Activity-Based Therapy: From Basic Science to Clinical Application for Recovery After Spinal Cord Injury

Abstract

Background and Purpose Collaboration between scientists and clinicians effectively accelerated translation of scientific evidence for activity-based therapies (ABT) into rehabilitation. This article addresses the basic scientific findings of activity-dependent plasticity that led to Locomotor Training (LT), an ABT, and its principles to advance recovery in adult and pediatric populations with spinal cord injury (SCI). Expansion to new therapies based on these common principles is highlighted, e.g., epidural stimulation. The article also describes a recently developed measure, the Neuromuscular Recovery Scale (NRS), and its psychometric properties. Summary of Key Points LT has led to recovery of walking in some individuals with motor-incomplete SCI even years after injury. Recent studies resulted in individuals with motor- complete SCI regaining some voluntary movements and standing in the presence of epidural stimulation. The level of success for LT and epidural stimulation appears dependent on spinal networks maintaining the appropriate central state of excitability for the desired task. As these new advances in restorative therapies required an outcome measure that measured performance without compensation, the NRS was developed. The NRS has strong psychometric properties in adults, and a pediatric version is under development. Application of LT in children is still novel. Preliminary evidence suggests that LT can improve trunk control, and also foster participation in children with chronic SCI. Recommendations for Clinical Practice Activity-based therapies may effectively promote neuromuscular recovery, improve function and participation in adults and children post-SCI. Evaluation of outcomes with valid measures, such as the NRS, is necessary to document the ability to perform functional tasks, and to assess progress as function improves.

Locomotor training with adjuvant testosterone preserves cancellous bone and promotes muscle plasticity in male rats after severe spinal cord injury

“…Similarly, in animal models of mild or moderate severity incomplete SCI, quadrupedal bodyweight-supported TM training attenuates muscle atrophy, increases muscle force production (Jayaraman, Liu, Ye, Walter, & Vandenborne, 2013;Liu, Bose, Walter, Thompson, & Vandenborne, 2008;Liu et al, 2010;Stevens et al, 2006), and promotes recovery of voluntary over-ground locomotion, in part, by improving afferent neuromodulation of the central pattern generator, by preventing axonal degradation, and by normalizing the spinal reflex pathways that regulate spasticity and motoneuron excitability (Bose, Hou, Parmer, Reier, & Thompson, 2012;Hou et al, 2014). However, after more severe SCI, humans (Behrman, Ardolino, & Harkema, 2017) and animal models (Battistuzzo, Callister, Callister, & Galea, 2012) exhibit only minimal muscular improvement and negligible recovery of over-ground walking ability in response to bodyweight-supported TM training. Similarly, the effectiveness of TM training and of other reloading strategies in regenerating bone after SCI remains contentious (Panisset, Galea, & El-Ansary, 2016), especially at the sites most prone to fracture (i.e., distal femur and proximal tibia) in this population (Cirnigliaro et al, 2017).…”

A Comparison of FES and SCS for Neuroplastic Recovery After SCI: Historical Perspectives and Future Directions

“…Some of the studies cited involve 100–200 locomotor training sessions. In a recent paper, Behrman recommended at least 60, lasting 1½ h per day for successful Activity Based Therapy ( 7 ). Morrison ( 34 ) provides useful cost data from the US.…”

“…Friedli et al (6) found, in 400 patients with tetraplegia, that asymmetry in the lesion allowed greater recovery, and also that, in monkeys, recovery correlated with corticospinal "detour circuits" below the injury. Many animal studies have demonstrated recovery after SCI following treadmill training, and this has reinforced the view that Activity-Based Therapy may enable patients with incomplete lesions to walk (7). Hubli and Dietz (8) described the knowledge gained as a "physiological basis for neurorehabilitation: a sufficient combination of sensory cues is required to generate and improve locomotor patterns.…”

Muscle Activation Patterns During Movement Attempts in Children With Acquired Spinal Cord Injury: Neurophysiological Assessment of Residual Motor Function Below the Level of Lesion

“…While these methods are sufficient for the gross evaluation of movement performance and may be easily used in clinical settings, distinctions between intentional movements, unintentional or "reflexive" movements, and "spasms" can be difficult (19). As recovery-focused interventions continue to be developed and improved (21)(22)(23)(24)(25)(26), determination of the presence of residual supraspinal-spinal connectivity after SCI has clear implications for rehabilitation goals and outcomes. There is an important need for age-based assessment of sensorimotor function in children with SCI.…”