Feasibility of complex exercise therapy with Standing Ovation and peripheral neuromodulation for gait rehabilitation after incomplete spinal cord injury—a case report

main topic Wien Med Wochenschr https://doi.org/10.1007/s10354-024-01046-8 Feasibility of complex exercise therapy with Standing Ovation and peripheral neuromodulation for gait rehabilitation after incomplete spinal cord injury—a case report Anna Pataraia · Winfried Mayr · Jose Luis Vargas Luna · Julia Sternik · Richard Crevenna Received: 16 February 2024 / Accepted: 2 May 2024 © The Author(s) 2024 Summary Background Spinal cord injuries (SCIs) are a global concern, annually affecting hundreds of thousands of individuals. Among these cases, incomplete SCIs, allowing some muscle activity below the injury, pose unique challenges. This case study focuses on a 55year-old male with a moderate incomplete SCI (AISD). Case presentation After initial treatments and pharmaceutical antispastic therapy, a novel intervention was introduced featuring the Standing Ovation gait exercise system (Standing Ovation GmbH, Hallwang, Austria). This individually tailored system, equipped with a rail system and seat-lifting unit, provided a secure environment for balance training. Over 14 training sessions spanning from October 13, 2021, to March 23, 2022, improvements in functional walking were observed. Discussion and conclusion Locomotor improvement in SCI rehabilitation is important; the potential of task-specific gait exercises with the Standing Ovation system in incomplete spinal cord injury seems to be a promising approach. Although promising, these findings call for further systematic studies with larger A. Pataraia, MD · W. Mayr · J. L. Vargas Luna · J. Sternik · R. Crevenna Department of Physical Medicine, Rehabilitation and Occupational Medicine, Medical University of Vienna, Vienna, Austria W. Mayr Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria A. Pataraia, MD () Department of Physical Medicine, Rehabilitation and Occupational Medicine, Medical University of Vienna, Währinger Gürtel 18–20, 1090 Vienna, Austria K patient cohorts to strengthen their reliability. Ongoing research endeavors are essential to fully understand the benefits and limitations of this intervention in spinal cord injury rehabilitation. Keywords Spinal cord injury · Exercise therapy · Standing Ovation · Neuromodulation Background Spinal cord injuries (SCIs) frequently lead to mobility constraints, reduced physical activity levels, and, consequently, a diminished quality of life [1, 2]. Every year, an estimated 250,000 to 500,000 new SCIs occur globally [1]. Approximately one third of these cases involve incomplete lesions, allowing for some muscle activity below the affected area [3]. In comparison to complete injuries, incomplete SCIs tend to be less severe, although patients still encounter limitations in various aspects of their lives, with an increased vulnerability to falls [4–7]. The most conspicuous sign of SCI is impaired locomotion, often accompanied by additional medical complications such as an elevated risk of fractures. Recognizing the complex nature of these challenges, efforts to enhance quality of life for individuals with incomplete or complete SCIs have evolved over time. The focus has shifted from merely extending life expectancy to facilitating independent living and an optimal quality of life. In this context, we present a case study of a patient with a moderate incomplete SCI (AIS-D). This individual engaged in task-specific overground gait exercises aimed at promoting locomotor improvement (Fig. 1). These exercises hold promise as a therapeutic approach to address the challenges posed by SCI and enhance walking ability in individuals with incomplete injuries. Feasibility of complex exercise therapy with Standing Ovation and peripheral neuromodulation for gait. . . main topic a b Fig. 1 a, b Exercise therapy in Standing Ovation (Standing Ovation GmbH, Hallwang, Austria). (Patient receives tailored physical therapy with simultaneous electrical stimulation to improve gait and reduce spasticity) Case presentation A 55-year-old male with an incomplete SCI below C6 after a diving injury (acute decompression syndrome) underwent initial treatment with decompression therapy and inpatient spinal cord rehabilitation. Two years later he was referred to the Department of Physical Medicine, Rehabilitation and Occupational Medicine, Medical University of Vienna, Austria, for spinal cord stimulation for spasticity reduction. At the time of first presentation, the patient had reduced ambulatory performance and endurance, muscle rigidity, reflex hypertonia, peroneal paresis on both sides, mild spasticity of the legs, and bladder dysfunction. His gait was impaired due to mild spasticity while walking as well as peroneal paresis. Since the very beginning of the injury, the patient had had antispastic treatment with baclofen 75 mg/d. Brain motor control assessment (BMCA) was performed, and the patient was instructed for afferent stimulation, but the home program was not regularly carried out. BMCA is a method to record electrical activity from selected muscles through surface electromyography (EMG) during the performance or attempted performance of volitional and reflex motor tasks [8]. It is used to characterize impaired motor control below the lesion and also to quantify changes induced by clinical interventions. As spasticity was not severe, the patient was asked to slowly taper and stop baclofen, and the intervention with the Standing Ovation stance and movement support system (Standing Ovation GmbH, Hallwang, Austria) was started. Standing Ovation is an individually adapted rail system with a seat-lifting unit, which allows a three-dimensional movement pattern, reduces the additional strain on the legs, and prevents fall risks during exercising. Fourteen training units were performed with interruptions (due to the pandemic lockdowns and strict testing regulations) between October 13, 2021, and March 23, 2022. In addition, a subthreshold afferent stimulation of the peroneal nerve was applied using a Cefar Rehab X2 stimulator (DJÖ FRANCE, Mouguerre, France) and bilateral hydrogel stimulation electrodes (Axion GmbH, Leonberg, Germany), one with a 3.2 cm round electrode (anode first phase) placed over the peroneal nerve proximally to the lateral fibular head, and a counter electrode 50 × 50 mm positioned at the proximal third of the tibialis anterior muscle. The stimulator delivered continuous trains of biphasic rectangular charge-balanced pulses with a phase duration of 400 µs and a frequency of 30 Hz. Intensity was adjusted to a slightly subsensory threshold. The patient applied stimulation during overground gait episodes in both in-home and wildlife environments for up to 2 h, but not on a consequently documented regular basis. Exercising secured by the Standing Ovation device provided secure conditions for complex balance skill exercising and showed promising developments in terms of restoring functional walking, which enabled him to (...truncated)