Effect of Robotic-Assisted Gait Training in Patients With Incomplete Spinal Cord Injury Repetitive Mass Practice or Focused Precise Practice for Retraining Walking After Incomplete Spinal Cord Injury? A Pilot Randomized Clinical Trial Restoring voluntary grasping function in individuals with incomplete chronic spinal cord injury: pilot study. The Effect of Electrical Passive Cycling on Spasticity in War Veterans with Spinal Cord Injury Lokomat Robotic-Assisted Versus Overground Training Within 3 to 6 Months of Incomplete Spinal Cord Lesion Effects of transcutaneous electrical nerve stimulation on pain in patients with spinal cord injury: a randomized controlled trial New Approach to Study the Contents and Outcomes of Spinal Cord Injury Rehabilitation: The SCIRehab Project Functional electrical therapy: retraining grasping in spinal cord injury Functional electric stimulation to augment partial weight-bearing supported treadmill training for patients with acute incomplete spinal cord injury: A pilot study. The effects of an arm ergometer training programme on wheelchair subjects Electrical stimulation plus progressive resistance training for leg strength in spinal cord injury: A randomized controlled trial Effects of practice combined with somatosensory or motor stimulation on hand function in persons with spinal cord injury. Training unsupported sitting does not improve ability to sit in people with recently acquired paraplegia: a randomised trial. Orthotic intervention for development of hand function with C-6 quadriplegia. Comparison of body weight-supported treadmill training versus body weight-supported overground training in people with incomplete tetraplegia: a pilot randomized trial A randomized trial assessing the effects of 4 weeks of daily stretching on ankle mobility in patients with spinal cord injuries. Effectiveness of aerobic physical training for treatment of chronic asymptomatic bacteriuria in subjects with spinal cord injury: a randomized controlled trial The addition of electrical stimulation to progressive resistance training does not enhance the wrist strength of people with tetraplegia: a randomized controlled trial Randomised trial of the effects of four weeks of daily stretch on extensibility of hamstring muscles in people with spinal cord injuries. Gait analysis following treadmill training with body weight support versus conventional physical therapy: a prospective randomized controlled single blind study Effect of a standard exercise protocol on shoulder pain in long-term wheelchair users Functional Electrical Stimulation Therapy of Voluntary Grasping Versus Only Conventional Rehabilitation for Patients With Subacute Incomplete Tetraplegia Sensory stimulation augments the effects of massed practice training in persons with tetraplegia. Improved motor function in tetraplegics following neuromuscular stimulation-assisted arm ergometry. Short-term progressive resistance exercise may not be effective at increasing wrist strength in people with tetraplegia: a randomised controlled trial. Spinal Cord Injury Rehabilitation Evidence: Methods of the SCIRE Systematic Review. Neuropathic pain post spinal cord injury part 1: systematic review of physical and behavioral treatment. Does 12 weeks of regular standing prevent loss of ankle mobility and bone mineral density in people with recent spinal cord injuries? Handrim wheelchair propulsion training effect on overground propulsion using biomechanical real-time visual feedback. Comparison of training methods to improve walking in persons with chronic spinal cord injury: a randomized clinical trial Strengthening and Optimal Movements for Painful Shoulders (STOMPS) in Chronic Spinal Cord Injury: A Randomized Controlled Trial
Objective To determine the effect of robotic-assisted gait training ( RAGT ) compared to conventional overground training . Methods Sixty patients with motor incomplete spinal cord injury ( SCI ) were included in a prospect i ve , r and omized clinical trial by comparing RAGT to conventional overground training . The RAGT group received RAGT three sessions per week at duration of 40 minutes with regular physiotherapy in 4 weeks . The conventional group underwent regular physiotherapy twice a day , 5 times a week . Main outcomes were lower extremity motor score of American Spinal Injury Association impairment scale ( LEMS ) , ambulatory motor index ( AMI ) , Spinal Cord Independence Measure III mobility section ( SCIM3-M ) , and walking index for spinal cord injury version II ( WISCI-II ) scale . Results At the end of rehabilitation , both groups showed significant improvement in LEMS , AMI , SCIM3-M , and WISCI-II . Based on WISCI-II , statistically significant improvement was observed in the RAGT group . For the remaining variables , no difference was found . Conclusion RAGT combined with conventional physiotherapy could yield more improvement in ambulatory function than conventional therapy alone . RAGT should be considered as one additional tool to provide neuromuscular reeducation in patient with incomplete SCI Background . Retraining walking following spinal cord injury using visually guided tasks may be especially efficacious because it engages the motor cortex , whose input may facilitate improvements in functional walking . Objectives . To contrast 2 methods of retraining , one emphasizing precise , visually guided walking over obstacles and on targets ( Precision Training ) , the other emphasizing mass practice of walking on a treadmill ( Endurance Training ) . Methods . A r and omized , single-blind , crossover design was used . Twenty-two participants , ≥7 months postinjury , were r and omly allocated to start with Precision or Endurance Training . Each phase of training was 5 times per week for 2 months , followed by a 2-month rest . Measures of walking speed , distance , skill , confidence , and depression were obtained before training , then monthly thereafter . Results . Both forms of training led to significant improvements in walking , with Endurance Training inducing bigger improvements in walking distance than Precision Training , especially for high-functioning walkers who had initial walking speeds > 0.5 m/s . The largest improvements in walking speed and distance occurred in the first month of Endurance Training , with minimal changes in the second month of training . In contrast , improvements in walking skill occurred over both months during both types of training . Retention of over ground walking speed , distance , and skill was excellent for both types of training . Conclusions . Intensive walking training in the chronic phase after spinal cord injury is effective in improving over ground walking . Visually guided tasks for training individuals with chronic spinal cord injury were not superior to mass practice on a treadmill BACKGROUND Functional electrical stimulation ( FES ) therapy has been shown to be one of the most promising approaches for improving voluntary grasping function in individuals with subacute cervical spinal cord injury ( SCI ) . OBJECTIVE To determine the effectiveness of FES therapy , as compared to conventional occupational therapy ( COT ) , in improving voluntary h and function in individuals with chronic ( ≥24 months post injury ) , incomplete ( American Spinal Injury Association Impairment Scale [ AIS ] B-D ) , C4 to C7 SCI . METHODS Eight participants were r and omized to the  intervention group  ( FES therapy ; n = 5 ) or the  control group ( COT ; n = 3 ) . Both groups received 39 hours of therapy over 13 to 16 weeks . The primary outcome measure was the Toronto Rehabilitation Institute-H and Function Test ( TRI-HFT ) , and the secondary outcome measures were Grade d Redefined Assessment of Strength Sensibility and Prehension ( GRASSP ) , Functional Independence Measure ( FIM ) self-care subscore , and Spinal Cord Independence Measure ( SCIM ) self-care subscore . Outcome assessment s were performed at baseline , after 39 sessions of therapy , and at 6 months following the baseline assessment . RESULTS After 39 sessions of therapy , the intervention group improved by 5.8 points on the TRI-HFT 's Object Manipulation Task , whereas the control group changed by only 1.17 points . Similarly , after 39 sessions of therapy , the intervention group improved by 4.6 points on the FIM self-care subscore , whereas the control group did not change at all . CONCLUSION The results of the pilot data justify a clinical trial to compare FES therapy and COT alone to improve voluntary h and function in individuals with chronic incomplete tetraplegia Introduction : Muscle atrophy , spasticity , and deformity are among long term complication of spinal cord injury ( SCI ) veterans . There are numerous studies evaluating effect of functional electrical stimulation on muscle properties of SCI people , but less research has focused on the benefits of passive cycling in the management of spasticity and improving ROM of lower limbs  in individuals with SCI . Aims : To evaluate the effect of electrical passive cycling on passive range of movement spasticity and electrodiagnostic parameters in SCI veterans . Methods : Sixty-four SCI veterans referred to two clinical and research center in Tehran were recruited in this prospect i ve clinical trial . The subjects were divided into two groups according to electrical passive cycling usage : ( 1 ) patients who did not use pedal exercise ( control group ) , ( 2 ) patients used Electrical passive cycling up to optimal level ( intervention group ) . Main outcome measures included hip , knee , and ankle range of motion , spasticity scale , and electrodiagnostic parameters including F-Wave Consistency , F-Wave Amplitude , H/M Ratio , F/M Ratio , H-Reflex Onset Latency , and H-Reflex Amplitude . Data were recorded at the time of receiving and 1 year after pedal exercise usage . Results : Sixty-four SCI patients including 95.3 % male , 4.7 % female with mean age 43 years old were included in this study . All patients except one suffered from complete SCI . The involved spinal levels were cervical ( 17.2 % ) , upper thoracic ( 34.4 % ) , lower thoracic ( 45.3 % ) , and lumbar ( 3.1 % ) . Spasticity scale decreased significantly after passive cycling in group 2 . Also hip , knee , and ankle ROM in group 2 were significantly improved after pedal exercise . There was a significant difference in H max/M max ( RT < ) and F/M ratio after versus before electric passive cycling system in group 2 . Conclusion : These findings suggest that passive rhythmic leg exercise can lead to decrease in spasticity , increase in passive ROM of lower limbs and improvement in electrodiagnostic parameters of spasticity in patients with SCI Background . About 75 % of persons with ASIA ( American Spinal Injury Association ) Impairment Scale C and D incomplete spinal cord injury ( SCI ) achieve walking ability . Objective . To compare a walking reeducation program using Lokomat with conventional overground training among individuals with incomplete SCI of both traumatic and nontraumatic etiology . Methods . A total of 80 participants from 3 to 6 months after onset admitted to 1 site for rehabilitation were included in a single-blind r and omized clinical trial of 2 parallel groups , with blind evaluation by independent observers . Patients received 40 walking reeducation sessions of equal time using a Lokomat program with overground practice or overground mobility therapy alone . Primary measurements of outcome were walking speed and the Walking Index for Spinal Cord Injury ( WISCI II ) . Secondary outcomes were the 6-minute walk test , locomotor section of the Functional Independence Measure , Lower Extremity Motor Score ( LEMS ) , Ashworth Scale , and Visual Analog Scale for pain . Results . No significant differences were found at entry between treatment groups . Walking speed for Lokomat ( 0.4 m/s [ 0.6 - 0.2 ] ) and overground therapy ( 0.3 m/s [ 0.5 - 0.2 ] ) groups did not differ . The WISCI II for the Lokomat group ( 16 [ 8.5 - 19 ] ) was better than for overground therapy ( 9 [ 8 - 16 ] ) . The 6-minute walk test and LEMS displayed significant differences in favor of Lokomat therapy but were not corrected for multiple comparisons . Conclusions . Robotic-assisted training was equivalent to conventional walk training in patients with a variety of nonprogressive spinal cord pathologies for walking speed , but the need for orthotics and assistive devices was reduced , perhaps because of greater leg strength in the robotic group [ Purpose ] To investigate the effects of transcutaneous electrical nerve stimulation ( TENS ) on pain in patients with spinal cord injury . [ Subjects and Methods ] Fifty-two spinal cord injury patients with central pain were r and omly allocated into two groups TENS and control with 26 subjects per group . The patients in TENS and control groups were treated with TENS and sham TENS for 20 min ( three times a week ) for 12 consecutive weeks , respectively . The two group ’s pain was assessed using visual analog scale ( VAS ) and the McGill Pain Question naire ( including pain rating index-total , pain rating index-affective , pain rating index-sensory , present pain intensity , and number of words chosen ) before and after the treatment . [ Results ] After the intervention , we found significant differences in VAS , pain rating index-total , pain rating index-affective , pain rating index-sensory , present pain intensity , and number of words chosen between the TENS group and the control group . [ Conclusion ] Our results suggest that TENS effectively decreases pain in patients with spinal cord injury Abstract Background / Objective : Limited research evidence is available to show the effectiveness of the many specific interventions provided in spinal cord injury ( SCI ) rehabilitation ; what is available typically focuses on effects of the full rehabilitation package but not specific therapy interventions , medical procedures , patient education , or counseling . Given the problems of conducting r and omized controlled trials ( RCTs ) in rehabilitation , practice -based evidence ( PBE ) research has been suggested as an alternative methodology for identifying which rehabilitation interventions are associated most strongly with positive outcomes , after controlling for patient differences . Using the PBE research methodology , the SCIRehab project attempts to " open the black box " of acute SCI rehabilitation , provide detailed information on treatments delivered by all rehabilitation disciplines , and contribute to outcomes -based guidelines for clinical decision-making . Methods : The SCIRehab project includes 1,500 patients with acute SCI , consecutively admitted to 1 of 6 US inpatient rehabilitation facilities . Details of the rehabilitation process are captured by clinicians from multiple disciplines documenting their interventions in h and held personal digital assistants after sessions with their patients . Outcome data are abstract ed from medical records ( clinical outcomes data ) and obtained from patient interviews at 6 and 12 months after injury . Extensive patient , injury , and other treatment characteristics are abstract ed from medical records . SCIRehab is the first research project to collect detailed information on individual interventions offered by the full rehabilitation team . Results : SCIRehab is the first research project to collect detailed information on individual interventions offered by the full rehabilitation team . These findings are presented in a series of 9 articles . Conclusions : To date , SCIRehab 's major contribution is a system for categorizing specific contributions of each discipline and a technology for documenting that detail . After data collection is complete , future manuscripts will relate those process elements to outcomes . The SCIRehab Project is an important step toward establishing outcomes -based guidelines for SCI rehabilitation Objective : To determine the clinical efficacy of functional electrical therapy in the rehabilitation of grasping function for quadriplegics . Study design : R and omized intervention-versus-control trial . Setting : Rehabilitation hospital for spinal cord injury in Toronto , Canada . Methods : A total of 21 people with new spinal cord injuries ranging from C3 to C7 were r and omly assigned to two groups : Control ( N=9 ) and Intervention ( N=12 ) . The intervention was functional electrical therapy , which consisted of repetitive grasping exercises using a neuroprosthesis that applied surface electrical stimulation to the arm to generate and /or assist grasping movements . It was applied by registered Occupational Therapists in a clinical setting . Main outcome measures were : Functional Independence Measure ( FIM ) , Spinal Cord Independence Measure ( SCIM ) , and the Rehabilitation Engineering Laboratory H and Function Test . Consumer perceptions of functional electrical therapy  were assessed via qualitative interviews . Results : Differences between the Control and Intervention groups could be observed although they are not significant due to an insufficient number of participants . Consumer perceptions were positive , including improved Activities of Daily Living and self-satisfaction . Conclusion : Functional electrical therapy has the potential to be an effective treatment modality to restore grasping function in quadriplegia . It can be implemented by occupational therapists in a clinical setting . Further research is required to establish suitable indications for participant selection . In addition , a larger number of participants is needed to demonstrate statistical significance of the Functional Electrical Therapy OBJECTIVE To study the application of partial weight-bearing ( PWB ) supported treadmill gait training augmented by functional electric stimulation ( FES ) in subjects with acute incomplete spinal cord injury ( SCI ) . DESIGN Before-after crossover trial with control ( A ) and intervention ( B ) periods . SETTING Physiotherapy ( PT ) department of a spinal injuries unit in Scotl and . PARTICIPANTS Fourteen in patients with acute incomplete SCI with American Spinal Injury Association class C or D injury . INTERVENTION Training consisted of treadmill walking with PWB support augmented by FES . Subjects walked on the treadmill for up to 25 minutes a day , 5 days a week for 4 weeks . The intervention was compared with a 4-week control period in which st and ard PT was given . MAIN OUTCOME MEASURES Overground walking endurance and speed , cadence , stride length , and observational gait analysis and walking speed , distance , and percentage PWB support on the treadmill . RESULTS A greater increase in overground walking endurance was achieved after the intervention ( AB group mean , 72.2 m ; confidence interval [ CI ] , 39.8 - 104.6 m ; BA group mean , 63.8 m ; CI , -10.2 to 137.9 m ) , as compared with after st and ard PT ( AB group mean , 38.4 m ; CI , 1.8 - 75.0 m ; BA group mean , 60.1 m ; CI , 9.2 - 110.9 m ) . A similar pattern was observed for overground walking speed . CONCLUSIONS This pilot study indicated that PWB supported treadmill training with FES had a positive effect on overground gait parameters and could potentially accelerate gait training in subjects with incomplete SCI . A larger r and omized trial is required to substantiate these findings The purpose of the present investigation was to study the effects of an arm ergometer training programme on several physiological variables of recreational wheelchair subjects . Ten paraplegics ( 5 experimental , 5 control ) were tested prior to and immediately after a 2 month exercise regimen at 80 % of peak heart rate ( 30 min per day , 5 days per week , for 8 consecutive weeks at 50 rev/min ) . The results demonstrated significant increases ( P<0.05 ) in VO2max ( 1 min-1 & ml kg-1 min-1 ) and workload but only mild improvements in maximal heart rate and post exercise blood lactates . Body fat , vital capacity and forced expiratory volume did not change with training . Triceps lateralis fibre distribution and fast twitch ( FT ) fibre area were unaffected by the endurance training programme . However , slow twitch ( ST ) fibre area increased ( P < 0·05 ) with training . The results indicate that physiological variables of paraplegic subjects  following an arm ergometer endurance training programme react similarly to changes previously observed in non-h and icapped subjects . The values when compared with normals are low as a result of the relative inactivity of the subjects due to the lack of available exercise programmes for wheelchair people Study design : A r and omized controlled trial . Objectives : To determine the effectiveness of electrical stimulation (ES)-evoked muscle contractions superimposed on progressive resistance training ( PRT ) for increasing voluntary strength in the quadriceps muscles of people with spinal cord injuries ( SCI ) . Setting : Sydney , Australia . Methods : A total of 20 people with established SCI and neurologically induced weakness of the quadriceps muscles participated in the trial . Participants were r and omized between experimental and control groups . Volunteers in the experimental group received ES superimposed on PRT to the quadriceps muscles of one leg thrice weekly for 8 weeks . Participants in the control group received no intervention . Assessment s occurred at the beginning and at the end of the 8-week period . The four primary outcomes were voluntary strength ( Nm ) and endurance ( fatigue ratio ) as well as the performance and satisfaction items of the Canadian Occupational Performance Measure ( COPM ; points ) . Results : The between-group mean differences ( 95 % confidence interval ( CI ) ) for voluntary strength and endurance were 14 Nm ( 1–27 ; P=0.034 ) and 0.1 ( −0.1 to 0.3 ; P=0.221 ) , respectively . The between-group median differences ( 95 % CI ) for the performance and satisfaction items of the COPM were 1.7 points ( −0.2 to 3.2 ; P=0.103 ) and 1.4 points ( −0.1 to 4.6 ; P=0.058 ) , respectively . Conclusion : ES superimposed on PRT  improves voluntary strength , although there is uncertainty about whether the size of the treatment effect is clinical ly important . The relative effectiveness of ES and PRT is yet to be determined BACKGROUND Individuals with chronic tetraplegia prioritize recovery of h and function as an important factor in improving their quality of life . Interventions that may improve h and function and increase corticomotor excitability are functional electrical stimulation ( FES ) , somatosensory stimulation ( SS ) , and task-oriented training . OBJECTIVE We compared functional and corticomotor outcomes in a control condition to changes associated with FES ( triggered via electromygraphic signals ) and with SS ( constant trains ) , each combined with either unimanual or bimanual training . METHODS Using a r and omized , clinical trial design , comparisons were made to a delayed intervention control group . Participants ( n = 24 ) had chronic tetraplegia , with the ability to activate thenar muscles , and were r and omly assigned to either the immediate intervention ( intervention ) or control/ delayed intervention groups . Primary analyses compared intervention ( FES or SS )  to control/delayed intervention . Secondary analyses compared subgroups of FES versus SS ( regardless of uni- or bilateral training ) and uni- versus bimanual training ( regardless of stimulation type ) . Outcomes were assessed before and after the control and the intervention period . RESULTS Compared to control/delayed intervention , the intervention group had greater changes in unimanual function and corticomotor area , regardless of whether practice was combined with FES or with SS . Irrespective of stimulation type , the bimanual subgroups improved to a greater extent than the unimanual subgroups on the bimanual h and function test . CONCLUSIONS H and training combined with either SS or FES was associated with improved h and use and corticomotor activity in persons with chronic tetraplegia . Both interventions appear to be equally effective QUESTION Do people with recently acquired paraplegia benefit from a six-week motor retraining program aim ed at improving their ability to sit unsupported ? DESIGN A r and omised controlled trial with concealed allocation , assessor blinding , and intention-totreat analysis . PARTICIPANTS 32 people with recently acquired paraplegia and limited ability to sit unsupported . INTERVENTION All participants undertook st and ard inpatient rehabilitation over a six-week period . Experimental participants received three additional 30-minute sessions per week of motor retraining directed at improving their ability to sit unsupported . OUTCOME MEASURES The three primary outcomes were the Maximal Lean Test , Maximal Sideward Reach Test , and the Performance Item of the Canadian Occupational Performance Measure ( COPM ) . The secondary outcomes were the Satisfaction Item of the COPM , Participants ' Impressions of Change , Clinicians ' Impressions of Change , the T-shirt Test , and the Spinal Cord Injury Falls Concern Scale . RESULTS The mean between-group differences for the Maximal Lean Test , Maximal Sideward Reach Test and the Performance Item of the COPM were -20 mm ( 95 % CI -64 to 24 ) , 5 % arm length ( 95 % CI -3 to 13 ) and 0.5 points ( 95 % CI -0.5 to 1.5 ) , respectively . The secondary outcomes did not differ significantly between groups . CONCLUSION People with recently acquired paraplegia do not benefit from a six-week motor retraining program directed specifically at improving their ability to sit unsupported . Their ability to sit unsupported does , however , improve over time , suggesting that the practice of activities of daily living has important carry-over effects on unsupported sitting , rendering additional training redundant . TRIAL REGISTRATION ACTRN12608000464369 OBJECTIVES Much has been written about the use of static orthoses to maintain proper position and prevent deformity , but there are few empirical data to determine whether static orthoses improve function , maintain range of motion , or prevent deformity in the h and . METHOD This study measured gains in h and function during a 3-month rehabilitation period in 13 persons with sixth cervical ( C-6 ) level complete quadriplegia , 7 of whom wore a static orthosis at night ( experimental group ) and 6 who did not wear the orthosis ( control group ) .  H and function , range of motion and strength were measured in all subjects 4 weeks and 8 weeks after the study commenced , and again after 12 weeks in only 69 % of the subjects . RESULTS No significant differences were found in h and function between control and experimental groups ; h and function had improved significantly in all 13 subjects . CONCLUSION As the effects of deformity have been clinical ly observed , future studies should examine the effects of static orthoses with increased daily wear or wear over a longer period of time Objective : To compare the effectiveness of body weight-supported treadmill training and body weight-supported overground training for improving gait and strength in people with traumatic incomplete tetraplegia . Design : Assessor blinded r and omized trial . Setting : Rehabilitation institute of a tertiary care teaching hospital in India . Participants : Sixteen participants with traumatic motor incomplete tetraplegia and within two years of injury . Interventions : Participants were r and omised to one of two groups : body weight-supported overground training on level ground and body weight-supported treadmill training . Both groups received 30 minutes of gait training per day , five days a week for eight weeks . In addition , both groups received regular rehabilitation which included flexibility , strength , balance , self care and functional training . Outcome measures : The primary outcome measure was the Walking Index for Spinal Cord Injury ( /20 points ) and the secondary outcome was the Lower Extremity Muscle Score ( /50 points ) . Results : There was no statistically significant between group differences in the Walking Index for Spinal Cord Injury [ mean difference=0.3points ; 95 % CI ( -4.8 to 5.4 ) ; p=0.748 ] or the Lower Extremity Muscle Score [ mean difference=0.2 points ; 95 % CI ( -3.8 to 5.1 ) ; p=0.749 ] . Conclusions : Gait training with body weight-supported overground training is comparable to treadmill training for improving locomotion in people with traumatic incomplete tetraplegia OBJECTIVE To determine the effect of 4 weeks of 30 minutes of daily stretching on ankle mobility in patients with recent spinal cord injuries ( SCIs ) . DESIGN Assessor-blinded r and omized controlled trial . SETTING Two spinal injury units in Sydney , Australia . PATIENTS Consecutive sample of 14 recently injured patients with paraplegia and quadriplegia . INTERVENTION Treated ankles were stretched continuously into dorsiflexion with a torque of 7.5 N x m for 30 minutes each weekday for 4 weeks . Contralateral ankles received no stretches . MAIN OUTCOME MEASURES Passive torque-angle curves for both ankles were obtained at study commencement , then at weeks 2 , 4 , and 5 ( ie , during , at the end of , and 1 week after the stretching program ) . Torque-angle measurements were obtained with the knee extended and flexed . Mean values for parameters ( baseline angle , angle at 10 N x m , slope ) describing the characteristics of the torque-angle curves were derived for each knee position . Changes from pretest to each subsequent test were calculated , as well as 95 % confidence intervals ( CIs ) for differences in these changes between stretched and controlled ankles . RESULTS The stretching intervention did not significantly change any of the 3 parameters describing the torque-angle curves of the ankle in either knee position . At the beginning of the study , the mean ( + /-SD ) angles obtained with the application of a st and ardized torque with the knee extended for the control and stretch ankles were 105 degrees ( + /- 10.4 degrees ) and 106 degrees ( + /- 9.8 degrees ) , respectively . After 4 weeks , these values were 106 degrees ( + /- 10.6 degrees ) and 107 degrees ( + /- 10.6 degrees ) ( mean difference in change of angle = 0 degrees ; 95 % CI , -3.3 degrees to 3.3 degrees ) . CONCLUSION Thirty minutes of daily stretching for 4 weeks does not significantly change ankle mobility in recently injured patients with SCIs Objective : To evaluate the effectiveness and safety of aerobic physical training for treatment of chronic asymptomatic bacteriuria in subjects with spinal cord injury . Design : R and omized controlled trial . Setting : University hospital . Subjects : Forty-two participants with spinal cord injury between C8 and T12 segments were r and omly assigned to intervention or control groups . Intervention : In the intervention group , subjects received a risk evaluation , stress test and urinary culture before the start of the study and after 16 weeks . The study consisted of aerobic physical conditioning with moderate intensity for the intervention group while the control group was asked to maintain their daily life activities . Main measures : Increase of estimated peak oxygen consumption and also if there was a decrease in the proportions of positive urinary culture . Results : The intervention group showed an increase of estimated peak oxygen consumption of between 939 ( 714–1215 ) and 1154 ( 1005–1351 ) mL/min ( P = 0.009 ) and a reduction of chronic asymptomatic bacteria of between 52.3 % ( 29.8–74.3 % ) and 14.2 % ( 3–36.3 % ) ( P < 0.001 ) . No adverse effects related to physical activity were recorded during the period of training . Conclusion : The regular practice of physical activity of moderate intensity applied to patients with spinal cord injury may be an effective and safe method for the treatment of chronic asymptomatic bacteriuria Objective : To determine whether the addition of electrical stimulation to progressive resistance training increases the voluntary strength of the wrist muscles in people with tetraplegia . Design : Assessor-blind within-subject r and omised controlled trial . Setting : Two Australian spinal cord injury units and the community . Participants : Sixty-four wrists of 32 people with tetraplegia and bilateral weakness of the wrist extensor or flexor muscles ( grade 2 - 4 Medical Research Council grade s ) . Interventions : Participants ' wrists were r and omly allocated to one of two conditions . Wrist muscles of the experimental arm received electrical stimulation superimposed on progressive resistance training . The wrist muscles of the contralateral arm received sham electrical stimulation superimposed on progressive resistance training . Both arms received 6 sets of 10 contractions three times a week for eight weeks such that the only difference between arms was the application of electrical stimulation . Main Measures : The primary outcome was maximal voluntary isometric strength . Secondary outcomes were a fatigue resistance ratio representing voluntary and electrically-stimulated endurance . Measurements were taken at the start and end of the eight-week treatment period . Results : The mean treatment effect ( 95 % Confidence Interval ) of electrical stimulation for voluntary strength was 0.04 Nm ( 95 % CI , -0.5 to 0.6 ; p = 0.89 ) . The mean treatment effect ( 95 % CI ) for fatigue ratio representing voluntary endurance and electrically-stimulated endurance was -0.01 ( 95 % CI , -0.1 to 0.1 ; p = 0.78 ) and -0.07 ( 95 % CI , -0.3 to 0.1 ; p = 0.47 ) , respectively . Conclusions : Voluntary strength of the wrist is not enhanced by the addition of electrical stimulation to progressive resistance training programs in people with tetraplegia The aim of this assessor-blind r and omised controlled trial was to determine the effect of four weeks of 30 minute stretches each weekday on extensibility of the hamstring muscles in people with recent spinal cord injuries . A consecutive sample of 16 spinal cord-injured patients with no or minimal voluntary motor power in the lower limbs and insufficient hamstring muscle extensibility to enable optimal long sitting were recruited . Subjects ' legs were r and omly allocated to experimental and control conditions . The hamstring muscles of the experimental leg of each subject were stretched with a 30 Nm torque at the hip for 30 minutes each weekday for four weeks . The hamstring muscles of the contralateral leg were not stretched during this period .  Extensibility of the hamstring muscles ( hip flexion range of motion with knee extended , measured with a 48 Nm torque at the hip ) of both legs was measured by a blinded assessor at the commencement of the study and one day after the completion of the four-week stretch period . Changes in hamstring muscle extensibility from initial to final measurements were calculated . The effect of stretching was expressed as the mean difference in these changes between stretched and non-stretched legs . The mean effect of stretching was 1 degree ( 95 % CI -2 to 5 degrees ) . Four weeks of 30 minute stretches each weekday does not affect the extensibility of the hamstring muscle in people with spinal cord injuries Study design : Single-blind r and omized , controlled clinical study . Objectives : To evaluate , using kinematic gait analysis , the results obtained from gait training on a treadmill with body weight support versus those obtained with conventional gait training and physiotherapy . Setting : Thirty patients with sequelae from traumatic incomplete spinal cord injuries at least 12 months earlier ; patients were able to walk and were classified according to motor function as ASIA ( American Spinal Injury Association ) impairment scale C or D. Methods : Patients were divided r and omly into two groups of 15 patients by the drawing of opaque envelopes : group A ( weight support ) and group B ( conventional ) . After an initial assessment , both groups underwent 30 sessions of gait training . Sessions occurred twice a week , lasted for 30 min each and continued for four months . All of the patients were evaluated by a single blinded examiner using movement analysis to measure angular and linear kinematic gait parameters .  Six patients ( three from group A and three from group B ) were excluded because they attended fewer than 85 % of the training sessions . Results : There were no statistically significant differences in intra-group comparisons among the spatial – temporal variables in group B. In group A , the following significant differences in the studied spatial – temporal variables were observed : increases in velocity , distance , cadence , step length , swing phase and gait cycle duration , in addition to a reduction in stance phase . There were also no significant differences in intra – group comparisons among the angular variables in group B. However , group A achieved significant improvements in maximum hip extension and plantar flexion during stance . Conclusion : Gait training with body weight support was more effective than conventional physiotherapy for improving the spatial – temporal and kinematic gait parameters among patients with incomplete spinal cord injuries Purpose : To analyze the effectiveness of a 6-month exercise protocol on shoulder pain experienced by wheelchair users during functional activities . Subjects : Forty-two wheelchair users , 35 males and seven females : average age of 35 years and an average duration of wheelchair use of 14 years . Methods : Subjects were r and omly assigned to treatment ( n=21 ) and control ( n=21 ) groups . The treatment group received instruction in five shoulder exercises which they performed daily for 6 months . The exercise protocol included two exercises for stretching anterior shoulder musculature and three exercises for strengthening posterior shoulder musculature . Outcome measures : All subjects completed a self-report question naire and the Wheelchair Users Shoulder Pain Index ( WUSPI ) initially and at bimonthly intervals during the 6-month intervention . Results : Seventy-five per cent of the subjects reported a history of shoulder pain since beginning wheelchair use . The average initial performance-corrected ( PC-WUSPI ) score of the 42 subjects was 17.7 ( ±21.3 ) with a range of 0–103.2 points . Over 83 % of the subjects ( 35 of 42 ) completed the 6-month study . Subjects in the treatment group decreased their PC-WUSPI score by an average of 39.9 % , compared to decreases of only 2.5 % in the control group . Conclusions : These findings supported the effectiveness of this exercise protocol in decreasing the intensity of shoulder pain which interferes with functional activity in wheelchair users Background . Functional electrical stimulation therapy ( FET ) has a potential to improve voluntary grasping among individuals with tetraplegia secondary to traumatic spinal cord injury ( SCI ) . Objective . This single-site , r and omized controlled trial examined the efficacy of 40 hours of FET with conventional occupational therapy ( COT ) compared with COT alone to improve grasping . Methods . Twenty-four subjects with subacute traumatic incomplete SCI ( C4-C7 , AIS B-D ) consented to participate in 40 hours of therapy over 8 weeks , beyond the conventional rehabilitation program . Subjects were r and omized to receive FET + COT ( n = 9 ) or COT ( n = 12 ) . The key outcomes were changes in Functional Independence Measure ( FIM ) self-care subscores , Spinal Cord Independence Measure ( SCIM ) self-care subscores , and Toronto Rehabilitation Institute H and Function Test ( TRI-HFT ) performed at baseline and follow-up . Results . At the end of the treatments , the change in mean FIM self-care subscore for the FET + COT group was 20.1 versus 10 ( P = .015 ) for the COT group . Subjects r and omized to FET + COT also had greater improvements in the SCIM and TRI-HFT . No longer term follow-up was feasible . Conclusion . FET significantly reduced disability and improved voluntary grasping beyond the effects of considerable conventional upper extremity therapy in individuals with tetraplegia OBJECTIVE To compare functional changes and cortical neuroplasticity associated with h and and upper extremity use after massed ( repetitive task-oriented practice ) training , somatosensory stimulation , massed practice training combined with somatosensory stimulation , or no intervention , in persons with chronic incomplete tetraplegia . DESIGN Participants were r and omly assigned to 1 of 4 groups : massed practice training combined with somatosensory peripheral nerve stimulation ( MP+SS ) , somatosensory peripheral nerve stimulation only ( SS ) , massed practice training only ( MP ) , and no intervention ( control ) . SETTING University medical school setting . PARTICIPANTS Twenty-four subjects with chronic incomplete tetraplegia . INTERVENTIONS Intervention sessions were 2 hours per session , 5 days a week for 3 weeks . Massed practice training consisted of repetitive practice of functional tasks requiring skilled h and and upper-extremity use . Somatosensory stimulation consisted of median nerve stimulation with intensity set below motor threshold . MAIN OUTCOME MEASURES Pre- and post-testing assessed changes in functional h and use ( Jebsen-Taylor H and Function Test ) , functional upper-extremity use ( Wolf Motor Function Test ) , pinch grip strength ( key pinch force ) , sensory function ( monofilament testing ) , and changes in cortical excitation ( motor evoked potential threshold ) . RESULTS The 3 groups showed significant improvements in h and function after training . The MP+SS and SS groups had significant improvements in upper-extremity function and pinch strength compared with the control group , but only the MP+SS group had a significant change in sensory scores compared with the control group . The MP+SS and MP groups had greater change in threshold measures of cortical excitability . CONCLUSIONS People with chronic incomplete tetraplegia obtain functional benefits from massed practice of task-oriented skills . Somatosensory stimulation appears to be a valuable adjunct to training programs design ed to improve h and and upper-extremity function in these subjects The effectiveness of neuromuscular stimulation (NMS)-assisted arm ergometry for strengthening triceps brachii was evaluated in 34 cervical spinal cord injured persons . Group I ( n = 12 ) received eight weeks of NMS-assisted ergometry . Group II ( n = 11 ) received four weeks of NMS-assisted ergometry followed by four weeks of arm ergometry alone . Group III ( N = 11 ) received only arm ergometry ( control group ) . Seventeen of 24 muscles in Group I subjects had improved manual muscle test scores after eight weeks , compared with 10 of 22 Group II muscles and five of 22 Group III muscles . Including only muscles with initial scores < or = 3 , Group I demonstrated significant improvements versus Group III after four weeks ( p < .003 ) and after eight weeks ( p < .0005 ) of exercise . A difference was also found between Groups II and III ( p < .03 ) after eight weeks . These results suggest that NMS-assisted ergometry is effective for strengthening voluntary triceps muscle contractions in tetraplegics QUESTIONS Is an 8-week progressive resistance exercise program effective for increasing strength in the wrist muscles of people with tetraplegia ? Is it effective for improving muscle endurance and participants ' perceptions about use of their h and s for activities of daily living ? DESIGN R and omised controlled trial with concealed allocation , assessor blinding , and intention-to-treat analysis . PARTICIPANTS Thirty-two people with tetraplegia and neurological weakness of their wrist flexor or extensor muscles . INTERVENTION The wrist muscles of one r and omly-chosen h and were trained 3 times a week for 8 weeks . The control group received no intervention . OUTCOME MEASURES The primary outcome was strength measured as maximal voluntary isometric torque in Nm . The secondary outcomes were muscle endurance measured as fatigue resistance and participants ' perceptions about use of their h and s using the Canadian Occupational Performance Measure . RESULTS The mean effect on maximal voluntary isometric torque was 0.2 Nm ( 95 % CI -0.5 to 0.8 ) . This represents an 8 % increase of mean initial strength ; less than the 20 % deemed clinical ly worthwhile at the commencement of the study . The mean effect on fatigue resistance was 0.1 ( 95 % CI 0.0 to 0.2 ) . The mean effect on participants ' perceptions of performance was -0.3 ( 95 % CI -1.9 to 1.2 ) and satisfaction was -0.3 ( 95 % CI -1.6 to 1.0 ) . CONCLUSION The results indicate that progressive resistance exercise has no effect on participants ' perceptions about h and function . However , it is not yet clear whether progressive resistance exercise programs improve strength and endurance in muscles with neurologically-induced weakness following tetraplegia The Spinal Cord Injury Rehabilitation Evidence ( SCIRE ) is a synthesis of the research evidence underlying rehabilitation interventions to improve the health of people living with SCI . SCIRE covers a comprehensive set of topics and in this issue we present six papers relevant to SCI rehabilitation clinicians ( SCI inpatient rehabilitation practice s , gait strategies , upper extremity reconstructive surgery , spasticity treatments , cardiovascular health and bone health ) . The SCIRE used a systematic and well-defined protocol to assess and synthesize the evidence . Each article was scored for its method ological quality using either the Physiotherapy Evidence Data base ( PEDro ) Score for r and omized controlled trials or the Downs and Black Tool for other types of studies . Following the individual study assessment , conclusions were drawn about the accumulated studies for each topic of interest based on the levels of evidence , quality of studies and concurring evidence . The SCIRE project was design ed for health professionals to inform them of best practice BACKGROUND Neuropathic pain has various physiologic and psychosocial aspects . Hence , there is a growing use of adjunct nonpharmacological therapy with traditional pharmacotherapy to reduce neuropathic pain post spinal cord injury ( SCI ) . OBJECTIVE The purpose of this study was to conduct a systematic review of published research on nonpharmacological treatment of neuropathic pain after SCI . METHODS MEDLINE , CINAHL , EMBASE , and PsycINFO data bases were search ed for articles addressing nonpharmacological treatment of pain post SCI . Articles were restricted to the English language . Article selection was conducted by 2 independent review ers with the following inclusion criteria : the subjects participated in a treatment or intervention for neuropathic pain ; at least 50 % of the subjects had an SCI ; at least 3 subjects had an SCI ; and a definable intervention was being studied . Data extracted included study design , study type , subject demographics , inclusion and exclusion criteria , sample size , outcome measures , and study results . R and omized controlled trials ( RCTs ) were assessed for quality using the Physiotherapy Evidence Data base ( PEDro ) assessment scale . Levels of evidence were assigned to each intervention using a modified Sackett scale . RESULTS The 16 articles selected for this review fell into 1 of 2 categories of nonpharmacological management of pain after SCI : physical and behavioral treatments . The pooled sample size of all studies included 433 participants . Of the 16 studies included , 7 were level 1 , 3 were level 2 , and 6 were level 4 studies . CONCLUSIONS Physical interventions demonstrated the strongest evidence based on quality of studies and numbers of RCTs in the nonpharmacological treatment of post-SCI pain . Of these interventions , transcranial electrical stimulation had the strongest evidence of reducing pain . Despite a growing body of literature , there is still a significant lack of research on the use of nonpharmacological therapies for SCI pain The purpose of this study was to determine the effects of a 12-week st and ing program on ankle mobility and femur bone mineral density in patients with lower limb paralysis following recent spinal cord injury . An assessor-blinded within-subject r and omised controlled trial was undertaken . Twenty patients with lower limb paralysis following a recent spinal cord injury were recruited . Subjects stood weight-bearing through one leg on a tilt-table for 30 minutes , three times each week for 12 weeks . By st and ing on one leg a large dorsiflexion stretch was applied to the ankle and an axial load was applied to the bones of the weight-bearing leg . Ankle mobility and femur bone mineral density of both legs were measured at the beginning and end of the study . Ankle mobility ( range of motion ) was measured with the application of a 17 Nm dorsiflexion torque .  Femur bone mineral density was measured using dual energy X-ray absorptiometry ( DEXA ) . The effect of st and ing was estimated from the difference between legs in mean change of ankle mobility and femur bone mineral density . The results indicated a mean treatment effect on ankle mobility of 4 degrees ( 95 % CI 2 to 6 degrees ) and on femur bone mineral density of 0.005 g/cm(2 ) ( 95 % CI -0.015 to 0.025 g/cm(2 ) ) . Tilt-table st and ing for 30 minutes , three times per week for 12 weeks has a small effect on ankle mobility , and little or no effect on femur bone mineral density . It is unclear whether clinicians and patients would consider such effects to be clinical ly worthwhile OBJECTIVE To compare the effects of 2 manual wheelchair propulsion training programs on h and rim kinetics , contact angle , and stroke frequency collected during overground propulsion . DESIGN R and omized controlled trial comparing h and rim kinetics between 3 groups : a control group that received no training , an instruction-only group that review ed a multimedia presentation , and a feedback group that review ed the multimedia presentation and real-time visual feedback . SETTING Research laboratory . PARTICIPANTS Full-time manual wheelchair users ( N=27 ) with spinal cord injury living in the Pittsburgh area . INTERVENTIONS Propulsion training was given 3 times over 3 weeks , and data were collected at baseline , immediately after training , and at 3 months . MAIN OUTCOME MEASURES Contact angle , stroke frequency , peak result ant force , and peak rate of rise of result ant force . RESULTS Both feedback and instruction-only groups improved their propulsion biomechanics across all surfaces ( carpet , tile , and ramp ) at both target and self-selected speeds compared with the control group . While controlling for velocity , both intervention groups showed long-term reductions in the peak rate or rise of result ant force , stroke frequency , and increased contact angle . CONCLUSIONS Long-term wheelchair users in both intervention groups significantly improved many aspects of their propulsion technique immediately after training and 3 months from baseline . Furthermore , training with a low-cost instructional video and slide presentation was an effective training tool alone Abstract Objective To compare two forms of device-specific training – body-weight-supported ( BWS ) ambulation on a fixed track ( TRK ) and BWS ambulation on a treadmill ( TM ) – to comprehensive physical therapy ( PT ) for improving walking speed in persons with chronic , motor-incomplete spinal cord injury ( SCI ) . Methods Thirty-five adult subjects with a history of chronic SCI ( > 1 year ; AIS ‘ C ’ or ‘ D ’ ) participated in a 13-week ( 1 hour/day ; 3 days per week ) training program . Subjects were r and omized into one of the three training groups . Subjects in the two BWS groups trained without the benefit of additional input from a physical therapist or gait expert . For each training session , performance values and heart rate were monitored . Pre- and post-training maximal 10-m walking speed , balance , muscle strength , fitness , and quality of life were assessed in each subject . Results All three training groups showed significant improvement in maximal walking speed , muscle strength , and psychological well-being . A significant improvement in balance was seen for PT and TRK groups but not for subjects in the TM group . In all groups , post-training measures of fitness , functional independence , and perceived health and vitality were unchanged . Conclusions Our results demonstrate that persons with chronic , motor-incomplete SCI can improve walking ability and psychological well-being following a concentrated period of ambulation therapy , regardless of training method . Improvement in walking speed was associated with improved balance and muscle strength . In spite of the fact that we withheld any formal input of a physical therapist or gait expert from subjects in the device-specific training groups , these subjects did just as well as subjects receiving comprehensive PT for improving walking speed and strength . It is likely that further modest benefits would accrue to those subjects receiving a combination of device-specific training with input from a physical therapist or gait expert to guide that training Background Shoulder pain is a common problem after spinal cord injury ( SCI ) , with negative effects on daily activities and quality of life ( QOL ) . Objective The purpose of this study was to determine the effect of an exercise program and instruction to optimize performance of upper-extremity tasks on shoulder pain in people with paraplegia from SCI . Methods / Design Eighty individuals with paraplegia from SCI and shoulder pain were r and omly assigned to receive either an exercise/movement optimization intervention or an attention control intervention . The exercise/movement optimization intervention consisted of a 12-week home-based program of shoulder strengthening and stretching exercises , along with recommendations on how to optimize the movement technique of transfers , raises , and wheelchair propulsion . The attention control group viewed a 1-hour educational video . Outcome measures of shoulder pain , muscle strength ( force-generating capacity ) , activity , and QOL were assessed at baseline , immediately after intervention , and 4 weeks later . Results Shoulder pain , as measured with the Wheelchair User 's Shoulder Pain Index , decreased to one third of baseline levels after the intervention in the exercise/movement optimization group , but remained unchanged in the attention control group . Shoulder torques , most 36-Item Short-Form Health Survey question naire ( SF-36 ) subscale scores , and QOL scores also were improved in the exercise/movement optimization group , but not in the attention control group . Improvements were maintained at the 4-week follow-up assessment . Limitations Many of the outcome measures were self-reported , and the participant dropout rate was high in both groups . Additional studies are needed to determine whether the results of this study can be generalized to individuals with tetraplegia . Conclusions This home-based intervention was effective in reducing long-st and ing shoulder pain in people with SCI . The reduction in pain was associated with improvements in muscle strength and health-related and overall QOL
Objectives : To determine the effectiveness of 22 commonly administered physiotherapy interventions for people with spinal cord injuries ( SCIs ) .