 16 weeks. Whole body and leg lean mass and whole body fat mass, measured with dual-energy X-ray absorptiometry, and lower-limb muscle cross-sectional area (CSA) and fat CSA, measured with peripheral computed tomography were assessed at baseline, 4 months, and 12 months. Intention-to-treat analyses using repeated measures general linear models were used to assess between-group differences. Results Thirty-four individuals were randomized (17 per group); 27 remained at 12 months. There were no significant main effects of FES-assisted walking on body composition variables in intention-to-treat analyses with group means. There was a significant group-by-time interaction for muscle area from baseline to 12 months (P = 0.04). Intention-to-treat analysis of muscle area change scores between baseline and 12 months revealed a significant difference between groups (mean (SD) muscle area change score 212 (517) mms for FES, −136 (268) mms for control, P = 0.026). There were 13 side effects or adverse events deemed related to study participation (7 intervention, 5 control); most were resolved with modifications to the protocol. One fainting episode resulted in a hospital visit and study withdrawal. Conclusions Thrice-weekly FES-assisted walking exercise over 4 months did not result in a change in body composition in individuals with chronic, motor incomplete C2 to T12 SCI (AIS classification C and D). However, longer-term follow-up revealed that it might maintain muscle area.

A randomized trial of functional electrical stimulation for walking in incomplete spinal cord injury: Effects on walking competency

Abstract Background Multi-channel surface functional electrical stimulation (FES) for walking has been used to improve voluntary walking and balance in individuals with spinal cord injury (SCI). Objective To investigate short- and long-term benefits of 16 weeks of thrice-weekly FES-assisted walking program, while ambulating on a body weight support treadmill and harness system, versus a non-FES exercise program, on improvements in gait and balance in individuals with chronic incomplete traumatic SCI, in a randomized controlled trial design. Methods Individuals with traumatic and chronic (≥18 months) motor incomplete SCI (level C2 to T12, American Spinal Cord Injury Association Impairment Scale C or D) were recruited from an outpatient SCI rehabilitation hospital, and randomized to FES-assisted walking therapy (intervention group) or aerobic and resistance training program (control group). Outcomes were assessed at baseline, and after 4, 6, and 12 months. Gait, balance, spasticity, and functional measures were collected. Results Spinal cord independence measure (SCIM) mobility sub-score improved over time in the intervention group compared with the control group (baseline/12 months: 17.27/21.33 vs. 19.09/17.36, respectively). On all other outcome measures the intervention and control groups had similar improvements. Irrespective of group allocation walking speed, endurance, and balance during ambulation all improved upon completion of therapy, and majority of participants retained these gains at long-term follow-ups. Conclusions Task-oriented training improves walking ability in individuals with incomplete SCI, even in the chronic stage. Further randomized controlled trials, involving a large number of participants are needed, to verify if FES-assisted treadmill training is superior to aerobic and strength training.

Functional Electrical Stimulation Therapy for Recovery of Reaching and Grasping in Severe Chronic Pediatric Stroke Patients

Stroke affects 2.7 children per 100,000 annually, leaving many of them with lifelong residual impairments despite intensive rehabilitation. In the present study the authors evaluated the effectiveness of 48 hours of transcutaneous functional electrical stimulation therapy for retraining voluntary reaching and grasping in 4 severe chronic pediatric stroke participants. Participants were assessed using the Rehabilitation Engineering Laboratory Hand Function Test, Quality of Upper Extremity Skills Test, Pediatric Evaluation of Disability Inventory, and Assisting Hand Assessment. All participants improved on all measures. The average change scores on selected Rehabilitation Engineering Laboratory Hand Function Test components were 14.5 for object manipulation (P = .042), 0.78 Nm for instrumented cylinder (P = .068), and 14 for wooden blocks (P = .068) and on the grasp component of Quality of Upper Extremity Skills Test was 25.93 (P = .068). These results provide preliminary evidence that functional electrical stimulation therapy has the potential to improve upper limb function in severe chronic pediatric stroke patients.

Restoring Voluntary Grasping Function in Individuals with Incomplete Chronic Spinal Cord Injury: Pilot Study

BACKGROUND Functional electrical stimulation (FES) therapy has been shown to be one of the most promising approaches for improving voluntary grasping function in individuals with subacute cervical spinal cord injury (SCI). OBJECTIVE To determine the effectiveness of FES therapy, as compared to conventional occupational therapy (COT), in improving voluntary hand function in individuals with chronic (≥24 months post injury), incomplete (American Spinal Injury Association Impairment Scale [AIS] B-D), C4 to C7 SCI. METHODS Eight participants were randomized to the intervention group (FES therapy; n = 5) or the control group (COT; n = 3). Both groups received 39 hours of therapy over 13 to 16 weeks. The primary outcome measure was the Toronto Rehabilitation Institute-Hand Function Test (TRI-HFT), and the secondary outcome measures were Graded Redefined Assessment of Strength Sensibility and Prehension (GRASSP), Functional Independence Measure (FIM) self-care subscore, and Spinal Cord Independence Measure (SCIM) self-care subscore. Outcome assessments were performed at baseline, after 39 sessions of therapy, and at 6 months following the baseline assessment. RESULTS After 39 sessions of therapy, the intervention group improved by 5.8 points on the TRI-HFTs Object Manipulation Task, whereas the control group changed by only 1.17 points. Similarly, after 39 sessions of therapy, the intervention group improved by 4.6 points on the FIM self-care subscore, whereas the control group did not change at all. CONCLUSION The results of the pilot data justify a clinical trial to compare FES therapy and COT alone to improve voluntary hand function in individuals with chronic incomplete tetraplegia.