The Effect of Perturbation-Based Balance Training and Conventional Intensive Balance Training on Reactive Stepping Ability in Individuals With Incomplete Spinal Cord Injury or Disease: A Randomized Clinical Trial

Abstract

Introduction: Impaired balance leads to falls in individuals with motor incomplete spinal cord injury or disease (iSCI/D). Reactive stepping is a strategy used to prevent falls and Perturbation-based Balance Training (PBT) can improve this ability.Objective: The objective of this study was to determine if PBT results in greater improvements in reactive stepping ability than frequency-matched Conventional Intensive Balance Training (CIBT) in adults with iSCI/D.Design: Randomized clinical trial.Setting: Tertiary SCI/D rehabilitation center.Participants: Twenty-one adults with chronic (>1 year) iSCI/D were randomized. Due to one drop out 20 participants completed the study.Methods: Participants were randomly allocated to complete either PBT or CIBT three times per week for 8 weeks. Both programs included challenging static and dynamic balance tasks, but the PBT group also experienced manual external balance perturbations.Main Outcome Measures: Assessments of reactive stepping ability using the Lean-and-Release test were completed at baseline, and after 4 and 8 weeks of training, and 3 and 6 months after training completion. A blinded assessor evaluated secondary outcomes.Results: Twenty-five participants were screened and 21 consented; one withdrew. Ten PBT and 10 CIBT participants were included in analyses. Across all participants there were improvements in reactive stepping ability (p = 0.049), with retention of improvements at follow up assessments. There were no differences in reactive stepping ability between groups [median (interquartile range): PBT 0.08 (0.68); CIBT 0.00 (0.22)]. One participant in the PBT group experienced a non-injurious fall during training.Conclusions: Balance training is beneficial for individuals with iSCI/D, but the addition of manual perturbations (i.e., PBT) did not prove advantageous for performance on a measure of reactive stepping ability.Clinical Trial Registration:www.ClinicalTrials.gov, identifier: NCT02960178.

A qualitative photo-elicitation study exploring the impact of falls and fall risk on individuals with subacute spinal cord injury

“…Second, providing a safe environment in which to experience losses of balance when standing, walking, wheeling and/or transferring may provide opportunities for experiential learning. While reactive balance training, which provides repetitive exposure to falls, has been studied in the chronic, ambulatory SCI/D population to date [ 46 ], there may be value in investigating its feasibility and efficacy in the subacute population and modifying the training to accommodate wheelchair users.…”

The effect of reactive balance training on falls in daily life: an updated systematic review and meta-analysis

“…Participants in studies included in this review were community-living older adults; 9, 31, 33-35, 40, 45, 47, 48, 51 adults with Parkinson’s disease, 27, 29, 32, 37, 38, 41, 42 stroke, 8, 30, 39, 44, 46 cerebral palsy, 36 and spinal cord injury; 49 and long-term care residents. 28, 43 All studies had RBT as either a sole or a significant component of the experimental intervention.…”

“…33, 35, 45 The frequency of RBT ranged from one training session total 33, 35, 48 to 3 times per week. 9, 27-32, 34, 41, 43, 47, 49 The duration of RBT training ranged from 15 minutes 33 to 1.5 hours 36 per session; most studies (19/25) conducted RBT for 30 to 60 minutes per session.…”

“…Three studies did not provide any intervention to the control group, 27,29,34 and the remaining studies used non-RBT exercise for the control intervention. The loss of balance during RBT was caused by manual perturbations, 8,27,30,32,34,36,37,39,41,49 challenging balance tasks to evoke internal perturbations, 8,49 single-axis or multi-directional perturbations on a treadmill or a moveable platform, 9,28,29,38,40,[42][43][44][45][46][47][48] and/or slip and trip perturbations on a walkway with movable tiles/platforms and tripping obstacles. 33,35,45 The frequency of RBT ranged from one training session total 33,35,48 to 3 times per week.…”

Invasive and Non-Invasive Approaches of Electrical Stimulation to Improve Physical Functioning after Spinal Cord Injury

“…Participants also demonstrated an increased center of pressure excursion in all directions when leaning in a standing position [57]. Gauthier et al (2020) recently demonstrated the feasibility of incorporating FES into perturbation-based balance training, which involves repetitively exposing individuals with SCI to external perturbations to help retrain reactive postural control [64][65][66]. Surface electrodes were placed on the common fibular nerve bilaterally to elicit the flexor withdrawal response.…”