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The Christopher and Dana Reeve Foundation NeuroRecovery Network

 

 

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A multivariate examination of temporal changes in Berg Balance Scale items for patients with ASIA Impairment Scale C and D spinal cord injuries.
Datta, S., Lorenz, D. J., Morrison, S., Ardolino, E., & Harkema, S. J. Archives of physical medicine and rehabilitation 90.7 (2009): 1208-1217.
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.


Marginal association measures for clustered data
Lorenz, D. J., Datta,S. & Harkema, H.J. Statistics in medicine 30.27 (2011): 3181-3191.

The use of correlation coefficients in measuring the association between two continuous variables is common, but regular methods of calculating correlations have not been extended to the clustered data framework. For clustered data in which observations within a cluster may be correlated, regular inferential procedures for calculating marginal association between two variables can be biased. This is particularly true for data in which the number of observations in a given cluster is informative for the association being measured. In this paper, we apply the principle of inverse cluster size reweighting to develop estimators of marginal correlation that remain valid in the clustered data framework when cluster size is informative for the correlation being measured. These correlations are derived as analogs to regular correlation estimators for continuous, independent data, namely, Pearson’s _ and Kendall’s _. We present the results of a simple simulation study demonstrating the appropriateness of our proposed estimators and the inherent bias of other inferential procedures for clustered data. We illustrate their use through an application to data from patients with incomplete spinal cord injury in the USA.


Restorative rehabilitation entails a paradigm shift in pediatric incomplete spinal cord injury in adolescence: an illustrative case series.
Behrman, A.L., Watson, E., Fried, F., D'Urso, K., D'Urso, D., Cavadini, N., Brooks, M., Kern, M., Wenzel, L., Taylor, H., & Ardolino, E. Journal of pediatric rehabilitation medicine 5.4 (2011): 245-259.

Physical rehabilitation after spinal cord injury (SCI) in adult and pediatric populations has traditionally compensated for paralysis and weakness using wheelchairs, assistive devices, and braces to achieve seated mobility, upright standing, or bracewalking. Recent evidence indicates efficacy of activity-based therapies in adults with SCI, specifically locomotor training (LT), to activate the neuromuscular system below the injury level and improve walking and postural control by restoring pre-morbid movements. The purpose of this paper is to demonstrate the feasibility of LT, using repetitive stepping practice on a treadmill and translated to over ground and the community, to meet the unique needs and demands of pediatric, adolescent rehabilitation. Three outpatient adolescents, T5 AIS D, age 15 (primary wheelchair user), T5 AIS C, age 14 (primary wheelchair user), and C2, AIS D, 14 years (primary ambulator), received a standardized protocol of LT 4–5 times per week for 75, 293, and 40 total sessions, respectively, across 1–3 episodes of care. Two adolescents became full-time ambulators, and one adolescent improved Locomotor skills, kinematics, and endurance with two individuals lacking significant increases in strength to account for the benefits. Motivational strategies were developmentally specific, parental involvement critical for carryover, and musculoskeletal considerations paramount with growth and maturation. In comparison to adults, adolescents’ continued musculoskeletal, cognitive, and social growth and maturation necessitate repeated episodes of therapy and bi-annual re-evaluations to identify needs and address new goals. The use of activity-based therapies, i.e. LT, represents a paradigm shift in pediatric rehabilitation towards activation of the neuromuscular system below the lesion via task-specific training and experience, minimizing compensation strategies, and targeting recovery of function achieved via use of pre-morbid movement patterns.


The ABLE scale: the development and psychometric properties of an outcome measure for the spinal cord injury population
Ardolino, E. M., Hutchinson, K. J., Zipp, G. P., Clark, M., & Harkema, S. J. Physical therapy 92.8 (2012) 1046-1054.

Background. A paucity of information exists on the psychometric properties of several balance outcome measures. With the exception of the Modified Functional Reach Test, none of these balance outcome measures were developed specifically for the population with spinal cord injury (SCI). A new balance assessment tool for people with SCI, the Activity-based Balance Level Evaluation (ABLE scale), was developed and tested.

Objective. The purposes of this study were: (1) to develop a scale capturing the wide spectrum of functional ability following SCI and (2) to assess the initial psychometric properties of the scale using a Rasch analysis.

Design. A methodological research design was used to test the initial psychometric properties of the ABLE scale.

Methods. The Delphi technique was used to establish the original 28-item ABLE scale. People with SCI at each of 4 centers (n104) were evaluated using the ABLE scale. A Rasch analysis was conducted to test for targeting, item difficulty, item bias, and unidimensionality. An analysis of variance was completed to test for discriminant validity.

Results. The Rasch analysis revealed a scale with minimal floor and ceiling effects and a wide range of item difficulty capturing the large scope of functional capacity after SCI. Multiple redundancies of item difficulty were observed.

Limitations. All raters were experienced physical therapists, which may have skewed the results. The sample size of 104 participants precluded a principal component analysis.

Conclusion. Development of an all-inclusive clinical instrument assessing balance in the SCI population was accomplished using the Delphi technique. Modifications of the ABLE scale based on the Rasch analysis yielded a 28-item scale with minimal floor or ceiling effects. Larger studies using the revised scale and factor analyses are necessary to establish unidimensionality and reduction of the total item number.


Establishing the NeuroRecovery Network: multisite rehabilitation centers that provide activity-based therapies and assessments for neurologic disorders.
Harkema, S. J., Schmidt-Read, M., Behrman, A. L., Bratta, A., Sisto, S. A., & Edgerton, V. R. Archives of physical medicine and rehabilitation 93.9 (2012): 1498-1507.

The mission of the NeuroRecovery Network (NRN) is to provide support for the implementation of specialized centers at rehabilitation sites in the United States. Currently, there are 7 NRN centers that provide standardized activity-based interventions designed from scientific and clinical evidence for recovery of mobility, posture, standing, and walking and improvements in health and quality of life in individuals with spinal cord injury. Extensive outcome measures evaluating function, health, and quality of life are used to determine the efficacy of the program. NRN members consist of scientists, clinicians, and administrators who collaborate to achieve the goals and objectives of the network within an organizational structure by designing and implementing a clinical model that provides consistent interventions and evaluations and a general education and training program.


Balance and ambulation improvements in individuals with chronic incomplete spinal cord injury using locomotor training–based rehabilitation.
Harkema, S. J., Schmidt-Read, M., Lorenz, D. J., Edgerton, V. R., & Behrman, A. L. Archives of physical medicine and rehabilitation 93.9 (2012): 1508-1517.

Objective: To evaluate the effects of intensive Locomotor training on balance and ambulatory function at enrollment and discharge during outpatient rehabilitation after incomplete SCI.

Design: Prospective observational cohort.

Setting: Seven outpatient rehabilitation centers from the Christopher and Dana Reeve Foundation NeuroRecovery Network (NRN).

Participants: Patients (N_196) with American Spinal Injury Association Impairment Scale (AIS) grade C or D SCI who received at least 20 locomotor training treatment sessions in the NRN.

Interventions: Intensive locomotor training, including step training using body-weight support and manual facilitation on a treadmill followed by overground assessment and community integration.

Main Outcome Measures: Berg Balance Scale; Six-Minute Walk Test; 10-Meter Walk Test.

Results: Outcome measures at enrollment showed high variability between patients with AIS grades C and D. Significant improvement from enrollment to final evaluation was observed in balance and walking measures for patients with AIS grades C and D. The magnitude of improvement significantly differed between AIS groups for all measures. Time since SCI was not associated significantly with outcome measures at enrollment, but was related inversely to levels of improvement.


NeuroRecovery Network provides standardization of locomotor training for persons with incomplete spinal cord injury
Morrison, S. A., Forrest, G. F., VanHiel, L. R., Davé, M., & D'Urso, D. Archives of physical medicine and rehabilitation 93.9 (2012): 1574-1577.

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.


Assessment of functional improvement without compensation reduces variability of outcome measures after human spinal cord injury.
Behrman, A. L., Ardolino, E., VanHiel, L. R., Kern, M., Atkinson, D., Lorenz, D. J., & Harkema, S. J. Archives of physical medicine and rehabilitation 93.9 (2012): 1518-1529.

Objective: To develop a scale (Neuromuscular Recovery Scale [NRS]) for classification of functional motor recovery after spinal cord injury (SCI) based on preinjury movement patterns that would reduce variability of the populations’ level of function within each class, because assessment of functional improvement after SCI is problematic as a result of high variability of the populations’ level of function and the insensitivity to change within the available outcome measures.

Design: Prospective observational cohort with longitudinal follow-up.

Setting: Seven outpatient rehabilitation centers from the Christopher and Dana Reeve Foundation NeuroRecovery Network (NRN).

Participants: Individuals (N_95) with American Spinal Injury Association Impairment Scale (AIS) grade C or AIS grade D having received at least 20 locomotor training treatment sessions in the NRN.

Interventions: Intensive locomotor training including stepping on a treadmill with partial body weight support and manual facilitation and translation of skills into home and community activities.

Main Outcome Measures: Berg Balance Scale, six-minute walk test, and ten-meter walk test.

Results: Individuals classified within each of the 4 phases of the NRS were functionally discrete, as shown by significant differences in the mean values of balance, gait speed, and walking endurance, and the variability of these measurements was significantly reduced by NRS classification. The magnitude of improvements in these outcomes was also significantly different among phase groups.

Conclusions: Assessment with the NRS provides a classification for functional motor recovery without compensation, which reduces variability in performance and improvements for individuals with injuries classified as AIS grades C and D.


Relationship between ASIA examination and functional outcomes in the NeuroRecovery Network locomotor training program.
Buehner, J. J., Forrest, G. F., Schmidt-Read, M., White, S., Tansey, K., & Basso, D. M. Archives of physical medicine and rehabilitation 93.9 (2012): 1530-1540.

Objective: To determine the effects of locomotor training on: (1) the International Standards for Neurological Classification of Spinal Cord Injury examination; (2) locomotion (gait speed, distance); (3) balance; and (4) functional gait speed stratifications after chronic incomplete spinal cord injury (SCI).

Design: Prospective observational cohort.

Setting: Outpatient rehabilitation centers in the NeuroRecovery Network (NRN).

Participants: Individuals (n_225) with American Spinal Injury Association Impairment Scale (AIS) grade C or D chronic motor incomplete SCI having completed locomotor training in the NRN.

Intervention: The NRN Locomotor Training Program consists of manual-facilitated body weight–supported standing and stepping on a treadmill and overground.

Main Outcome Measures: AIS classification, lower extremity pin prick, light touch and motor scores, ten-meter walk and six-minute walk tests, and the Berg Balance Scale.

Results: Significant gains occurred in lower extremity motor scores but not in sensory scores, and these were only weakly related to gait speed and distance. Final Berg Balance Scale scores and initial lower extremity motor scores were positively related. Although 70% of subjects showed significantly improved gait speed after locomotor training, only 8% showed AIS category conversion.

Conclusions: Locomotor training improves gait speed to levels sufficient for independent in-home or community ambulation after chronic motor incomplete SCI. Changes in lower extremity motor and sensory scores do not capture the full extent of functional recovery, nor predict responsiveness to locomotor training. Functional classification based on gait speed may provide an effective measure of treatment efficacy or functional improvement after incomplete SCI.


Ambulation and balance outcomes measure different aspects of recovery in individuals with chronic, incomplete spinal cord injury
Forrest, Gail F., Lorenz, D. J., Hutchinson, K., VanHiel, L.R., Basso,D. M., Datta, S., Sisto, S.A., & Harkema, S.J. Archives of physical medicine and rehabilitation 93.9 (2012): 1553-1564.

Objective: To evaluate relationships among ambulation and balance outcome measures over time for incomplete spinal cord injury (SCI) after locomotor training, in order to facilitate the selection of effective and sensitive rehabilitation outcomes.

Design: Prospective observational cohort.

Setting: Outpatient rehabilitation centers (N_7) from the Christopher and Dana Reeve Foundation NeuroRecovery Network.

Participants: Patients with incomplete SCI (N_182) American Spinal Injury Association Impairment Scale level C (n_61) and D (n_121).

Interventions: Intensive locomotor training, including step training using body weight support and manual facilitation on a treadmill followed by overground assessment and community integration.

Main Outcome Measures: Six-minute and 10-meter walk tests, Berg Balance Scale, Modified Functional Reach, and Neuromuscular Recovery Scale collected at enrollment, approximately every 20 sessions, and on discharge.

Results: Walking and standing balance measures for all participants were strongly correlated (r_.83 for all pairwise outcome correlations), standing and sitting balance measures were not highly correlated (r_.48 for all pairwise outcome correlations), and walking measures were weakly related to sitting balance. The strength of relationships among outcome measures varied with functional status. Correlations among evaluation-to-evaluation changes were markedly reduced from performance correlations. Walk tests, when conducted with different assistive devices, were strongly correlated but had substantial variability in performance.

Conclusions: These results cumulatively suggest that changes in walking and balance measures reflect different aspects of recovery and are highly influenced by functional status and the utilization of assistive devices. These factors should be carefully considered when assessing clinical progress and designing clinical trials for rehabilitation.


Dynamic longitudinal evaluation of the utility of the Berg Balance Scale in individuals with motor incomplete spinal cord injury.
Datta, S., Lorenz, D. J., & Harkema, S.J. Archives of physical medicine and rehabilitation 93.9 (2012): 1565-1573.

Objectives: To examine the utility of the Berg Balance Scale among patients with motor incomplete spinal cord injuries (SCIs), to determine how the utility of the Berg Balance Scale changes over time with activity-based therapy, and to identify differences in scale utility across patient groups defined by status of recovery.

Design: Prospective observational cohort.

Setting: The NeuroRecovery Network (NRN), a network of clinical centers for patients with motor incomplete SCI.

Participants: Patients with motor incomplete SCI (n_124) with American Spinal Injury Association Impairment Scale grade C or D, who were enrolled in the NRN between February 2008 and June 2009.

Intervention: Standardized locomotor training.

Main Outcome Measure: The Berg Balance Scale items were examined with longitudinal principal components analyses. Patients were categorized by phase using the Neuromuscular Recovery Scale.

Results: In the full sample, the first principal component explained a large percentage of overall scale variance (77%), items were loaded homogeneously on the first principal component, and item scores were well correlated with first principal component scores. In subgroups of low and high functioning of patients, first principal component variance accounting was reduced (49%) and only a few of the simplest and most difficult items substantially loaded onto the first principal component. Item loading coefficients evolved over time as patients recovered, with simpler items becoming less important to the full scale and difficult items more important.

Conclusions: The utility of the Berg Balance Scale in patients with motor incomplete SCI in early and advanced phases of recovery is limited. Specific item utility changes as patients recover. Thus, a more comprehensive and dynamic instrument is necessary to adequately measure balance across the spectrum of patients with motor incomplete SCI.


Longitudinal patterns of functional recovery in patients with incomplete spinal cord injury receiving activity-based rehabilitation
Lorenz, D. J., Datta, S., & Harkema, S. J. Archives of physical medicine and rehabilitation 93.9 (2012): 1541-1552.

Objective: To model the progression of 3 functional outcome measures from patients with incomplete spinal cord injury (SCI) receiving standardized locomotor training.

Design: Observational cohort.

Setting: The NeuroRecovery Network (NRN), a specialized network of treatment centers providing standardized, activity-based therapy for SCI patients.

Participants: Patients (N_337) with incomplete SCI (grade C or D on the International Standards for Neurological Classification of Spinal Cord Injury scale) who were enrolled in the NRN between February 2008 and March 2011.

Intervention: All enrolled patients received standardized Locomotor training sessions, as established by NRN protocol, and were evaluated monthly for progress.

Main Outcome Measures: Berg Balance Scale, 6-minute walk test, and 10-meter walk test. Progression over time was analyzed via the fitting of linear mixed effects models.

Results: There was significant improvement on each outcome measure and significant attenuation of improvement over time. Patients varied significantly across groups defined by recovery status and American Spinal Injury Association Impairment Scale (AIS) grade at enrollment with respect to baseline performance and rates of change over time. Time since SCI was a significant determinant of the rate of recovery for all measures.

Conclusions: Locomotor training, as implemented in the NRN, results in significant improvement in functional outcome measures as treatment sessions accumulate. Variability in patterns of recovery over time suggest that time since SCI and patient functional status at enrollment, as measured by the Neuromuscular Recovery Scale, are important predictors of performance and recovery as measured by the targeted outcome measures.


Cardiovascular status of individuals with incomplete spinal cord injury from 7 NeuroRecovery Network rehabilitation centers
Sisto, S. A., Lorenz, D. J., Hutchinson, K., Wenzel, L., Harkema, S. J., & Krassioukov, A. Archives of physical medicine and rehabilitation 93.9 (2012): 1578-1587.

Objective: To examine cardiovascular (CV) health in a large cohort of individuals with incomplete spinal cord injury (SCI). The CV health parameters of patients were compared based on American Spinal Injury Association Impairment Scale (AIS), neurologic level, sex, central cord syndrome, age, time since injury, Neuromuscular Recovery Scale, and total AIS motor score.

Design: Cross-sectional study.

Setting: Seven outpatient rehabilitation clinics.

Participants: Individuals (N_350) with incomplete AIS classification C and D were included in this analysis.

Interventions: Not applicable.

Main Outcome Measures: Heart rate, systolic and diastolic blood pressure during resting sitting and supine positions and after an orthostatic challenge.

Results: CV parameters were highly variable and significantly differed based on patient position. Neurologic level (cervical, high and low thoracic) and age were most commonly associated with CV parameters where patients classified at the cervical level had the lowest resting CV parameters. After the orthostatic challenge, blood pressure was highest for the low thoracic group, and heart rate for the high thoracic group was higher. Time since SCI was negatively related to blood pressure at rest but not after orthostatic challenge. Men exhibited higher systolic blood pressure than women and lower heart rate. The prevalence of orthostatic hypotension (OH) was 21% and was related to the total motor score and resting seated blood pressures. Cervical injuries had the highest prevalence.

Conclusions: Resting CV parameters of blood pressure and heart rate are affected by position, age, and neurologic level. OH is more prevalent in cervical injuries, those with lower resting blood pressures and who are lower functioning. Results from this study provide reference for CV parameters for individuals with incomplete SCI. Future research is needed on the impact of exercise on CV parameters.


Basic concepts of activity-based interventions for improved recovery of motor function after spinal cord injury
Roy, R. R., Harkema, S.J., & Edgerton, V.R. Archives of physical medicine and rehabilitation 93.9 (2012): 1487-1497.

Spinal cord injury (SCI) is a devastating condition that affects a large number of individuals. Historically, the recovery process after an SCI has been slow and with limited success. Recently, a number of advances have been made in the strategies used for rehabilitation, resulting in marked improved recovery, even after a complete SCI. Several rehabilitative interventions, that is, assisted motor training, spinal cord epidural stimulation, and/or administration of pharmacologic agents, alone or in combination, have produced remarkable recovery in motor function in both humans and animals. The success with each of these interventions appears to be related to the fact that the spinal cord is smart, in that it can use ensembles of sensory information to generate appropriate motor responses without input from supraspinal centers, a property commonly referred to as central pattern generation. This ability of the spinal cord reflects a level of automaticity, that is, the ability of the neural circuitry of the spinal cord to interpret complex sensory information and to make appropriate decisions to generate successful postural and locomotor tasks. Herein, we provide a brief review of some of the neurophysiologic rationale for the success of these interventions.


Locomotor training: as a treatment of spinal cord injury and in the progression of neurologic rehabilitation
Harkema, S. J., Hillyer, J., Schmidt-Read, M., Ardolino, E., Sisto, S. A., & Behrman, A. L. Archives of physical medicine and rehabilitation 93.9 (2012): 1588-1597.

Scientists, clinicians, administrators, individuals with spinal cord injury (SCI), and caregivers seek a common goal: to improve the outlook and general expectations of the adults and children living with neurologic injury. Important strides have already been accomplished; in fact, some have labeled the changes in neurologic rehabilitation a “paradigm shift.” Not only do we recognize the potential of the damaged nervous system, but we also see that “recovery” can and should be valued and defined broadly. Quality-of-life measures and the individual’s sense of accomplishment and well-being are now considered important factors. The ongoing challenge from research to clinical translation is the fine line between scientific uncertainty (ie, the tenet that nothing is ever proven) and the necessary burden of proof required by the clinical community. We review the current state of a specific SCI rehabilitation intervention (locomotor training), which has been shown to be efficacious although thoroughly debated, and summarize the findings from a multicenter collaboration, the Christopher and Dana Reeve Foundation’s NeuroRecovery Network.


Life care planning projections for individuals with motor incomplete spinal cord injury before and after locomotor training intervention: a case series
Morrison, S. A., Pomeranz, J. L., Yu, N., Read, M. S., Sisto, S. A., & Behrman, A. L. Journal of Neurologic Physical Therapy 36.3 (2012): 144-153.

Background/Purpose: We present a retrospective case series of 2 individuals with motor-incomplete spinal cord injury (SCI) to examine differences in lifetime cost estimates before and after participation in an intensive locomotor training (LT) program. Sections of a life care plan (LCP) were used to determine the financial implications associated with equipment, home renovations, and transportation for patients who receive LT. An LCP is a viable method of quantifying outcomes following any therapeutic intervention.

Case Description: The LCP cases analyzed were a 61-year-old woman and a 4½-year-old boy with motor-incomplete SCI and impairments classified by the American Spinal Injury Association Impairment Scale (AIS) as AIS D and AIS C, respectively.

Interventions: Each patient received an intensive outpatient LT program 3 to 5 days per week. The 61-year-old woman received 198 sessions over 57 weeks and the 4½-year-old boy received 76 sessions over 16 weeks.

Outcomes: The equipment, home renovation, and transportation costs of an LCP were calculated before and after LT. Prior to the implementation of LT, the 61-year-old woman had estimated lifetime costs between $150 247.00 and $199 654.00. Following LT, the estimated costs decreased to between $2010.00 and $2446.00 (a decrease of $148 237.00 and $197 208.00). Similarly, the 4-year-old boy had estimated lifetime costs for equipment, home renovation, and transportation between $535 050.00 and $771 665.00 prior to LT. However, the estimated costs decreased to between $97 260.00 and $200 047.00 (a decrease of $437 790.00 and $571 618.00) following LT.

Discussion: The lifetime financial costs associated with equipment, home renovations, and transportation following a motor-incomplete SCI were decreased following an intensive LT program for the 2 cases presented in this article. The LCP, including costs of rehabilitation and long-term medical and personal care costs, may be an effective tool to discern cost benefit of rehabilitation interventions.


Are the 10 meter and 6 minute walk tests redundant in patients with spinal cord injury?
Forrest, G. F., Hutchinson, K., Lorenz, D. J., Buehner, J. J., VanHiel, L. R., Sisto, S. A., & Basso, D. M. PloS one 9.5 (2014): e94108.

Objective: To evaluate the relationship and redundancy between gait speeds measured by the 10 Meter Walk Test (10MWT) and 6 Minute Walk Test (6MWT) after motor incomplete spinal cord injury (iSCI). To identify gait speed thresholds supporting functional ambulation as measured with the Spinal Cord Injury Functional Ambulation Inventory (SCI-FAI).

Design: Prospective observational cohort.

Setting: Seven outpatient rehabilitation centers from the Christopher and Dana Reeve Foundation NeuroRecovery Network (NRN).

Participants: 249 NRN patients with American Spinal Injury Association Impairment Scale (AIS) level C (n = 20), D (n = 179)
and (n = 50) iSCI not AIS evaluated, from February 2008 through April 2011.

Interventions: Locomotor training using body weight support and walking on a treadmill, overground and home/community practice.

Main Outcome Measure(s): 10MWT and 6MWT collected at enrollment, approximately every 20 sessions, and upon discharge.

Results: The 10MWT and 6MWT speeds were highly correlated and the 10MWT speeds were generally faster. However, the predicted 6MWT gait speed from the 10MWT, revealed increasing error with increased gait speed. Regression lines remained significantly different from lines of agreement, when the group was divided into fast (≥0.44 m/s) and slow walkers (<0.44 m/s). Significant differences between 6MWT and 10MWT gait speeds were observed across SCI-FAI walking mobility categories (Wilcoxon sign rank test p<.001), and mean speed thresholds for limited community ambulation differed for each measure. The smallest real difference for the 6MWT and 10MWT, as well as the minimally clinically important difference (MCID) values, were also distinct for the two tests.

Conclusions: While the speeds were correlated between the 6MWT and 10MWT, redundancy in the tests using predictive modeling was not observed. Different speed thresholds and separate MCIDs were defined for community ambulation for each test.


Inter-rater reliability of the Neuromuscular Recovery Scale for spinal cord injury.
Basso, D. M., Velozo, C., Lorenz, D., Suter, S., & Behrman, A. L. Archives of physical medicine and rehabilitation 96.8 (2015): 1397-1403.

Objective: To determine the interrater reliability of the Neuromuscular Recovery Scale (NRS), an outcome measure designed to classify people with complete or incomplete spinal cord injury (SCI) into 4 phase-of-injury groups by assessing motor performance based on normal preinjury function and disallowing use of compensation for 4 treadmill-based items and 6 overground/mat items.

Design: Masked comparison, multicenter observational study.

Setting: Outpatient rehabilitation.

Participants: Raters (N=14) and a criterion standard expert assigned scores to 10 video NRS assessments of persons with SCI. The raters were volunteers from the NeuroRecovery Network.

Intervention: Not applicable.

Main Outcome Measure: Interrater reliability measured with the Kendall coefficient of concordance (W).

Results: Interrater reliability was generally strong (W=.91e.98; 95% confidence interval [CI], .65e.99), while lower reliability occurred for treadmill stand retraining (W=.87; 95% CI, .06–1) and seated trunk extension (W=.82; 95% CI, .28–.94). Less experienced raters assigned slightly lower scores than the expert for most items, but the difference was less than half a point and did not weaken concordance.

Conclusions: NRS had strong interrater reliability, a necessary first step in establishing its utility as a clinical and research outcome measure.


Test-retest reliability of the Neuromuscular Recovery Scale.
Behrman, A. L., Velozo, C., Suter, S., Lorenz, D., & Basso, D. M. Archives of physical medicine and rehabilitation 96.8 (2015): 1375-1384.

Objective: To determine the test-retest reliability of the Neuromuscular Recovery Scale (NRS), a measure to classify lower extremity and trunk recovery of individuals with spinal cord injury (SCI) to typical preinjury performance of functional tasks without use of external and behavioral compensation.

Design: Multicenter observational study.

Setting: Five outpatient rehabilitation clinics.

Participants: Physical therapists (N=13), trained and competent in conducting NRS, rated outpatients with SCI (N=69) using the NRS. Testing occurred on 2 days, separated by 24 to 48 hours, on the same patient by the same therapist.

Interventions: Not applicable.

Main Outcome Measures: Spearman rank correlation coefficients to compare NRS results. The NRS scores of motor performance were based on normal, preinjury function on 11 items: 4 treadmill-based items (standing and stepping), 7 overground/mat items (sitting, sit-up, reverse sit-up, trunk extension, sit to stand, standing, walking).

Results: Test-retest reliability was very strong for the NRS items. Ten of the 11 items exhibited Spearman correlation coefficients ≥.92, and lower bounds of the 95% confidence intervals (CIs) for these items met or exceeded .83. The exception was stand retraining (ρ=.84; 95% CI, .68–.96). The test-retest reliability of the measurement model-derived summary score was very strong (ρ=.99; 95% CI, .96–.99).

Conclusions: The NRS had excellent test-retest reliability when conducted by trained therapists in adults with chronic SCI across all levels of injury severity. All raters had undergone standardized training in use of the NRS. The minimal requirement of training to achieve test-retest reliability has not been established.


Validity of the Neuromuscular Recovery Scale: A Measurement Model Approach.
Velozo, C., Moorhouse, M., Ardolino, E., Lorenz, D., Suter, S., Basso, D. M., & Behrman, A. L. Archives of physical medicine and rehabilitation 96.8 (2015): 1385-1396.

Objective: To determine how well the Neuromuscular Recovery Scale (NRS) items fit the Rasch, 1-parameter, partial-credit measurement model.

Design: Confirmatory factor analysis (CFA) and principal components analysis (PCA) of residuals were used to determine dimensionality. The Rasch, 1-parameter, partial-credit rating scale model was used to determine rating scale structure, person/item fit, point-measure item correlations, item discrimination, and measurement precision.

Setting: Seven NeuroRecovery Network clinical sites.

Participants: Outpatients (NZ188) with spinal cord injury.

Interventions: Not applicable.

Main Outcome Measure: NRS.

Results: While the NRS met 1 of 3 CFA criteria, the PCA revealed that the Rasch measurement dimension explained 76.9% of the variance. Ten of 11 items and 91% of the patients fit the Rasch model, with 9 of 11 items showing high discrimination. Sixty-nine percent of the ratings met criteria. The items showed a logical item-difficulty order, with Stand retraining as the easiest item and Walking as the most challenging item. The NRS showed no ceiling or floor effects and separated the sample into almost 5 statistically distinct strata; individuals with an American Spinal Injury Association Impairment Scale (AIS) D classification showed the most ability, and those with an AIS A classification showed the least ability. Items not meeting the rating scale criteria appear to be related to the low frequency counts.

Conclusions: The NRS met many of the Rasch model criteria for construct validity.


A nonparametric analysis of waiting times from a multistate model using a novel linear hazards model approach.
Lorenz, D. J., & Datta, S. Electronic Journal of Statistics 9 (2015): 419-443.

Traditional methods for the analysis of failure time data are often employed in the analysis of waiting times of transient states from multistate models. However, such methods can exhibit bias when waiting times among model states are dependent, even when censoring is random. Furthermore, right-censoring can occur prior to entry into the transient state of interest, preventing the observation of transitions from the state and providing another potential source of bias. We introduce a nonparametric linear hazards model for waiting times from multistate models, analogous to Aalen’s linear hazards model for failure time data, where proper estimation can be carried out via reweighting, a method flexible enough to incorporate general forms of induced and other dependent censoring. We illustrate the approximate unbiasedness of the proposed regression coefficient estimators through a simulation study, while also demonstrating the bias arising from traditional Aalen’s linear hazards model estimators obtained from correlated waiting time data. Theoretical results for the parameter estimators are provided. The reweighted estimators are used in the analysis of two data sets, to identify predictors of ambulatory recovery in a data set of spinal cord injury patients receiving activity-based rehabilitation and to identify prognostic indicators for patients receiving bone marrow transplant.


Responsiveness of the Neuromuscular Recovery Scale During Outpatient Activity-Dependent Rehabilitation for Spinal Cord Injury
Tester, N.J., Lorenz, D.J., Suter, S.P., Buehner, J.J., Falanga, D., Watson, E., Velozo, C.A., Behrman, A.L., Basso, D.M. Neurorehabilitation and Neural Repair 30.6 (2016): 528-538.

Background. The Neuromuscular Recovery Scale (NRS) was developed by researchers and clinicians to functionally classify people with spinal cord injury (SCI) by measuring functionally relevant motor tasks without compensation. Previous studies established strong interrater and test-retest reliability and validity of the scale.

Objective. To determine responsiveness of the NRS, a version including newly added upper-extremity items, in an outpatient rehabilitation setting.

Methods. Assessments using the NRS and 6 other instruments were conducted at enrollment and discharge from a locomotor training program for 72 outpatients with SCI classified as American Spinal Injury Association Impairment Scale grades A to D (International Standards for Neurological Classification of Spinal Cord Injury). Mixed-model t statistics for instruments were calculated and adjusted for confounding factors (eg, sample size, demographic variables) for all patients and subgroups stratified by injury level and/or severity. The resulting adjusted response means (ARMs) and 95% confidence intervals (CIs) were used to determine responsiveness, and significant differences between instruments were identified with pairwise comparisons.

Results. The NRS was significantly responsive for SCI outpatients (ARM = 1.05; CI = 0.75-1.35). Changes in motor function were detected across heterogeneous groups. Regardless of injury level or severity, the responsiveness of the NRS was equal to, and often significantly exceeded, the responsiveness of other instruments.

Conclusions. The NRS is a responsive measure that detects change in motor function during outpatient neurorehabilitation for SCI. There is potential utility for its application in randomized controlled trials and as a measure of clinical recovery across diverse SCI populations.


Assessment of functional improvement without compensation for human spinal cord injury: extending the Neuromuscular Recovery Scale to the upper extremities
Harkema, S.J., Shogren, C., Ardolino, E., Lorenz, D. J. Journal of Neurotrauma 33.24 (2016): 2181-2190. doi:10.1089/neu.2015.4213.

The Neuromuscular Recovery Scale (NRS) is tool for measuring functional recovery in spinal cord injured (SCI) individuals based on tasks that test pre-injury functional capability. The NRS has been shown to be a valid, reliable, and responsive instrument for measuring functional recovery. The NRS has been updated to include three items measuring upper extremity function, and a new scoring mechanism defined. The purpose of this prospective, observational study was to explore the properties of the expanded NRS, introduce and evaluate the new scoring method, and to examine the score’s relationship with other SCI outcome measures. The NRS and seven other SCI outcome measures were assessed at enrollment and after every 20 locomotor training sessions in 64 participants of the NeuroRecovery Network (NRN) of the Christopher and Dana Reeve Foundation (CDRF). The NRS exhibited a dominant first principal component that correlated strongly with the new NRS score, as well as a potential secondary component discriminating upper extremity function. The new NRS score and its empirical subscales were generally well-correlated with International Standards for the Neurological Classification of Spinal Cord Injury (ISNCSCI) motor scores and other established SCI functional measures, but exhibited substantial variability at their boundary values. The NRS score was more strongly correlated with other SCI functional measures than ISNCSCI motor scores were. The new NRS score was most responsive to change brought on by locomotor training. The expanded NRS appears to be a valuable tool in measuring functional recovery from SCI; further evaluation of its psychometric properties is warranted.


The Development and Initial Validation of the Pediatric Neuromuscular Recovery Scale.
Ardolino, E.M., Mulcahely M.J., Trimble S.A., Bienowski M., Mullen C., Argetsinger L., Behrman A.L. Pediatric Physical Therapy 28.4 (2016): 416-426.

Purpose: The Neuromuscular Recovery Scale (NRS) was developed to assess the capacity of adults’ post-spinal cord injury (SCI) to perform functional tasks without compensation. Application of the NRS to children has been challenging. The purpose of this study was to develop and complete the initial validation of a pediatric version of the NRS.

Methods: First, the investigative team developed a draft Pediatric NRS. Next, a Delphi method was used to amend the draft by 12 pediatric experts. Finally, the revised Pediatric NRS was field-tested on a sample of children with SCI (n = 5) and without (n = 7).

Results: After the Delphi process and field testing, the Pediatric NRS consists of 13 items scored on a 12-point scale. All items, except 1, achieved 80% agreement by experts.

Conclusions: This is the first step in development and validation of a pediatric SCI scale that evaluates neuromuscular capacity, in the context of pediatric function, without compensation.


Establishing the NeuroRecovery Network Community Fitness and Wellness facilities: multi-site fitness facilities provide activity-based interventions and assessments for evidence-based functional gains in neurologic disorders.
Tolle, H., Rapacz, A., Weintraub, B., Shogren, C., Harkema, S. J., & Gibson, J.L. Disability and Rehabilitation (2017); DOI: 10.1080/09638288.2017.1365178

Background: Physical fitness is a necessity for those living with a spinal cord injury, yet access to fitness facilities, equipment, and specially trained fitness experts are limited.

Methods: This article introduces the concept of a network of fitness facilities specially geared towards individuals with spinal cord injury and other neurological disorders.

Results: The Community Fitness and Wellness branch of the NeuroRecovery Network was created to provide a continuum of care after traditional rehabilitation for individuals living with a spinal cord injury and other neurological disorders. Community Fitness and Wellness facilities translate activity-based interventions performed during rehabilitation into a community setting as well as provide other fitness and wellness opportunities. Community Fitness and Wellness facilities are staffed by professionals with training on the specialized needs of individuals living with spinal cord injury or other neurological disorders. Standardized assessments evaluate functional, health, and quality of life gains at regular intervals. A national database gathers information on standardized interventions and assessment outcomes providing a mechanism for evaluation of interventions performed in the community setting.

Conclusions: The establishment of Community Fitness and Wellness facilities allows for the rapid translation into practice and the real-world evaluation of novel, effective approaches developed in a research setting to individuals in their communities.


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