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Objective To determine the impact of long-term, body weight–supported locomotor training after chronic, incomplete spinal cord injury (SCI), and to estimate the health care costs related to lost recovery potential and preventable secondary complications that may have occurred because of visit limits imposed by insurers. Design Prospective observational cohort with longitudinal follow-up. Setting Eight outpatient rehabilitation centers that participate in the Christopher & Dana Reeve Foundation NeuroRecovery Network (NRN). Participants Individuals with motor incomplete chronic SCI (American Spinal Injury Association Impairment Scale C or D; N=69; 0.1–45y after SCI) who completed at least 120 NRN physical therapy sessions. Interventions Manually assisted locomotor training (LT) in a body weight–supported treadmill environment, overground standing and stepping activities, and community integration tasks. Main Outcome Measures International Standards for Neurological Classification of Spinal Cord Injury motor and sensory scores, orthostatic hypotension, bowel/bladder/sexual function, Spinal Cord Injury Functional Ambulation Inventory (SCI-FAI), Berg Balance Scale, Modified Functional Reach, 10-m walk test, and 6-minute walk test. Longitudinal outcome measure collection occurred every 20 treatments and at 6- to 12-month follow-up after discharge from therapy. Results Significant improvement occurred for upper and lower motor strength, functional activities, psychological arousal, sensation of bowel movement, and SCI-FAI community ambulation. Extended training enabled minimal detectable changes at 60, 80, 100, and 120 sessions. After detectable change occurred, it was sustained through 120 sessions and continued 6 to 12 months after treatment. Conclusions Delivering at least 120 sessions of LT improves recovery from incomplete chronic SCI. Because walking reduces rehospitalization, LT delivered beyond the average 20-session insurance limit can reduce rehospitalizations and long-term health costs.

Morrison SA, Forrest GF, VanHiel LR, Dave M, D'Urso D. NeuroRecovery Network provides standardization of locomotor training for persons with incomplete spinal cord injury. Objective To illustrate the continuity of care afforded by a standardized locomotor training program across a multisite network setting within the Christopher and Dana Reeve Foundation NeuroRecovery Network (NRN). Design Single patient case study. Setting Two geographically different hospital-based outpatient facilities. Participants This case highlights a 25-year-old man diagnosed with C4 motor incomplete spinal cord injury with American Spinal Injury Association Impairment Scale grade D. Intervention Standardized locomotor training program 5 sessions per week for 1.5 hours per session, for a total of 100 treatment sessions, with 40 sessions at 1 center and 60 at another. Main Outcome Measures Ten-meter walk test and 6-minute walk test were assessed at admission and discharge across both facilities. For each of the 100 treatment sessions percent body weight support, average, and maximum treadmill speed were evaluated. Results Locomotor endurance, as measured by the 6-minute walk test, and overground gait speed showed consistent improvement from admission to discharge. Throughout training, the patient decreased the need for body weight support and was able to tolerate faster treadmill speeds. Conclusions Data indicate that the patient continued to improve on both treatment parameters and walking function. Standardization across the NRN centers provided a mechanism for delivering consistent and reproducible locomotor training programs across 2 facilities without disrupting training or recovery progression.

Datta S, Lorenz DJ, Morrison S, Ardolino E, Harkema SJ. A multivariate examination of temporal changes in Berg Balance Scale items for patients with ASIA Impairment Scale C and D spinal cord injuries. Objective To provide a multivariate examination of the Berg Balance Scale (BBS) in patients with spinal cord injury (SCI) as a first step in developing a balance tool for the SCI population. Design Observational cohort. Setting The NeuroRecovery Network (NRN), a specialized network of treatment centers providing standardized, activity-based therapy for patients with SCI. Participants Patients (N=97) with American Spinal Injury Association Impairment Scale C or D SCI who were enrolled in the NRN between March 1, 2005, and June 12, 2007. Interventions All enrolled patients received 3 to 5 locomotor training sessions a week, according to NRN protocol, and were periodically evaluated for progress on functional outcome measurements. Main Outcome Measures Scores on the items of the BBS, six-minute walk test distances, ten-meter walk test speeds, and scores on the SCI Functional Ambulation Index. Temporal rates of change of the BBS items were examined with a principal components and correlation analysis. Results The first principal component accounted for nearly half of the overall variability in the BBS, correlated well with rates of change in functional mobility measures, and had good stability in its composition as verified by a resampling analysis. Further analysis showed that the composition of the first principal component varied with the patient's level of recovery. Conclusions The BBS captures a significant amount of information about balance recovery in persons with SCI and may be a good foundation for a balance tool. However, the utility of BBS items may be dependent on a patient's level of recovery. A dynamic balance instrument for the SCI population may be needed.

To gain insight into who is likely to benefit from activity-based therapy (ABT), as assessed by secondary analysis of data obtained from a clinical trial.Secondary analysis of results from a randomized controlled trial with delayed treatment design.Outpatient program in a private, nonprofit rehabilitation hospital.Volunteer sample of adults (N=38; 27 men; 11 women; age, 22-63y) with chronic (≥12mo postinjury), motor-incomplete (American Spinal Injury Association [ASIA] Impairment Scale [AIS] grade C or D) spinal cord injury (SCI).A total of 9h/wk of ABT for 24 weeks including developmental sequencing; resistance training; repetitive, patterned motor activity; and task-specific locomotor training. Algorithms were used to guide group allocation, functional electrical stimulation utilization, and locomotor training progression.Walking speed and endurance (10-meter walk test and 6-minute walk test) and functional ambulation (timed Up and Go test).This secondary analysis identified likely responders to ABT on the basis of injury characteristics: AIS classification, time since injury, and initial walking ability. Training effects were the most clinically significant in AIS grade D participants with injuries3 years in duration. This information, along with information about preliminary responsiveness to therapy (gains after 12wk), can help predict the degree of recovery likely from participation in an ABT program.ABT has the potential to promote neurologic recovery and enhance walking ability in individuals with chronic, motor-incomplete SCI. However, not everyone with goals of walking recovery will benefit. Individuals with SCI should be advised of the time, effort, and resources required to undertake ABT. Practitioners are encouraged to use the findings from this trial to assist prospective participants in establishing realistic expectations for recovery.

Objective To examine the effects of activity-based therapy (ABT) on neurologic function, walking ability, functional independence, metabolic health, and community participation. Design Randomized controlled trial with delayed treatment design. Setting Outpatient program in a private, nonprofit rehabilitation hospital. Participants Volunteer sample of adults (N=48; 37 men and 11 women; age, 18–66y) with chronic (≥12mo postinjury), motor-incomplete (ASIA Impairment Scale grade C or D) spinal cord injury (SCI). Interventions A total of 9h/wk of ABT for 24 weeks including developmental sequencing; resistance training; repetitive, patterned motor activity; and task-specific locomotor training. Algorithms were used to guide group allocation, functional electrical stimulation utilization, and locomotor training progression. Main Outcome Measures Neurologic function (International Standards for Neurological Classification of Spinal Cord Injury); walking speed and endurance (10-meter walk test, 6-minute walk test, and Timed Up and Go test); community participation (Spinal Cord Independence Measure, version III, and Reintegration to Normal Living Index); and metabolic function (weight, body mass index, and Quantitative Insulin Sensitivity Check). Results Significant improvements in neurologic function were noted for experimental versus control groups (International Standards for Neurological Classification of Spinal Cord Injury total motor score [5.1±6.3 vs 0.9±5.0; P =.024] and lower extremity motor score [4.2±5.2 vs −0.6±4.2; P =.004]). Significant differences between experimental and control groups were observed for 10-meter walk test speed (0.096±0.14m/s vs 0.027±0.10m/s; P =.036) and 6-minute walk test total distance (35.97±48.2m vs 3.0±25.5m; P =.002). Conclusions ABT has the potential to promote neurologic recovery and enhance walking ability in individuals with chronic, motor-incomplete SCI. However, further analysis is needed to determine for whom ABT is going to lead to meaningful clinical benefits.

Stewart MW, Melton-Rogers SL, Morrison S, Figoni SF. The measurement properties of fitness measures and health status for persons with spinal cord injuries. Arch Phys Med Rehabil 2000;81:394-400. Objective: To assess the measurement properties of measures used to evaluate fitness and health status in the spinal cord injury (SCI) population. Design: Inception cohort assessed during standardized exercise protocols at admission, discharge, and 8-week follow-up from a SCI rehabilitation program. Setting: Urban tertiary care hospital. Patients: One hundred two patients with SCI. Results: Measures at higher levels of physical exertion generally showed higher stability between test and retest. Resting measures, blood lactates, and respiratory exchange ratios were not stable. Heart rate, blood pressure, lactate levels, ventilation rates, and activities of daily living measures did not reflect the construct of aerobic fitness. The use of ratings of perceived exertion to predict heart rate was found to be inaccurate in the SCI population. Conclusion: Power output and VO 2 at maximal workload, and ratings of perceived exertion at a standard workload demonstrated stability and sensitivity to therapeutic change, indicating acceptable measurement properties for the assessment of aerobic fitness in SCI patients. Some other commonly used measures can be used with less confidence. © 2000 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation