Activity‐based restorative therapies: Concepts and applications in spinal cord injury‐related neurorehabilitation

Abstract

Physical rehabilitation following spinal cord injury-related paralysis has traditionally focused on teaching compensatory techniques, thus enabling the individual to achieve day-to-day function despite significant neurological deficits. But the concept of an irreparable central nervous system (CNS) is slowly being replaced with evidence related to CNS plasticity, repair, and regeneration, all related to persistently maintaining appropriate levels of neurological activity both below and above the area where the damage occurred. It is now possible to envision functional repair of the nervous system by implementing rehabilitative interventions. Making the transition from "bench to bedside" requires careful analysis of existing basic science evidence, strategic focus of clinical research, and pragmatic implementation of new therapeutic tools. Activity, defined as both function specific motor task and exercise appears to be a necessity for optimization of functional, metabolic, and neurological status in chronic paralysis. Crafting a comprehensive rehabilitative intervention focused on functional improvement through neurological gains seems logical. The terms activity-based restorative therapies, activity-based therapies, and activity-based rehabilitation have been coined in the last 10 years to describe a new fundamental approach to deficits induced by neurological paralysis. The goal of this approach is to achieve activation of the neurological levels located both above and below the injury level using rehabilitation therapies. This article reviews basic and clinical science evidence pertaining to implementation of physical activity and exercise as a therapeutic tool in the management of chronic spinal cord-related neurological paralysis.

Chronic activity-based therapy does not improve body composition, insulin-like growth factor-I, adiponectin, or myostatin in persons with spinal cord injury

“…Of these modalities, FES is frequently cited 1,3 as having the most significant effect upon body composition in SCI versus other modalities. However, ABT is designed to improve motor gains and achieve activation of the neurological levels both above and below the injury level 13 and does not solely target the leg muscles as does FES, so its inability to promote muscle hypertrophy is not surprising. Furthermore, its energy cost is less than other modalities typically performed in SCI.…”

“…This regimen elicits intensities ranging from 5 to 8 ml/kg/minute, similar to circuit training and resistance exercise 33 yet lower than arm ergometry or wheelchair ambulation. 17 ABT promotes activation of the neurological levels located both above and below the injury level using rehabilitation therapies 13 and was previously shown 14 to enhance motor gains in persons with chronic SCI. Training was individualized for each client based on their baseline function, and each day, progression was instituted based on participant tolerance to training and level of adaptation.…”

“…In addition, there is a growing use of activity-based therapy (ABT) targeting regions below the level of injury to improve standing, motor function, and locomotion. 13 This exercise modality is of high volume (>6 hours/week) and typically includes dynamic resistance training, FES, body weight-supported treadmill training, and load bearing and/or standing. Various components of ABT are used at the Kennedy Krieger Institute (Baltimore, MD), Shepherd Center (Atlanta, GA), and throughout the NeuroRecovery Network in the United States as well as abroad (University of Sydney) to aid in the rehabilitation of persons with SCI.…”

Technology for mobility in SCI 10 years from now

“…A critical aspect of recovery of movement after SCI is central nervous system neuroplasticity. Neuroplastic changes can be influenced both by the environment and activity, which can be manipulated through interventions ranging from activity-based therapy 24,25 to electrical stimulation 26 to cellular implants, to local or systemic application of various substances. Here, we focus on neuromodulation via electrical stimulation and via chemical agents.…”

Effectiveness of intense, activity-based physical therapy for individuals with spinal cord injury in promoting motor and sensory recovery: Is olfactory mucosa autograft a factor?

“…[3][4][5][6] Human studies have focused on the effects of body weight-supported treadmill training (BWSTT) [7][8][9] and functional electric stimulation cycling. [10][11][12] Considerable evidence demonstrates that individuals with incomplete SCI have the potential to transition from BWSTT and regain over-ground ambulation; 7,8,13,14 however, even when the SCI is complete, the neural networks below the level of the lesion generate locomotor activity. 7,9 The goal of activity-based therapy is to promote neuromuscular plasticity through interventions that provide activation of the neuromuscular system below the level of the spinal lesion and perform repetitive practice of the desired motor tasks.…”