Sarah Morrison

A Multivariate Examination of Temporal Changes in Berg Balance Scale Items for Patients With ASIA Impairment Scale C and D Spinal Cord Injuries

OBJECTIVE To provide a multivariate examination of the Berg Balance Scale (BBS) in patients with spinal cord injury (SCI) as a first step in developing a balance tool for the SCI population. DESIGN Observational cohort. SETTING The NeuroRecovery Network (NRN), a specialized network of treatment centers providing standardized, activity-based therapy for patients with SCI. PARTICIPANTS Patients (N=97) with American Spinal Injury Association Impairment Scale C or D SCI who were enrolled in the NRN between March 1, 2005, and June 12, 2007. INTERVENTIONS All enrolled patients received 3 to 5 locomotor training sessions a week, according to NRN protocol, and were periodically evaluated for progress on functional outcome measurements. MAIN OUTCOME MEASURES Scores on the items of the BBS, six-minute walk test distances, ten-meter walk test speeds, and scores on the SCI Functional Ambulation Index. Temporal rates of change of the BBS items were examined with a principal components and correlation analysis. RESULTS The first principal component accounted for nearly half of the overall variability in the BBS, correlated well with rates of change in functional mobility measures, and had good stability in its composition as verified by a resampling analysis. Further analysis showed that the composition of the first principal component varied with the patients level of recovery. CONCLUSIONS The BBS captures a significant amount of information about balance recovery in persons with SCI and may be a good foundation for a balance tool. However, the utility of BBS items may be dependent on a patients level of recovery. A dynamic balance instrument for the SCI population may be needed.

Locomotor training: is translating evidence into practice financially feasible?

Purpose: Several lines of evidence suggest that locomotor training (LT) modalities, such as body weight–supported treadmill training (BWSTT), improves gait in individuals with incomplete spinal cord injury (SCI). Yet, manual BWSTT has been criticized for being cost prohibitive due to the number of staff required to perform this treatment. This study examined the financial viability of a LT program using manual BWSTT. Methods: This retrospective study analyzed data from individuals with motor incomplete SCI who had participated in manual BWSTT in a hospital-based outpatient clinic between 2003 and 2005. Individuals were between 18 and 68 years of age and were medically stable. Descriptive statistics were performed to determine the mean for each of the following: date of injury, age, impairment, gender, total number of visits, total procedures billed, charges, basic reimbursement information, and costs associated with the treatment. Results: The majority of individuals were male, classified as ASIA C, and had private insurance. Physical therapy evaluation, gait training, and therapeutic exercise were the most commonly billed procedures for all individuals. It was found that this locomotor training program, using the delivery model of one physical therapist, two physical therapy technicians, and one volunteer, was profitable. Conclusions: The findings from this study suggest that LT using manual BWSTT in a hospital-based outpatient clinic can be financially feasible when provided by one trained physical therapist, two technicians, and one well-trained volunteer.

Activity-based therapy for recovery of walking in individuals with chronic spinal cord injury: results from a randomized clinical trial.

OBJECTIVE To examine the effects of activity-based therapy (ABT) on neurologic function, walking ability, functional independence, metabolic health, and community participation. DESIGN Randomized controlled trial with delayed treatment design. SETTING Outpatient program in a private, nonprofit rehabilitation hospital. PARTICIPANTS Volunteer sample of adults (N=48; 37 men and 11 women; age, 18-66y) with chronic (≥12mo postinjury), motor-incomplete (ASIA Impairment Scale grade C or D) spinal cord injury (SCI). INTERVENTIONS A total of 9h/wk of ABT for 24 weeks including developmental sequencing; resistance training; repetitive, patterned motor activity; and task-specific locomotor training. Algorithms were used to guide group allocation, functional electrical stimulation utilization, and locomotor training progression. MAIN OUTCOME MEASURES Neurologic function (International Standards for Neurological Classification of Spinal Cord Injury); walking speed and endurance (10-meter walk test, 6-minute walk test, and Timed Up and Go test); community participation (Spinal Cord Independence Measure, version III, and Reintegration to Normal Living Index); and metabolic function (weight, body mass index, and Quantitative Insulin Sensitivity Check). RESULTS Significant improvements in neurologic function were noted for experimental versus control groups (International Standards for Neurological Classification of Spinal Cord Injury total motor score [5.1±6.3 vs 0.9±5.0; P=.024] and lower extremity motor score [4.2±5.2 vs -0.6±4.2; P=.004]). Significant differences between experimental and control groups were observed for 10-meter walk test speed (0.096±0.14m/s vs 0.027±0.10m/s; P=.036) and 6-minute walk test total distance (35.97±48.2m vs 3.0±25.5m; P=.002). CONCLUSIONS ABT has the potential to promote neurologic recovery and enhance walking ability in individuals with chronic, motor-incomplete SCI. However, further analysis is needed to determine for whom ABT is going to lead to meaningful clinical benefits.

Activity-Based Therapy for Recovery of Walking in Chronic Spinal Cord Injury: Results From a Secondary Analysis to Determine Responsiveness to Therapy

OBJECTIVE To gain insight into who is likely to benefit from activity-based therapy (ABT), as assessed by secondary analysis of data obtained from a clinical trial. DESIGN Secondary analysis of results from a randomized controlled trial with delayed treatment design. SETTING Outpatient program in a private, nonprofit rehabilitation hospital. PARTICIPANTS Volunteer sample of adults (N=38; 27 men; 11 women; age, 22-63y) with chronic (≥12mo postinjury), motor-incomplete (American Spinal Injury Association [ASIA] Impairment Scale [AIS] grade C or D) spinal cord injury (SCI). INTERVENTIONS A total of 9h/wk of ABT for 24 weeks including developmental sequencing; resistance training; repetitive, patterned motor activity; and task-specific locomotor training. Algorithms were used to guide group allocation, functional electrical stimulation utilization, and locomotor training progression. MAIN OUTCOME MEASURES Walking speed and endurance (10-meter walk test and 6-minute walk test) and functional ambulation (timed Up and Go test). RESULTS This secondary analysis identified likely responders to ABT on the basis of injury characteristics: AIS classification, time since injury, and initial walking ability. Training effects were the most clinically significant in AIS grade D participants with injuries <3 years in duration. This information, along with information about preliminary responsiveness to therapy (gains after 12wk), can help predict the degree of recovery likely from participation in an ABT program. CONCLUSIONS ABT has the potential to promote neurologic recovery and enhance walking ability in individuals with chronic, motor-incomplete SCI. However, not everyone with goals of walking recovery will benefit. Individuals with SCI should be advised of the time, effort, and resources required to undertake ABT. Practitioners are encouraged to use the findings from this trial to assist prospective participants in establishing realistic expectations for recovery.

NeuroRecovery Network Provides Standardization of Locomotor Training for Persons With Incomplete Spinal Cord Injury

OBJECTIVE To illustrate the continuity of care afforded by a standardized locomotor training program across a multisite network setting within the Christopher and Dana Reeve Foundation NeuroRecovery Network (NRN). DESIGN Single patient case study. SETTING Two geographically different hospital-based outpatient facilities. PARTICIPANTS This case highlights a 25-year-old man diagnosed with C4 motor incomplete spinal cord injury with American Spinal Injury Association Impairment Scale grade D. INTERVENTION Standardized locomotor training program 5 sessions per week for 1.5 hours per session, for a total of 100 treatment sessions, with 40 sessions at 1 center and 60 at another. MAIN OUTCOME MEASURES Ten-meter walk test and 6-minute walk test were assessed at admission and discharge across both facilities. For each of the 100 treatment sessions percent body weight support, average, and maximum treadmill speed were evaluated. RESULTS Locomotor endurance, as measured by the 6-minute walk test, and overground gait speed showed consistent improvement from admission to discharge. Throughout training, the patient decreased the need for body weight support and was able to tolerate faster treadmill speeds. CONCLUSIONS Data indicate that the patient continued to improve on both treatment parameters and walking function. Standardization across the NRN centers provided a mechanism for delivering consistent and reproducible locomotor training programs across 2 facilities without disrupting training or recovery progression.

Longitudinal Recovery and Reduced Costs After 120 Sessions of Locomotor Training for Motor Incomplete Spinal Cord Injury

OBJECTIVE To determine the impact of long-term, body weight-supported locomotor training after chronic, incomplete spinal cord injury (SCI), and to estimate the health care costs related to lost recovery potential and preventable secondary complications that may have occurred because of visit limits imposed by insurers. DESIGN Prospective observational cohort with longitudinal follow-up. SETTING Eight outpatient rehabilitation centers that participate in the Christopher & Dana Reeve Foundation NeuroRecovery Network (NRN). PARTICIPANTS Individuals with motor incomplete chronic SCI (American Spinal Injury Association Impairment Scale C or D; N=69; 0.1-45y after SCI) who completed at least 120 NRN physical therapy sessions. INTERVENTIONS Manually assisted locomotor training (LT) in a body weight-supported treadmill environment, overground standing and stepping activities, and community integration tasks. MAIN OUTCOME MEASURES International Standards for Neurological Classification of Spinal Cord Injury motor and sensory scores, orthostatic hypotension, bowel/bladder/sexual function, Spinal Cord Injury Functional Ambulation Inventory (SCI-FAI), Berg Balance Scale, Modified Functional Reach, 10-m walk test, and 6-minute walk test. Longitudinal outcome measure collection occurred every 20 treatments and at 6- to 12-month follow-up after discharge from therapy. RESULTS Significant improvement occurred for upper and lower motor strength, functional activities, psychological arousal, sensation of bowel movement, and SCI-FAI community ambulation. Extended training enabled minimal detectable changes at 60, 80, 100, and 120 sessions. After detectable change occurred, it was sustained through 120 sessions and continued 6 to 12 months after treatment. CONCLUSIONS Delivering at least 120 sessions of LT improves recovery from incomplete chronic SCI. Because walking reduces rehospitalization, LT delivered beyond the average 20-session insurance limit can reduce rehospitalizations and long-term health costs.

Life care planning projections for individuals with motor incomplete spinal cord injury before and after locomotor training intervention: a case series.

BACKGROUND/PURPOSE We present a retrospective case series of 2 individuals with motor-incomplete spinal cord injury (SCI) to examine differences in lifetime cost estimates before and after participation in an intensive locomotor training (LT) program. Sections of a life care plan (LCP) were used to determine the financial implications associated with equipment, home renovations, and transportation for patients who receive LT. An LCP is a viable method of quantifying outcomes following any therapeutic intervention. CASE DESCRIPTION The LCP cases analyzed were a 61-year-old woman and a 4½-year-old boy with motor-incomplete SCI and impairments classified by the American Spinal Injury Association Impairment Scale (AIS) as AIS D and AIS C, respectively. INTERVENTIONS Each patient received an intensive outpatient LT program 3 to 5 days per week. The 61-year-old woman received 198 sessions over 57 weeks and the 4½-year-old boy received 76 sessions over 16 weeks. OUTCOMES The equipment, home renovation, and transportation costs of an LCP were calculated before and after LT. Prior to the implementation of LT, the 61-year-old woman had estimated lifetime costs between

The measurement properties of fitness measures and health status for persons with spinal cord injuries

150,247.00 and

Biofeedback to Facilitate Unassisted Ventilation in Individuals with High-level Quadriplegia

199,654.00. Following LT, the estimated costs decreased to between

Cardiorespiratory responses to exercise in acute spinal cord individuals

2010.00 and