Outcomes of Activity-Based Locomotor Training in 3 Children with Spinal Cord Injuries Acquired before age 1 year.

Case Study Report
Population: Pediatric

MacKenzie T Roberts, DPT, Research Physical Therapist, Frazier Rehab Institute mackenzieroberts@kentuckyonehealth.org

Shelley Trimble, PT, Pediatric NeuroRecovery and Translational Research Specialist, Frazier Rehab Institute shelleytrimble@kentuckyonehealth.org

Laura Argetsinger, DPT, Physical Therapist, Frazier Rehab Institute lauraargetsinger@kentuckyonehealth.org

Emily Fox, PT, DPT, PhD, NCS, Research Assistant Professor, University of Florida ejfox@phhp.ufl.edu

Sarah Suter, PT, Physical Therapist, University of Florida spstic@phhp.ufl.edu

Keywords: Plasticity, Activity-Based Therapies, Outcomes, Trunk Control

Background and Purpose: The catastrophic impact of spinal cord injury (SCI) in young children (Schottler 2012) is magnified not only by abrupt interruption of growth and development, but also by the effects of ongoing maturation. Children injured prior to age 5 have a 96% chance of developing scoliosis and a 57% chance of developing hip dysplasia (Schottler 2012). Beyond skeletal muscle paralysis, ramifications to other physiological systems (e.g., respiratory, urinary) are devastating and, again, compounded for those injured at a very early age. Typical rehabilitation after SCI teaches compensatory strategies, braces weak and paralyzed muscles, and strengthens muscles above the lesion. Activity-Based Locomotor Training (AB-LT) is an intervention developed for adults with SCI to activate the SC below the lesion to promote neuromuscular recovery and functional gains (Harkema 2012). Translation to a child with chronic SCI, injured at 3 yrs, demonstrated significant gains with AB-LT (Behrman 2008). Our purpose is to describe the effects of AB-LT on children with chronic SCIs acquired prior to 1 yr old.
Case Description: Three children injured prior to 1 yr (birth, 2 mos, 6 mos; respectively) enrolled in either a clinical program (n=2) or research study (n=1) where they received AB-LT. Mean time since injury at start of AB-LT was 2 yrs, 2 mos. Patients had cervical (n=2) or thoracic (n=1) injuries and were non-ambulatory. No voluntary movement was demonstrated below the lesion and all demonstrated clonus. None could sit independently without arm support nor stand without external support (i.e., stander). Mobility was by power wheelchair/KidKart™ (n=1) and stroller (n=2). AB-LT was conducted with the same protocol in the clinic and research settings for 5 dys/wk (Behrman 2008). Training was divided between step and stand training on the treadmill (1 hr), followed by assessment of skill development off the treadmill (e.g., sitting, standing, stepping) and community integration. Parents reported lack of bladder control. All patients had previously received therapeutic interventions.
Outcomes: Mean AB-LT sessions received was 93 [53-120]. All patients demonstrated improved trunk control; clinical patients improved 3/20 and 9/20 on the Segmental Assessment of Trunk Control and research patient through improved functional abilities. Parents reported improved trunk and bladder control and other functional gains, e.g., coming to sit, sit in grocery cart on own. One patient gained the ability to independently ambulate using a posterior rolling walker without braces and another the ability to step in a context-dependent environment without braces. One child progressed from power wheelchair mobility to independent manual wheelchair propulsion.
Discussion: Three children injured before age 1 year and never expected to get better, improved dramatically following AB-LT and in contrast to the outcomes from previous therapies. The potential change in trajectory for improved quality of life, function and health with reduced health care costs is tremendous, however, yet to be demonstrated.

Roberts, MacKenzie T, DPT; Trimble, Shelley A, PT; Argetsinger, Laura C, DPT; Fox, Emily J, PT, DPT, PhD, NCS; Suter, Sarah , PT. Outcomes of Activity-Based Locomotor Training in 3 Children with Spinal Cord Injuries Acquired before age 1 year.. Poster Presentation. IV STEP Conference, American Physical Therapy Association, Columbus, OH, July 17, 2016. Online. https://u.osu.edu/ivstep/poster/abstracts/072_roberts-et-al/