Spatiotemporal Parameters of Gait Among Adolescent Athletes with Concussion When Performing a Visuospatial Cognitive Task.

Background: Adolescent athletes aged 10 to 19 years are at the highest risk of experiencing sport-related concussions (SRCs). Despite the known deficits and battery of assessments following concussion, postural stability during dual-task gait remains understudied in this population. Purpose: The purpose of this study was to evaluate the dual-task cost (DTC) in adolescents with an acute or chronic SRC compared to reference values from healthy athlete peers for spatiotemporal parameters of gait during walking with and without a concurrent visuospatial memory task presented on a hand-held tablet. Researchers hypothesized that adolescents during the acute phase of concussion would be likely to experience a greater DTC compared to healthy peers in at least one spatiotemporal parameter of gait when walking within the dual-task paradigm. Study Design: Cross-sectional, observational cohort design. Methods: Adolescents with concussion were recruited to participate. Subjects were divided into acute and chronic categories based on significant differences in the neuropsychological function after a period of 28 days. They walked at a self-selected speed along the 5.186-meter GAITRite® Walkway System with and without a concurrent visuospatial cognitive task presented on a hand-held tablet. Outcomes included normalized velocity (m/s), step length (m), and double limb (DLS) and single limb support (SLS) (defined as the percent of a gait cycle [%GC]). The data were then compared to the previously published reference values established using the same methods in the healthy athlete participants for all spatiotemporal parameters of gait. Results: Data was collected on 29 adolescent athletes with SRC. Among males (15.53+/-1.12 years) with SRC, 20% of acute and 10% of chronic cases experienced a greater DTC compared to healthy athlete reference values. A similarly increased DTC was experienced by 83% of acute and 29% of chronic SRC cases for females (15.58+/-1.16 years). Conclusions: Adolescent athletes with concussion may continue demonstrating deficits in gait capabilities even in the chronic phase, and compensatory gait strategies were not the same between males and females. Dual-task cost assessment using the GAITRite® may be a valuable adjunct to comprehensive analysis of gait following SRC. Level of Evidence: 2.

Static and Dynamic Balance Assessment in Healthy and Concussed Adolescent Athletes.

OBJECTIVE: The purpose of this study was to explore the utilization of the Y Balance Test (YBT) alongside the Balance Error Scoring System (BESS) during examination of healthy adolescent athletes (14-18 year old) as well as those with acute and chronic concussion. DESIGN: A repeated-measures study of balance in a cross-sectional convenience sample of adolescents participating in high-school athletics. SETTING: Data were collected on healthy athletes in their school setting for comparison purposes and on concussed athletes in the physical therapy rehabilitation center at the hospital. PARTICIPANTS: Participants were a convenience sample of male and female athletes between the ages of 14 to 18 year old [180 healthy (111 male, 69 female) and 44 (28 male, 16 female) with concussion]. ASSESSMENT OF RISK FACTORS: All participants were cleared for participation by preparticipation examination or by the treating sport medicine physician. MAIN OUTCOME MEASURES: Healthy athletes performed the YBT, a dynamic assessment of balance. Athletes with concussion also performed the BESS, a static assessment of balance. RESULTS: Means for each YBT reach direction were statistically different for both healthy males and females ( P < 0.05). Within both the acute and chronic subsets of the concussed sample, some participants performed over the median value for the BESS but not the YBT. CONCLUSIONS: These data may suggest that dynamic balance testing in conjunction with static balance testing could be valuable in both the acute and chronic phases of concussion to ensure a comprehensive assessment of the necessary balance skills for athletic play.

Does Dosing of Pediatric Experiential Learning Impact the Development of Clinical Reasoning, Self-Efficacy, and Critical Thinking in DPT Students?

AIMS: The purpose of this study was to explore the changes in clinical reasoning, self-efficacy, and critical thinking of a group of Doctor of Physical (DPT) students who completed a high and low dose of pediatric experiential learning (EL) as a component of their semester-long pediatric course. METHODS: A convenience sample of students at two DPT programs in the United States were recruited. A pre-test post-test comparison group design was used to examine the change in students' clinical reasoning, self-efficacy, and critical thinking following completion of a pediatric course that contained a high or low dose of EL. Students completed the Self-Assessment of Clinical Reflection and Reasoning, Physical Therapy Self-Efficacy Scale, and Health Science Reasoning Test during the first and last weeks of the semester. Students in the high-dose group reported a significant increase (p=0.000) over time in self-perceived clinical reasoning and self-efficacy. Overall critical thinking abilities significantly improved (p=0.044) over time in both groups. CONCLUSION: A high dose of pediatric EL seems to aid students in the development of self-perceived clinical reasoning and self-efficacy. Providing students with EL opportunities prior to pediatric rotations may help to bolster these important skills, leading to improved clinical performance.

Examining Factors That Contribute to Delayed Wound Healing in Children with Tracheostomy Wounds.

OBJECTIVE: To identify variables that may contribute to delayed wound healing times in pediatric patients with tracheostomy wounds. DESIGN: Researchers identified 134 charts spanning January 2013 to June 2017; 95 charts met the inclusion criteria. The study examined Pressure Ulcer Scale for Healing (PUSH) scores, pressure injury staging, and albumin levels. SETTING: Arkansas Children's Hospital. PATIENTS: Patients (birth to 18 years) who developed or were admitted with a wound caused by a tracheostomy device. MAIN OUTCOME MEASURE: Time in days to wound closure. MAIN RESULTS: There was a moderate positive correlation between albumin and days to healing (r = 0.432, n = 22, P = .045) with higher albumin levels associated with shorter healing times. The PUSH scores and pressure injury stage were significant in explaining 14.1% of variance in days to healing (F77,2 = 7.458; P < .001). CONCLUSIONS: Wound healing appears to be multifactorial in nature in the pediatric population; albumin levels, pressure injury stage, and PUSH scores are all positively correlated with healing times. Further research is needed to investigate the contribution of race to healing time predication for the pediatric population.

Pediatric Tracheostomy Wound Healing: A Retrospective Cohort Study.

OBJECTIVE: To compare wound products by measuring time to granulation tissue and time to complete wound healing for tracheostomy wounds in the pediatric population. METHODS: Investigators identified 134 charts of patients treated January 2013 and June 2017; 93 charts met the inclusion criteria. This study compared the use of a foam dressing (n = 34) to the foam dressing plus a wound filler (n = 59) in patients who developed or were admitted with a wound caused by a tracheostomy device. PRIMARY OUTCOME MEASURES: Time in days to granulation tissue and to wound closure. RESULTS: The average time to complete wound closure for participants in this study was 14 days. There was no statistically significant difference in time to granulation tissue or wound closure formation between the wound care products (F2,34 = 1.11, P = .34). Cluster analysis (10 splits) revealed that pressure injury stage was the best predictor, accounting for 41% of the variance in the high treatment response group (those healing in <14 days). Patients who were African American with a stage 2 pressure injury, had a PUSH score of 5 or more, and were using a foam plus a wound filler dressing were 86% more likely to be in the high-response group. CONCLUSIONS: All wounds reviewed healed with current wound care practices without surgical intervention. Best practice for healing tracheostomy wounds in pediatric patients should include the wound filler in the first 14 days based on variable interaction.

SPATIOTEMPORAL PARAMETERS OF ADOLESCENT GAIT WHEN PERFORMING A VISUOSPATIAL MEMORY TASK.

BACKGROUND: Accurate assessment of recovery following mild traumatic brain injury in adolescents can be difficult. When compared to single-task models, dual-task models that combine cognitive and motor demands may more accurately identify residual deficits that manifest during daily life and athletic play in adolescents with concussion. Previous studies have examined gait changes during a concurrent auditory task, or cognitive task. PURPOSE: The purpose of this study was to collect and present data from a sample of healthy 14-18 year old male and female athletes on spatiotemporal parameters of gait for walking with and without a concurrent visuospatial memory task presented on a hand-held tablet. STUDY DESIGN: A two-way repeated measures study of spatiotemporal gait parameters in a cross-sectional convenience sample of adolescent subjects participating in high school athletics. METHODS: Subjects comprised a total of 178 adolescent athletes (128 males; 50 females) ages 14-18 years old at six area high schools. Subjects were instructed to walk "how you normally do" on the GAITRite® portable gait analysis walkway for three undivided and three divided attention trials performing a visuospatial memory task on a hand-held tablet. RESULTS: Significant differences (p < 0.0001) were present between males and females during typical gait in each of the measured parameters except step length (p = 0.0715). Female participants walked with a significantly faster gait velocity (by 0.21 m/s) than male participants (p < 0.0001). The females spent a significantly smaller (-2.27%) percent of the gait cycle in double limb support (p < 0.0001) and a significantly greater (+1.10%) percent of the gait cycle in single limb support (p < 0.0001) than did the males. Both groups experienced a similar, dual-task cost during the divided attention trials (p < 0.0001) for each of the four gait parameters. Previous studies have shown that adults decrease their gait velocity by approximately 33% when performing a task on a hand-held device. The current study revealed that adolescents decreased their gait velocity by 8-9% by shortening their step length by 7.4 centimeters (p < 0.0001), increased the percent of the gait cycle spent in double limb support (2.73%, p < 0.0001) and decreased the percent of the gait cycle spent in single limb support (1.38%, p < 0.0001) during the dual-task. CONCLUSION: These data provide preliminary reference values specific to the adolescent population for the dual-task cost during a visuospatial memory task. More research is needed to determine the dual-task cost during a visuospatial memory task for adolescents with concussion. LEVEL OF EVIDENCE: 2b.

Peripheral Infiltration and Extravasation Injury Methodology: A Retrospective Study.

Peripheral infiltration is defined as the inadvertent delivery of nonvesicant fluid or medication into surrounding tissue that has the potential to harm the patient. Vesicant fluid that has leaked into the tissue space is called extravasation. At present, there is no agreement in the literature on the best practice for managing these injuries in pediatric patients. The purpose of this study was to identify occurrences of peripheral infiltration injuries and examine treatment modalities used to treat pediatric patients who suffered such an injury.

Collagenase for Wound Debridement in the Neonatal Intensive Care Unit: A Retrospective Case Series.

BACKGROUND/OBJECTIVES: The use of collagenase for enzymatic wound debridement has been studied extensively and has been established as the standard of care for nonhealing and necrotic wounds in individuals for whom surgical intervention is not an option. Collagenase has been shown to be effective in adults but has been studied in a limited capacity in infants and neonates. The purpose of this study was to investigate the use of collagenase in the neonatal intensive care unit (NICU). METHODS: Retrospective chart review of infants and neonates admitted to the NICU at Arkansas Children's Hospital with nonhealing wounds for which collagenase was used for wound healing over a 1-year time period. Six wounds were identified: five surgical wound dehiscence and one intravenous infiltrate. RESULTS: Before the use of collagenase, five of the six wounds had been treated with an alternative dressing. Once collagenase was initiated, three of these wounds reached complete granulation and closure in less time than in the episode of prior therapy. The number of days to reach 100% granulation once treated with collagenase was 5 to 18 days (mean 12.2 days). Surgical intervention for the debridement and closure of these wounds was not required, providing cost savings to the patient. Daily wound care was completed with negligible pain recordings. CONCLUSION: The use of collagenase for enzymatic debridement can be beneficial, safe, and effective for the treatment of nonhealing and necrotic wounds in infants and neonates.

Does noninvasive electrical stimulation of acupuncture points reduce heelstick pain in neonates?

AIM: Noninvasive electrical stimulation at acupuncture points (NESAP) for analgesia is used in children, but has not been widely studied in neonates. The purpose of this study was to determine whether NESAP alone or in combination with sucrose relieved heelstick pain in neonates. METHODS: Term neonates (n = 162) receiving routine heelsticks for newborn screening were enrolled following parental consent. All infants received facilitated tucking and non-nutritive sucking. Neonates were randomised to standard care, sucrose, NESAP or sucrose plus NESAP. NESAP (3.5 mA, 10 Hz) or sham was administered over four acupuncture points. The Premature Infant Pain Profile (PIPP), heart rate variability (HRV) and salivary cortisol were used to measure heelstick pain. RESULTS: PIPP scores among all four treatment groups increased during heelstick, F (9,119) = 1.95, p = 0.05 and NESAP therapy had no significant effect on PIPP scores. However, PIPP scores from baseline to heelstick increased the most in the two groups not receiving sucrose (p < 0.01). Mean PIPP scores remained below five during the heelstick in all four groups, indicating minimal or no pain. Differences in HRV and salivary cortisol among groups were insignificant. CONCLUSION: NESAP at 3.5 mA, 10 Hz is not effective in relieving pain during heelsticks in neonates.

Systemic Absorption of Cyclopentolate and Adverse Events After Retinopathy of Prematurity Exams.

PURPOSE: Preterm infants undergoing Retinopathy of Prematurity Eye Exams (ROPEE) may experience adverse events, possibly from systemic absorption of cyclopentolate. The purpose of this study was to analyze the association between adverse events and drug levels found in neonates undergoing ROPEE. MATERIALS AND METHODS: 25 infants were randomized into two groups during routine ROP screening: 5 infants for blood collection before mydriatic drops and 20 for blood collection 1 h after eye drops. Blood was collected onto dried blood spot cards, extracted, and analyzed for cyclopentolate and phenylephrine using liquid chromatography and mass spectrometry. Relationships between drug levels and adverse events were assessed. RESULTS: Cyclopentolate (range 6-53 ng/ml) was observed in 15 of 18 infants, while phenylephrine was not detected. Levels of cyclopentolate were significantly higher in infants who were on oxygen (p = 0.01). There was a significant association between cyclopentolate levels and gastric residuals in tube-fed infants not receiving oxygen (p = 0.01). CONCLUSIONS: Cyclopentolate levels varied among preterm infants after ROPEE. Cyclopentolate was positively associated with increased gastric residuals. Underlying medical conditions requiring oxygen administration may affect absorption and metabolism of cyclopentolate. There is a need to predict infants at risk for high blood levels of cyclopentolate in order to prevent or treat adverse events after ROPEE.

Body Weight Support Treadmill Training for Children With Developmental Delay Who Are Ambulatory.

PURPOSE: To examine the effect of body weight-supported treadmill training (BWSTT) on gait and gross motor skill development in children (2-5 years old) with developmental delay who are ambulatory. METHODS: Twenty-four subjects (12 control and 12 BWSTT) were enrolled in this randomized control trial. All subjects continued to receive physical therapy. Subjects were tested at baseline, 4 weeks, 6 weeks, and at 6 weeks after completion of BWSTT. Outcomes were assessed using the 10-m walk test and Gross Motor Function Measure-D and E. RESULTS: Significant improvements were seen in gait velocity and gross motor skill attainment. With positive interactions in both the 10-m walk test and Gross Motor Function Measure-E, the BWSTT group as compared with the control group demonstrated functional gains in gait velocity and gross motor skills, P = .033 and .017, respectively. CONCLUSIONS: A 6-week high-intensity BWSTT program can improve gait velocity and influence functional gains.

The effects of massage therapy to induce sleep in infants born preterm.

PURPOSE: The aim of this study was to determine whether massage therapy can be used as an adjunct intervention to induce sleep in infants born preterm. METHODS: Thirty infants born at a minimum of 28 weeks gestational age, who were at the time of the study between 32 and 48 weeks adjusted gestational age, were randomly assigned to receive massage therapy on 1 day and not receive massage on an alternate day. The Motionlogger Micro Sleep Watch Actigraph recorded lower extremity activity on the morning of each day. RESULTS: No significant difference was found between groups for sleep efficiency (P = .13) during the time period evaluated. Groups differed significantly during the time period after the massage ended with more infants sleeping on the nonmassage day (χ = 4.9802, P = .026). CONCLUSIONS: Massage is well tolerated in infants born preterm and infants do not fall asleep faster after massage than without massage.

Safety of Noninvasive Electrical Stimulation of Acupuncture Points During a Routine Neonatal Heel Stick.

BACKGROUND: Hospitalized infants may undergo frequent painful procedures with inadequate pain relief. Alternative pain relief interventions are needed. OBJECTIVE: The aim of this research was to determine the safety of noninvasive electrical stimulation of acupuncture points (NESAP) in neonates who were receiving routine heel sticks. DESIGN: This was a descriptive study performed to assess the safety of using a transcutaneous electrical nerve stimulation (TENS) unit to deliver NESAP to neonates. SETTING/SUBJECTS: The subjects were healthy newborn infants<3 days old before hospital discharge. INTERVENTION: The intervention was NESAP delivered via a TENS unit, administered before, during, and after heel stick. The electrodes of the TENS unit were applied at four acupuncture points. Settings were gradually increased: 6 infants received 1.0 mA, 2 Hz; the second 6 infants received 2.0 mA, 10 Hz; and the last 18 infants received 3.5 mA, 10 Hz. MAIN OUTCOME MEASURES: THREE MAIN MEASURES WERE USED: (1) skin assessment (2) vital signs; (3) pain scores using the Premature Infant Pain Profile (PIPP). RESULTS: There were no significant changes in vital signs during and after NESAP. There were no changes in PIPP scores in the first 12 infants after initiation of NESAP. A slight but nonsignificant increase in PIPP scores (from 2.65 to 3.5 on a scale of 0-18) occurred in the last 18 infants. There were no adverse events during or after NESAP. CONCLUSIONS: NESAP is safe for infants with low settings on a TENS unit.

Wind-up of stretch reflexes as a measure of spasticity in chronic spinalized rats: The effects of passive exercise and modafinil.

Spasticity is a common disorder following spinal cord injury that can impair function and quality of life. While a number of mechanisms are thought to play a role in spasticity, the role of motoneuron persistent inward currents (PICs) is emerging as pivotal. The presence of PICs can be evidenced by temporal summation or wind-up of reflex responses to brief afferent inputs. In this study, a combined neurophysiological and novel biomechanical approach was used to assess the effects of passive exercise and modafinil administration on hyper-reflexia and spasticity following complete T-10 transection in the rat. Animals were divided into 3 groups (n=8) and provided daily passive cycling exercise, oral modafinil, or no intervention. After 6weeks, animals were tested for wind-up of the stretch reflex (SR) during repeated dorsiflexion stretches of the ankle. H-reflexes were tested in a subset of animals. Both torque and gastrocnemius electromyography showed evidence of SR wind-up in the transection only group that was significantly different from both treatment groups (p<0.05). H-reflex frequency dependent depression was also restored to normal levels in both treatment groups. The results provide support for the use of passive cycling exercise and modafinil in the treatment of spasticity and provide insight into the possible contribution of PICs.

L-Dopa effect on frequency-dependent depression of the H-reflex in adult rats with complete spinal cord transection.

This study investigated whether l-dopa (DOPA), locomotor-like passive exercise (Ex) using a motorized bicycle exercise trainer (MBET), or their combination in adult rats with complete spinal cord transection (Tx) preserves and restores low frequency-dependent depression (FDD) of the H-reflex. Adult Sprague-Dawley rats (n=56) transected at T8-9 had one of five treatments beginning 7 days after transection: Tx (transection only), Tx+Ex, Tx+DOPA, Tx+Ex+DOPA, and control (Ctl, no treatment) groups. After 30 days of treatment, FDD of the H-reflex was tested. Stimulation of the tibial nerve at 0.2, 1, 5, and 10Hz evoked an H-reflex that was recorded from plantar muscles of the hind paw. No significant differences were found at the stimulation rate of 1Hz. However, at 5Hz, FDD of the H-reflex in the Tx+Ex, Tx+DOPA and Ctl groups was significantly different from the Tx group (p<0.01). At 10Hz, all of the treatment groups were significantly different from the Tx group (p<0.01). No significant difference was identified between the Ctl and any of the treatment groups. These results suggest that DOPA significantly preserved and restored FDD after transection as effectively as exercise alone or exercise in combination with DOPA. Thus, there was no additive benefit when DOPA was combined with exercise.

The effects of passive exercise therapy initiated prior to or after the development of hyperreflexia following spinal transection.

Hyperreflexia develops after spinal cord injury (SCI) in the human and in the spinal cord transected animal, and can be measured by the loss of low frequency-dependent depression of the H-reflex. Previous studies demonstrated normalization of low frequency-dependent depression of the H-reflex using passive exercise when initiated prior to the development of hyperreflexia. We examined the effects of passive exercise prior to compared to after the development of hyperreflexia in the transected rat. Adult female rats underwent complete transection (Tx) at T10. Frequency-dependence of the H-reflex was tested following passive exercise for 30 days, initiated prior to hyperreflexia in one group compared to initiation after hyperreflexia became established, and compared to intact and untreated Tx groups. An additional Tx group completed 60 days of exercise initiated after hyperreflexia was established. Lumbar enlargement tissue was harvested for western blot to compare Connexin-36 protein levels in control vs Tx animals vs Tx animals that were passively exercised. No differences in whole tissue were evident, although regional differences may still be present in Connexin-36 levels. Statistically significant decreases in low frequency-dependent depression of the H-reflex were observed following 30 days of exercise initiated prior to the onset of hyperreflexia, and also after 60 days of exercise when initiated after hyperreflexia had been established, compared with Tx only animals. We concluded that modulation of spinal circuitry by passive exercise took place when initiated before and after the onset of hyperreflexia, but different durations of exercise were required.

Traumatic dislocation of the hip in a high school football player.

BACKGROUND: Although traumatic dislocation of the hip often occurs as a result of automobile accidents, dislocations have been reported to occur during sports activities. OBJECTIVE: Using the experience in treating a 17-year-old high school football player with a posterior dislocation, complicated by involvement of the sciatic nerve, this case report provides background information on hip dislocations and provides a description of the immediate treatment by the physician, followed by 6 weeks of immobilization, and a detailed account of the 5-month intervention. CASE DESCRIPTION: The patient was injured while making a tackle during a high school football game when another player fell on him from behind. The case report describes his plan of care after immediate hip reduction surgery and 6 weeks on crutches. Generally, the program utilized a progression of non-weight-bearing resistance training and stretching in the initial stages of intervention and progressed to weight-bearing activities (on land and in the pool) as the patient was able to tolerate more stress. In addition, the treatment of the sciatic nerve using electrical stimulation during treadmill walking is described. OUTCOMES: The patient was seen in an outpatient physical therapy clinic an average of 2 times per week for 5 months. At the end of 5 months, results of the Lower Extremity Functional Scale (LEFS) indicated that recreational and sporting activities were within normal limits, and the patient was able to return to playing on his high school football team the next year.

Evidence for Electrical Coupling in the SubCoeruleus (SubC) Nucleus.

SubCoeruleus (SubC) neurons, which are thought to modulate rapid-eye-movement (REM) sleep, were recorded in brain stem slices from 7- to 20-day rats and found to manifest spikelets, indicative of electrical coupling. Spikelets occurred spontaneously or could be induced by superfusion of the cholinergic agonist carbachol. Whole cell recordings revealed that carbachol induced membrane oscillations and spikelets in the theta frequency range in SubC neurons in the presence of fast synaptic blockers. Electrical coupling in neurons is mediated by the gap junction protein connexin 36 (Cx 36). We found that Cx 36 gene expression and protein in the mesopontine tegmentum decreased during development. Cx 36 protein levels specifically in the SubC decreased in concert with the developmental decrease in REM sleep. The presence of electrical coupling in the SubC introduces a novel potential mechanism of action for the regulation of sleep-wake states.

Use of a motorized bicycle exercise trainer to normalize frequency-dependent habituation of the H-reflex in spinal cord injury.

BACKGROUND/OBJECTIVES: Spasticity in patients with spinal cord injury (SCI) is difficult to manage. Exercise and stretching is advocated as a management tool, but these activities are difficult to perform for most patients as a result of multiple barriers. This report shows the effect of passive range-of-motion exercise in a walking-like pattern on frequency-dependent habituation of the H-reflex in the lower extremities of an individual with spastic tetraplegia due to SCI. METHODS: The participant, a man with a chronic ASIA B C7 SCI due to a gunshot wound, used a motorized bicycle exercise trainer (MBET) developed at the Jackson T. Stephens Spine & Neurosciences Institute at the University of Arkansas for Medical Sciences that could be operated from the individual's wheelchair. He used the MBET for 1 hour, 5 days a week, for 13 weeks. H-reflex habituation was tested at the beginning of the study and then periodically over the course of 17 weeks, including 4 weeks after exercise had ceased. RESULTS: Significant habituation of the H-reflex was evident beginning at the 10th week of training. The habituation in the H-reflex reached a normal level at 5- and 10-Hz frequencies at 12 weeks. Subjective assessment of spasticity indicated that it was significantly reduced. The H-reflex amplitude was maintained at normal levels during the remaining week of the course of exercise and for 2 additional weeks after exercise ceased. The H-reflex habituation, however, returned to near baseline when reassessed at week 17, 4 weeks after the exercise program had concluded. Subjective assessment indicated that spasticity also had returned to pretraining levels. CONCLUSIONS: Habituation of the H-reflex, and perhaps spasticity, can be managed by a routine passive range-of-motion exercise program using a MBET, but the exercise program may need to be continuous. The benefit of reduced medication for spasticity and possibly improved quality of life could be a motivating factor for an individual with SCI and spasticity to continue the program. Because of the low complexity of the program, ease of use, and small size, this system could be inexpensive and could be used by an individual in the home. Ongoing studies will determine the minimum amount of MBET training required for maintaining long-term H-reflex habituation.