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Progress in locomotor rehabilitation has created an increasing need to understand the factors that contribute to motor behavior, to determine whether these factors are modifiable, and if so, to determine how best to modify them in a way that promotes improved function. Currently available clinical measures do not have the capacity to distinguish between neuromotor recovery and compensation for impaired underlying body structure/functions. This Special Interest article examines the state of outcomes measurement in physical therapy in regard to locomotor rehabilitation, and suggests approaches that may improve assessment of recovery and clinical decision-making capabilities. We examine historical approaches to measurement of locomotor rehabilitation outcomes, including rating scales, timed movement tasks, and laboratory-based outcome measures, and we discuss the emerging use of portable technology to assess walking in a free-living environment. The ability to accurately measure outcomes of rehabilitation, both in and away from the clinical/laboratory setting, allows assessment of skill acquisition, retention, and long-term carryover in a variety of environments. Accurate measurement allows behavioral changes to be observed, and assessments to be made, regarding an individual's ability to adapt during interventions and to incorporate new skills into real-world behaviors. The result of such an approach to assessment may be that interventions truly translate from clinical/laboratory to real-world environments. Future locomotor measurement tools must be based on a theoretical framework that can guide their use to accurately quantify treatment effects and provide a basis upon which to develop and refine therapeutic interventions.

Cutaneous feedback from the hand could assist with coordination between the arms and legs during locomotion. Previously we used a reduced walking model of combined arm and leg (ARM&LEG) cycling to examine the separate effects of rhythmic arm (ARM) and leg (LEG) movement. Here we use this same paradigm to test the modulation H-reflexes with and without interlimb cutaneous conditioning evoked by stimulating a nerve innervating the hand (superficial radial, SR). It was hypothesized that both ARM and LEG would contribute significantly to suppression of H-reflex amplitude during ARM&LEG. We also predicted a conservation of interlimb cutaneous conditioning during movement and an interaction between arm and leg rhythmic movement control. Subjects were seated in a recumbent ARM&LEG cycle ergometer and maintained a low-level soleus contraction for all tasks. H-reflex amplitude was facilitated by cutaneous conditioning evoked by stimulation of the SR nerve. H-reflex amplitudes were taken from recruitment curves and included modulation of 50% H max and H max. The suppressive effect of arm was less than that for LEG and ARM&LEG, while suppression during LEG and ARM&LEG were generally equivalent. For H-reflexes conditioned by cutaneous input, amplitudes during ARM&LEG instead were in between those for ARM and LEG modulation. Multiple regression analysis revealed a significant contribution for arm only in trials when SR stimulation was used to condition H-reflex amplitudes. We suggest that there is a measurable interaction between neural activity regulating arm and leg movement during locomotion that is specifically enhanced when cutaneous input from the hand is present.

This study examined the experiences of persons with incomplete spinal cord injury who participated in loco-motor training (LT). LT is an emerging rehabilitation intervention for enhancing the recovery of walking in persons with central nervous system disorders. Multiple interviews and field observations provided data from eight participants, including four veterans. Findings indicate that experiences of bodily changes were prevalent among participants. Themes included (1) experiencing impaired or absent proprioception, (2) struggling for bodily control, and (3) experiencing emergent bodily sensations. Themes 1 and 2 reflected bodily disruption as a result of spinal cord injury and were challenging to participants as they attempted to reconnect the body and self through LT. Theme 3 reflected bodily sensations (burning, soreness) that were seen as positive signs of recovery and resulted in hope and motivation. Understanding how LT participants experience bodily changes may enable therapists to develop improved participant-centered intervention approaches.

Background and Purpose: The use of locomotor training with a body-weight-support system and treadmill (BWST) and manual assistance has increased in rehabilitation. The purpose of this case report is to describe the process for retraining walking in a person with an incomplete spinal cord injury (SCI) using the BWST and transferring skills from the BWST to overground assessment and community ambulation., Case Description: Following discharge from rehabilitation, a man with an incomplete SCI at C5-6 and an American Spinal Injury Association (ASIA) Impairment Scale classification of D participated in 45 sessions of locomotor training., Outcomes: Walking speed and independence improved from 0.19 m/s as a home ambulator using a rolling walker and a right ankle-foot orthosis to 1.01 m/s as a full-time ambulator using a cane only for community mobility. Walking activity (mean+/-SD) per 24 hours increased from 1,054+/-543 steps to 3,924+/-1,629 steps., Discussion: In a person with an incomplete SCI, walking ability improved after locomotor training that used a decision-making algorithm and progression across training environments.

Background. For clinical trials in stroke rehabilitation, self-selected walking speed has been used to stratify persons to predict functional walking status and to define clinical meaningfulness of changes. However, this stratification was validated primarily using self-report questionnaires. Objective. This study aims to validate the speed-based classification system with quantitative measures of walking performance.Methods. A total of 59 individuals who had hemiparesis for more than 6 months after stroke participated in this study. Spatiotemporal and kinetic measures included the percentage of total propulsion generated by the paretic leg (Pp), the percentage of the stride length accounted for by the paretic leg step length (PSR), and the percentage of the gait cycle spent in paretic preswing (PPS). Additional measures included the synergy portion of the Fugl-Meyer Assessment and the average number of steps/day in the home and community measured with a step activity monitor. Participants were stratified by self-selected gait speed into 3 groups: household (<0.4 m/s), limited community (0.4-0.8 m/s), and community (>0.8 m/s) ambulators. Group differences were analyzed using a Kruskal-Wallis H test with rank sums test post hoc analyses. Results. Analyses demonstrated a main effect in all measures, but only steps/day and PPS demonstrated a significant difference between all 3 groups. Conclusions. Classifying individuals poststroke by self-selected walking speed is associated with home and community-based walking behavior as quantified by daily step counts. In addition, PPS distinguishes all 3 groups. Pp differentiates the moderate from the fast groups and may represent a contribution to mechanisms of increasing walking speed. Speed classification presents a useful yet simple mechanism to stratify subjects poststroke and may be mechanically linked to changes in PPS. [ABSTRACT FROM AUTHOR]

Physical rehabilitation after spinal cord injury has been based on the premise that the nervous system is hard-wired and irreparable. Upon this assumption, clinicians have compensated for irremediable sensorimotor deficits using braces, assistive devices, and wheelchairs to achieve upright and seated mobility. Evidence from basic science, however, demonstrates that the central nervous system after injury is malleable and can learn, and this evidence has challenged our current assumptions. The evidence is especially compelling concerning locomotion. The purpose of this perspective article is to summarize the evidence supporting an impending paradigm shift from compensation for deficits to rehabilitation as an agent for walking recovery. A physiologically based approach for the rehabilitation of walking has developed, translating evidence for activity-dependent neuroplasticity after spinal cord injury and the neurobiological control of walking. Advanced by partnerships among neuroscientists, clinicians, and researchers, critical rehabilitation concepts are emerging for activity-based therapy to improve walking recovery, with promising clinical findings. [Behrman AL, Bowden MG, Nair PM. Neuroplasticity after spinal cord injury and training: an emerging paradigm shift in rehabilitation and walking recovery. Phys Ther. 2006;86:1406 -1425.] [ABSTRACT FROM AUTHOR]