Responsiveness of the Neuromuscular Recovery Scale During Outpatient Activity-Dependent Rehabilitation for Spinal Cord Injury.

BACKGROUND: The Neuromuscular Recovery Scale (NRS) was developed by researchers and clinicians to functionally classify people with spinal cord injury (SCI) by measuring functionally relevant motor tasks without compensation. Previous studies established strong interrater and test-retest reliability and validity of the scale. OBJECTIVE: To determine responsiveness of the NRS, a version including newly added upper-extremity items, in an outpatient rehabilitation setting. METHODS: Assessments using the NRS and 6 other instruments were conducted at enrollment and discharge from a locomotor training program for 72 outpatients with SCI classified as American Spinal Injury Association Impairment Scale grades A to D (International Standards for Neurological Classification of Spinal Cord Injury). Mixed-model t statistics for instruments were calculated and adjusted for confounding factors (eg, sample size, demographic variables) for all patients and subgroups stratified by injury level and/or severity. The resulting adjusted response means (ARMs) and 95% confidence intervals (CIs) were used to determine responsiveness, and significant differences between instruments were identified with pairwise comparisons. RESULTS: The NRS was significantly responsive for SCI outpatients (ARM = 1.05; CI = 0.75-1.35). Changes in motor function were detected across heterogeneous groups. Regardless of injury level or severity, the responsiveness of the NRS was equal to, and often significantly exceeded, the responsiveness of other instruments. CONCLUSIONS: The NRS is a responsive measure that detects change in motor function during outpatient neurorehabilitation for SCI. There is potential utility for its application in randomized controlled trials and as a measure of clinical recovery across diverse SCI populations.

Are the 10 meter and 6 minute walk tests redundant in patients with spinal cord injury?

OBJECTIVE: To evaluate the relationship and redundancy between gait speeds measured by the 10 Meter Walk Test (10MWT) and 6 Minute Walk Test (6MWT) after motor incomplete spinal cord injury (iSCI). To identify gait speed thresholds supporting functional ambulation as measured with the Spinal Cord Injury Functional Ambulation Inventory (SCI-FAI). DESIGN: Prospective observational cohort. SETTING: Seven outpatient rehabilitation centers from the Christopher and Dana Reeve Foundation NeuroRecovery Network (NRN). PARTICIPANTS: 249 NRN patients with American Spinal Injury Association Impairment Scale (AIS) level C (n = 20), D (n = 179) and (n = 50) iSCI not AIS evaluated, from February 2008 through April 2011. INTERVENTIONS: Locomotor training using body weight support and walking on a treadmill, overground and home/community practice. MAIN OUTCOME MEASURE(S): 10MWT and 6MWT collected at enrollment, approximately every 20 sessions, and upon discharge. RESULTS: The 10MWT and 6MWT speeds were highly correlated and the 10MWT speeds were generally faster. However, the predicted 6MWT gait speed from the 10MWT, revealed increasing error with increased gait speed. Regression lines remained significantly different from lines of agreement, when the group was divided into fast (≥0.44 m/s) and slow walkers (<0.44 m/s). Significant differences between 6MWT and 10MWT gait speeds were observed across SCI-FAI walking mobility categories (Wilcoxon sign rank test p<.001), and mean speed thresholds for limited community ambulation differed for each measure. The smallest real difference for the 6MWT and 10MWT, as well as the minimally clinically important difference (MCID) values, were also distinct for the two tests. CONCLUSIONS: While the speeds were correlated between the 6MWT and 10MWT, redundancy in the tests using predictive modeling was not observed. Different speed thresholds and separate MCIDs were defined for community ambulation for each test.

Treadmill training after surgical removal of a spinal tumor in infancy.

BACKGROUND AND PURPOSE: Step training on a treadmill is a common intervention for adult and pediatric patients with spinal cord injuries (SCI). Treadmill training has not been used as an intervention for infants and toddlers with SCI before walking onset. This case report describes the intervention and stepping behaviors on a treadmill and overground of a toddler after the surgical removal of a rare spinal tumor resulting in SCI. CASE DESCRIPTION: The toddler presented with an inability to step on the left, rare stepping on the right, and an apparent lack of sensation in the lower extremities. After spinal tumor excision at 5.5 weeks of age, step training on a treadmill and overground occurred once per week from 15 to 35 months of age in addition to traditional physical therapy. OUTCOMES: Independent symmetrical stepping emerged both on and off the treadmill over 20 months. Improvements in the number and pattern of steps occurred with training. Walking speed increased, and milestones important to overground walking developed. DISCUSSION: Independent steps developed during the intervention with little motor development of the lower extremities during the first year of life. Furthermore, improvements in stepping alternation, standing, and walking occurred despite no evidence of sensation in the lower extremities.

Relationship between ASIA examination and functional outcomes in the NeuroRecovery Network Locomotor Training Program.

OBJECTIVE: To determine the effects of locomotor training on: (1) the International Standards for Neurological Classification of Spinal Cord Injury examination; (2) locomotion (gait speed, distance); (3) balance; and (4) functional gait speed stratifications after chronic incomplete spinal cord injury (SCI). DESIGN: Prospective observational cohort. SETTING: Outpatient rehabilitation centers in the NeuroRecovery Network (NRN). PARTICIPANTS: Individuals (n=225) with American Spinal Injury Association Impairment Scale (AIS) grade C or D chronic motor incomplete SCI having completed locomotor training in the NRN. INTERVENTION: The NRN Locomotor Training Program consists of manual-facilitated body weight-supported standing and stepping on a treadmill and overground. MAIN OUTCOME MEASURES: AIS classification, lower extremity pin prick, light touch and motor scores, ten-meter walk and six-minute walk tests, and the Berg Balance Scale. RESULTS: Significant gains occurred in lower extremity motor scores but not in sensory scores, and these were only weakly related to gait speed and distance. Final Berg Balance Scale scores and initial lower extremity motor scores were positively related. Although 70% of subjects showed significantly improved gait speed after locomotor training, only 8% showed AIS category conversion. CONCLUSIONS: Locomotor training improves gait speed to levels sufficient for independent in-home or community ambulation after chronic motor incomplete SCI. Changes in lower extremity motor and sensory scores do not capture the full extent of functional recovery, nor predict responsiveness to locomotor training. Functional classification based on gait speed may provide an effective measure of treatment efficacy or functional improvement after incomplete SCI.