ADVANCING THE PRACTICE OF ACTIVITY BASED THERAPY AND NEURO-MODULATION FOR THE RESTORATION OF UPPER LIMB FUNCTION AFTER SPINAL CORD INJURY

U. Gopaul¹, M. Bayley¹, S. Kalsi-Ryan¹

¹University Health Network, Toronto Rehabilitation Institute-KITE Research, Toronto, Canada

Background: Improving hand and arm function is an important goal for individuals with tetraplegia. Activity Based Therapy (ABT) is a method of neurorehabilitation that incorporates a high intensity, long duration and effortful engagement from the individual receiving therapy, to garner improvements in sensory and motor function. Transcutaneous spinal cord stimulation (TCSCS) is a method to neuromodulate nerves through surface electrodes placed directly over the spinal cord to improve function.

Purpose: To report a Phase 1 study on the development and design of a complex intervention delivering an Activity Based Therapy and Neuromodulation (ABTaN) program designed for restoration of the upper limbs (UL) for individuals with tetraplegia (traumatic and non-traumatic SCI), using the Rehabilitation Treatment Specification (RTS) System.

Methods: In line with the revised Medical Research Council guidelines, the ABTaN was developed in a Phase 1 study through the following stages: 1) Generating the components and the active ingredients; 2) Determining the mechanism of actions and; 3) Determining the treatment targets of the ABTaN program. The RTS system was used to describe the tripartite structure of the ABTaN program. We have also developed a detailed treatment regimen guidelines for the delivery of the ABTaN to facilitate standardization of therapy. The therapy program will be customized for each patient.

Results: The RTS of the ABTaN program constitutes: 1)Active ingredients: Four components of the ABT program include: strengthening exercises (20 minutes), postural and weight-bearing exercises (20 minutes), cardio-fitness exercises (10 minutes) and functional/task specific exercises (25 minutes). Cervical TCSCS is delivered between the C3 and C7 vertebrae, using the MyndSearch stimulator in a continuous mode of balanced biphasic waveforms at a frequency of 30-50 Hz with a pulse width ranging from 500-1000 µs. Intensity is initially set at 5mA, which is progressively increased to an intensity at which task performance is easiest. Treatment schedule is thrice a week for 14 weeks (ABT alone-4 weeks, followed by combined ABT and cervical TSCSC-10 weeks), 2) Mechanism of actions: The ABT program targets the neuro-restoration process to improve the neurological deficit by restoring motor strength and sensory function, which then translates to physical independence and function. Cervical TCSCS targets the neuromodulation process to alter nerve activity by modulating abnormal neural pathway; 3) ABTaN targets improvement in: UL strength, sensory and motor function during grasp, grip, pinch, object handling and manipulation, fine-motor coordination and dexterity. The overarching rehabilitation goals of the ABTaN program are to enhance independence, function and restore neurological deficit of the UL after SCI.

Conclusions: It is feasible to combine ABT with cervical TSCSC for restoration of the UL for individuals with tetraplegia. The RTS system is an efficient way to specify treatment ingredients and targets for the development and design of a complex ABTaN UL intervention used in Phase I trials in SCI research.

Implications: The feasibility and efficacy of the ABT program is ready to be evaluated in a Phase 2 trial. This study contributes towards building the evidence about the implementation of cervical TCSCS combined with effective rehabilitation approaches to restore UL function in tetraplegics.

Funding acknowledgements: Ontario Neurotrauma Foundation

Keywords:
Spinal cord injury
Spinal cord stimulation
Activity-based therapy

Topics:
Neurology: spinal cord injury
Disability & rehabilitation

Did this work require ethics approval? Yes

Institution: University Health Network

Committee: Research Ethics Board

Ethics number: UHN REB #20-6276