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Lower Limb, Balance and Walking Following Spinal Cord Injury

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Lower Limb, Balance and Walking Following Spinal Cord Injury Lower Limb, Balance and Walking Following Spinal Cord Injury Tania Lam, PhD Cynthia Tse, MSc Shannon Sproule, BSc (PT) Janice J Eng, PhD, BSc (PT/OT) www.scireproject.com Version 6.0 Key Points Neuromuscular Electrical Stimulation (NMES) programs are beneficial in preventing and restoring lower limb muscle atrophy as well as improving stimulated lower limb muscle strength and endurance but the persistence of effects after the NMES has ended is not known Functional Electrical Stimulation (FES)-assisted exercise is beneficial in preventing and restoring lower limb muscle atrophy as well as improving lower limb muscle strength and endurance in motor complete SCI. Community-based ambulation training that is progressively challenged may result in long-lasting benefits in incomplete SCI. For patients less than 12 months post-SCI, Body-weight Supported Treadmill Training (BWSTT) may have similar effects on gait outcomes as overground mobility training of similar intensity. Body weight-support gait training strategies can improve gait outcomes in chronic, incomplete SCI, but most body weight-support strategies (overground, treadmill, with FES) are equally effective at improving walking speed. Robotic training was the least effective at improving walking speed. Down-conditioning (DC) reflex protocols of the soleus could facilitate gait outcomes. Repetitive transcranial magnetic stimulation (rTMS) combined with overground locomotor training may not afford further benefits over overground locomotor training alone. There is limited evidence for the benefits of combining the use of certain pharmacological agents with gait training on ambulation in individuals with SCI. FES-assisted walking can enable walking or enhance walking speed in incomplete SCI or complete (T4-T11) SCI. Regular use of FES in gait training or activities of daily living can lead to improvement in walking even when the stimulator is not in use. BWSTT combined with FES of the common peroneal nerve can lead to an overall enhancement of short-distance functional ambulation. Electrical stimulation is shown to be a more effective form of locomotor training than manual assistance and braces. Stimulation with FES while ambulating on a BWS treadmill can increase SCIM mobility scores. BWSTT combined with FES to the quadriceps and hamstrings muscles can enhance functional ambulation. While an 8 channel neuroprosthesis system is safe and reliable, its use with rehabilitation training showed no statistically significant difference in walking outcomes. An ankle-foot-orthosis can enhance walking function in incomplete SCI patients who have drop- foot. Reciprocal Gait Orthosis (RGO) can enable slow walking in participants with thoracic lesions, and not at speeds sufficient for community ambulation. The advantages of RGOs appear largely restricted to the general health, well-being and safety benefits related to practice of standing and the ability to ambulate short-distances in the home or indoor settings. Powered Gait Orthosis (PGO), more commonly known as exoskeletons, can enable safe walking and reduce energy expenditure compared to passive bracing in patients with thoracic injuries. There is limited evidence that a combined approach of bracing and FES results in additional benefit to functional ambulation in paraplegic patients with complete SCI. There is limited evidence that whole body vibration improves walking function in incomplete SCI. Electromyography (EMG) Biofeedback may improve gait outcomes in incomplete SCI. Locomotor training programs are beneficial in improving lower limb muscle strength although in acute SCI similar strength increases may be obtained with conventional rehabilitation. The real benefit of locomotor training on muscle strength may be realized when it is combined with conventional therapy. This should be further explored in acute, incomplete SCI where better functional outcomes may be realized with the combination of therapies. Table of Contents 1.0 Executive Summary ............................................................................................................... 5 2.0 Introduction ............................................................................................................................ 7 3.0 Systematic Reviews ............................................................................................................... 8 4.0 Sitting, Standing and Balance Training ............................................................................... 15 5.0 Strengthening lower limb function ....................................................................................... 23 5.1 Enhancing Strength Following Locomotor Training in Incomplete SCI .......................... 23 5.2 Electrical Stimulation to Enhance Lower Limb Muscle Function (NMES/FES non- ambulatory muscle stim) ........................................................................................................ 28 5.3 Neuromuscular Electrical Stimulation (NMES)................................................................ 30 5.4 Functional Electrical Stimulation ...................................................................................... 34 6.0 Gait Retraining Strategies to Enhance Functional Ambulation .......................................... 45 6.1 Overground training ......................................................................................................... 45 6.2 Body-Weight Supported Treadmill Training (BWSTT) .................................................... 48 6.2.1 BWSTT in Acute/Sub-Acute SCI .............................................................................. 50 6.2.2 BWSTT in Chronic SCI ............................................................................................. 54 6.2.3 BWSTT Combined with Spinal Cord Stimulation ..................................................... 65 7.0 Orthoses/Braces .................................................................................................................. 66 7.1 Ankle Foot Orthosis in SCI .............................................................................................. 67 7.2 Hip-Knee-Ankle-Foot Orthosis in SCI (RGO/HKAFO/KAFO) ......................................... 68 7.3 Powered Gait Orthosis and Robotic Exoskeletons in SCI .............................................. 73 8.0 Functional Electrical Stimulation (FES) and Walking ......................................................... 77 8.1 Functional Electrical Stimulation to Improve Locomotor Function.................................. 77 8.2 Functional Electrical Stimulation with Gait Training to Improve Locomotor Function .... 81 8.3 Bracing Combined with FES in SCI ................................................................................. 85 8.4 Biofeedback and Gait Rehabilitation ............................................................................... 88 8.5 Whole-Body Vibration and Lower Limb Motor Output .................................................... 90 9.0 Pharmacological interventions to augment Gait/ambulation .............................................. 92 9.1 Combined Gait Training and Pharmacological Interventions ......................................... 92 10.0 Emerging experimental approaches ................................................................................. 99 10.1 Conditioning Reflex Protocols........................................................................................ 99 10.3 Repetitive Transcranial Magnetic Stimulation ............................................................. 100 10.4 Cellular Transplantation Therapies to Augment Strength and Walking Function ...... 103 10.5 Case Report: Nutrient Supplement to Augment Walking Distance ............................ 104 Gap: Lower limb edema after SCI .................................................................................... 105 Gap: Footcare after SCI ................................................................................................... 106 Abbreviations ......................................................................................................................... 124 This review has been prepared based on the scientific and professional information available in 2018. The SCIRE information (@ www.scireproject.com) is provided for informational and educational purposes only. If you have or suspect you have a health problem, you should consult your health care provider. The SCIRE editors, contributors and supporting partners shall not be liable for any damages, claims, liabilities, costs or obligations arising from the use or misuse of this material. Lam T, Tse C, Sproule S, Eng JJ, Sproule S (2019). Lower Limb Rehabilitation Following Spinal Cord Injury. In: Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, Sproule S, McIntyre A, Querée M, editors. Spinal Cord Injury Rehabilitation Evidence. Version 6.0. Vancouver: p 1-125. Special thanks to previous author Dalton Wolfe and Lisa Harvey for reviews of this material www.scireproject.com 1.0 Executive Summary What Lower Limb, Balance, and Walking problems occur after injury? • Loss of function in the lower limbs due to SCI can extend from complete paralysis to varying levels of voluntary muscle activation. The rehabilitation of lower extremity function after SCI has generally focused on the recovery of gait. Even when functional ambulation may not be possible (e.g. in complete tetraplegia), lower limb interventions can be
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