Using a divided-attention stepping accuracy task to improve balance and functional outcomes in an individual with incomplete spinal cord injury: A case report

Abstract

A spinal cord injury (SCI) frequently results in impaired balance, endurance, and strength with subsequent limitations in functional mobility and community participation. The purpose of this case report was to implement a training program for an individual with a chronic incomplete SCI using a novel divided-attention stepping accuracy task (DASAT) to determine if improvements could be made in impairments, activities, and participation. The client was a 51-year-old male with a motor incomplete C4 SCI sustained 4 years prior. He presented with decreased quality of life (QOL) and functional independence, and deficits in balance, endurance, and strength consistent with central cord syndrome. The client completed the DASAT intervention 3 times per week for 6 weeks. Each session incorporated 96 multi-directional steps to randomly-assigned targets in response to 3-step verbal commands. QOL, measured using the SF-36, was generally enhanced but fluctuated. Community mobility progressed from close supervision to independence. Significant improvement was achieved in all balance scores: Berg Balance Scale by 9 points [Minimal Detectable Change (MDC) = 4.9 in elderly]; Functional Reach Test by 7.62 cm (MDC = 5.16 in C5/C6 SCI); and Timed Up-and-Go by 0.53 s (MDC not established). Endurance increased on the 6-Minute Walk Test, with the client achieving an additional 47 m (MDC = 45.8 m). Lower extremity isokinetic peak torque strength measures were mostly unchanged. Six minutes of DASAT training per session provided an efficient, low-cost intervention utilizing multiple trials of variable practice, and resulted in better performance in activities, balance, and endurance in this client.

The Effect of Perturbation-Based Balance Training and Conventional Intensive Balance Training on Reactive Stepping Ability in Individuals With Incomplete Spinal Cord Injury or Disease: A Randomized Clinical Trial

“…Virtual realitybased balance training has also been shown to improve lower extremity strength in individuals with iSCI/D when five muscle groups were tested manually (16,17). A case study examining the effects of a divided attention stepping task, however, did not find any effects on lower extremity strength following training, but this testing was done with a dynamometer on three muscle groups (18). Our results may differ from these findings for several reasons.…”

“…On the FES-I, mean (standard deviation) changes scores were −4.4 (6.1) for the PBT group and −3.7 (5.0) for the CIBT group. There were no significant group-by-time or group effects (F (1,18) = 0.07, p = 0.80, F (1,18) = 2.30, p = 0.15, respectively), but there was a significant effect for time (F (1,18) = 10.44, p = 0.010). One participant out of 10 from the PBT and two out of 10 from the CIBT group moved below the cut-off score of 22 points; there was no difference between groups with respect to the proportion of participants who moved below the cut-off point (χ 2 = 0.39, p = 0.53).…”

“…The participants in these studies were stronger at baseline than many of our participants, indicating a need for future research to include participants with varying levels of impairment. While one study targeted a stepping task (18), the studies using virtual reality targeted different lower extremity movements, such as ankle dorsiflexion and hip abduction/adduction (16,17).…”

“…Previously studied balance interventions have focused on anticipatory balance control, which is used to stabilize the body before a volitional movement (13). For example, using visual feedback during standing balance tasks (14,15), virtual reality (16,17), or a divided-attention stepping task (18) that focuses on voluntary movements to train balance. Balance studies in iSCI/D research are often pre-post analyses (14,16,17), include retrospective controls (15), or are case studies (18), which are considered lower levels of evidence than randomized trials.…”

“…For example, using visual feedback during standing balance tasks (14,15), virtual reality (16,17), or a divided-attention stepping task (18) that focuses on voluntary movements to train balance. Balance studies in iSCI/D research are often pre-post analyses (14,16,17), include retrospective controls (15), or are case studies (18), which are considered lower levels of evidence than randomized trials. Furthermore, studies that do use a balance-focused intervention typically only include outcomes that measure standing balance (14,15,18), even though most falls experienced by ambulatory individuals with iSCI/D occur during walking (4).…”