Activity-based Therapies in Spinal Cord
Injury: Clinical Focus and Empirical
Evidence in Three Independent Programs
Michael L. Jones, PhD,1 Eric Harness, CSCS, CSRS III,2 Paula Denison, PT, OMPT,3
Candy Tefertiller, DPT, ATP, NCS,4 Nicholas Evans, MS,5
and Cathy A. Larson, PT, PhD3
Virginia C. Crawford Research Institute, Shepherd Center, Atlanta, Georgia; 2Project Walk, Spinal Cord Injury Recovery Center,
Carlsbad, California; 3Center for Spinal Cord Injury Recovery, Rehabilitation Institute of Michigan, Detroit, Michigan;
4
Craig Hospital, Englewood, Colorado; 5Beyond Therapy Program, Shepherd Center, Atlanta, Georgia

1

This article summarizes presentations of a symposium examining the potential impact of activity-based therapies (ABT) in
promoting neurological and functional recovery after spinal cord injury (SCI). The symposium addressed 3 key questions
concerning activity-based therapy in SCI: (1) What clinical approaches are used? (2) Is there empirical evidence supporting
efficacy of ABT in promoting neurological recovery and improving overall function, health, and quality of life? (3) What are
the issues related to long-term viability of ABT? Key words: activity-based therapy, fitness and health, functional recovery,
neurologic recovery, quality of life, spinal cord injury, therapeutic exercise

A

ctivity-based therapy (ABT) refers to“interventions that target activation of theneuromuscular system below the level ofthe lesion, with the goal of retraining the nervous
system to recover a specific motor task.”1 Intense
physical activity has been shown to improvephysiological function and health outcomes inindividuals with chronic (> 1 year postinjury)
spinal cord injury (SCI). The effects of intense
activity on neurological and functional recovery,
however, have not been fully investigated nor
verified.
This article summarizes presentations of a
symposium examining the potential impact of
ABT in promoting neurological and functional
recovery after SCI. The symposium addressed
3 key questions concerning ABT in SCI: (1)What clinical approaches are used? Principles
and techniques used in 3 independent programs– Project Walk, the Center for SCI Recovery at
the Rehabilitation Institute of Michigan, andShepherd Center’s Beyond Therapy program – arecompared and contrasted. (2) Is there empiricalevidence supporting efficacy of ABT in promoting
neurological recovery and improving overall
function, health, and quality of life? Preliminary
findings from each program are presented. (3)What are the issues related to long-term viability

34

of ABT? Discussion focused on determining
who benefits from ABT, gauging the point ofdiminishing return with respect to functional
recovery, and strategies for maintaining any gains
achieved from therapy.
Description of Activity-Based
Therapy Programs
Project Walk is an outpatient facility in Carlsbad,
California, that has been treating persons with SCI
since 1999. From its inception, Project Walk has
seen more than 1,000 individuals with SCI fromaround the world. Requirements to participate
in the program are an SCI C2 or lower, non–ventilator-dependent, and a physician’s clearance
for intensive exercise.
Project Walk originated from a sports training
philosophy of designing programs aroundreturning athletes to their respective competition;for SCI, this would be walking. As the founders had
no real prior knowledge of what could or could
not be accomplished with SCI, the goal was always
Top Spinal Cord Inj Rehabil 2012;18(1):34–42© 2012 Thomas Land Publishers, Inc.
www.thomasland.com
doi: 10.1310/sci1801-34

Activity-based Therapies

to attempt to regain function below the level of
injury. This was initially accomplished throughtrial and error; what worked with some clientswould not work with others. Over time, morestructured guidelines were developed to assist
with determining what modalities would be mostappropriate for the functional abilities of eachclient. These guidelines became the basis for the
5 phases of recovery and associated intervention
approaches:• Phase I/II: Reactivation/Reorganization &Development/Stabilization – Stimulate thenervous system with active assistive exercise
and use developmental sequencing to develop
joint stabilization.
• Phase III: Strength – Initiate eccentric andconcentric muscle contractions throughpositional movement or stimulation.
• Phase IV: Function and Coordination –Improve coordinated movement throughall planes of movement and motion. Most
exercises are performed in a load-bearing
position, mainly free standing.
• Phase V: Gait Training – Focus on proper
gait mechanics and the ability to move overground in multiple planes of motion.
Several modalities are used to implement thephases of recovery. The most basic modality is
active assistive exercise or what Project Walk terms
active nervous system recruitment (ANSR). Thisis used when clients have little to no voluntary
movement and consists of helping the client
through different ranges of motion and providinga resistance less than gravity. Clients are instructed
to attempt or visualize actively assisting or resisting
the movement performed. ANSR attempts toprovide a sensory stimulus and elicit a motor
response. The goal is to generate patterned neuralactivity2 and ultimately, using a high number ofrepetitions, long-term potentiation.3 Load-bearing
exercises or developmental movement patterns(DMPs) are used at all levels of motor function andare characterized by the hands or elbows and/or
feet or knees in contact with the ground, with somepercentage of body weight supported through theextremities. DMPs consist of pushing the torso
up out of a prone position, sitting unsupported,
elbows/hands and knees position (“on all fours”),
high kneeling, standing, and walking. These

35

movements and positions are designed to mimic
the human developmental process. Project
Walk also includes many technologies in clients’programs including body weight support treadmill
training (Robomedica; Robomedica Inc, San Viejo,
California), partial body weight loading (Total
Gym; Total Gym Fitness), whole body vibration(PowerPlate; Power Plate North America, Irvine,
California), FES (RT300; Restorative Therapies,
Baltimore, Maryland), assisted standing/ squats(EasyStand Evolv; Altimate Medical, and Keiser
Power Rack; Keiser Corportation), and a fullcomplement of resistance training equipment.
Each client is evaluated upon entry to theprogram and every 3 to 6 months thereafter. Fromthe initial evaluation, it is determined in whichof the 5 phases of recovery the client is placed. A
client will provide one or more long-term goals,
and the training specialist will break these down
into short- and medium-term goals that align withthe phase(s) in which the client has been placed.
Although clients are formally evaluated every 3 to
6 months, they are also being informally evaluatedon a daily basis. If a client shows new activity in a
muscle or new functional abilities, the specialists
have the freedom to change a client’s program.
The Center for SCI Recovery – Rehabilitation
Institute of Michigan started in Detroit in 2004.
The Center was developed as an extension of
the continuum of care to provide people withSCI an opportunity to continue working towardfunctional recovery in an intense, recoveryfocused therapy program. Three major guidelines
were used in developing the program: (1) anemphasis on recovery versus compensation, (2)a concentration of treatment below the level of
injury, and (3) a high dosage/intensity of physicalrehabilitation. The overall goal is to facilitate
neural plasticity using treatment activities basedon forced use of involved areas,4,5 central patterngeneration,6,7 and an enriched environment.8,9Duration, session length, and intensity ofrehabilitation need to be longer to promote neuralplasticity compared to traditional rehabilitation,but effective dosage elements are far from clear.
Therefore treatment parameters are based partly
on practicality. Treatment intensity is 3 hours/
day, 3 to 5 days per week. Optimal duration oftherapy varies, because progress is expected to be36

Topics in Spinal Cord Injury Rehabilitation/Winter 2012much slower and it is difficult to determine whena plateau is reached. The staffing model consists ofphysical therapists working with athletic trainersand exercise physiologists. This addresses the labor
intensity and contributes to a desired fitness-type
environment. The recovery focus of the program
refers to potential neurological improvement,
but functional recovery is expected. The program
appeals to a sense of optimism and hope that is far
from guaranteed and, therefore, care is taken insetting expectations for recovery.
Therapeutic techniques and equipment used
are somewhat varied in keeping with the conceptof an enriched environment. Locomotor activities
include body weight support treadmill training
and overground walking with or without assistive
devices and with or without overhead support.
Developmental activities include crawling withor without body support, kneel walking, and avariety of mat activities designed to build corestrength and trunk stability. Whole body vibration
is used to decrease spasticity or increase muscle
activity prior to other activities, primarily walking.
Supplemental activities include FES cycling,strengthening exercises with resistance or withactive assistance using, among other equipment,
an overhead strap/sling system, stretching, balance
activities, and other specific interventions as
indicated by individual needs.
Shepherd Center’s Beyond Therapy Program
was developed in June 2005 in response to thegrowing number of requests from former patients
to participate in an activity-based exercise program
following their traditional course of rehabilitation.
Optimizing functional recovery and decreasing
the likelihood of secondary complications thattypically occur among people with neurologicaldisorders are central objectives of the program.
Program staff consists of therapists who
specialize in exercise physiology and physicaltherapy. The program combines the concepts ofathletic training and physical therapy to promoteneural plasticity in the injured nervous system.
Clinicians integrate the neural development andstrength goals of each client into an intensive
rehabilitation program, incorporating the useof innovative treatments and technologies
designed to facilitate some level of recovery. The
approaches used in the program originate from

3 primary concepts believed to be important toneurorecovery: (1) developmental sequencing/core rehabilitation focused on strengthening the
primary stabilizing muscles of the trunk and pelvis
because of their central role in core stability; (2)repetition and patterned motor activity; and (3)functional training and task specificity. Locomotor
training is a task-specific practice and an importantcomponent in the training plan of those clients
who present with an AIS C or D injury.
Each client entering the program is evaluatedby a physical therapist who designs an intense
9 hour per week program that combines the 3
primary concepts described above in ratios thatare appropriate for their current level of function.
Even though each client receives individualized
treatment, the program and subsequent
progression is based on a clinical algorithm basedon the client’s functional status (Table 1) andappropriate clinical decision making by a skilled
therapist. Clients progress through the levels oftreatment as they demonstrate neuromuscular
and/or functional improvement. The treatment
algorithm is based on current evidence as well
as clinical experience and divides a client’s totaltreatment time into developmental sequencing,strengthening, and locomotor training.
Evidence of Clinical Efficacy
Several studies have been published on the ABT
performed at Project Walk. Harness et al10 looked
at 21 ABT subjects and 8 controls over a 6-monthtime course. Outcome measures pre and post were
ASIA motor and sensory scores, CHART (Craig
Handicap Assessment and Reporting Technique),and the EQ-5D thermometer. CHART and EQ-5D(self-rated general health assessment) scores
were not significantly different between ABT andcontrols after 6 months. However, ABT subjects
showed significantly greater gains than controls
during the 6-month interval for total ASIA motorscore (4.8±4.5 vs -0.1±1.45; P < .001); 71% of theABT participants had an increase in total ASIA
motor score. As noted in Figure 1, this change
in score correlated significantly with total timespent in the ABT program (P < .02). The mean
increase in total ASIA motor score was 4.8 points.
Note that these total ASIA motor score gains inActivity-based Therapies

37

Table 1. Clinical algorithm for client placement and prescription of treatment

Level

Client functional status

Development
sequencing

Strengthening
exerciseLocomotor training (LT)1

Demonstrates complete loss of motorand sensory function below injury level(LOI)

4 hours

5 hours

None

2

Demonstrates complete loss of motor
function but sacral sparing below LOI

3 hours

3 hours

1 hour full weight bearing/standing using
FES to appropriate muscle groups; 2 hours
robotic LT

3Able to initiate one step without
assistance and walk less than 50 ft withphysical assistance

2 hours

3 hours

2 hours robotic or manual LT; 2 hours overground gait training using FES

4Able to walk > 50 ft with 1-person
assistance

2 hours

2 hours

2 hours robotic or manual LT; 3 hours
overground gait training using FES

5Able to walk > 150 ft without physicalassistance

1 hour4 hours resistanceand plyometrictraining

2 hours LT with or w/out body weightsupport; 2 hours overground gait training
using FES

Note: FES = functional electrical stimulation.

ABT subjects varied in relation to baseline deficits:
subjects who were motor complete (AIS A or B,
n=12), as compared to subjects who were motor
incomplete (AIS C or D, n=9), had significantly
less gains (2.8±4.32 vs 7.4±3.3; P < .02), a finding
entirely attributable to changes in lower extremity
motor scores.

Yozbatiran et al11 found increases in lower
extremity isometric strength in 21 participants
after 6 months of training. This change in force
production correlated significantly with changes
in total ASIA motor score (P < .001). Alterations inlower extremity lean body mass (LBM) and bonedensity have also been observed over 6 months in

Figure 1.

Figure 1. Changes in ASIA Motor score as a function of exercise.

38

Topics in Spinal Cord Injury Rehabilitation/Winter 2012

Figure 2. Total Larson Basic Movement Skills Inventory (BMSI).

a single C5 ASIA A participant .12 Lower extremity
LBM increased by 11% and distal femur bonedensity increased by 10% with training.
The Rehabilitation Institute of Michigan
has completed an analysis of outcomes for 23
participants in the CSCIR program. Average age
at program initiation was 30.1 ± 9.8 years andtime since injury averaged 5.1 ± 6.4 years. SCI
levels ranged from C4 to T11; 13 participants
experienced tetraplegia and 10 paraplegia. Fourteen
participants had ASIA Impairment Scale (AIS)
classification of A, 2 AIS B, 5 AIS C, 1 AIS D, and1 cauda equina. Participants engaged in intensive
ABT for an average of 7.1 ± 1.7 hours per week
over an average of 4.6 ± 2.8 months. Total hours oftherapy averaged 137.3 ± 83.9. Multiple outcome
measures were assessed for each participantpre- and posttreatment. Results reported here
include mat mobility, overground ambulation, life
satisfaction, physical independence, and mobilitychanges over the course of therapy.

The Larson Basic Movement Skills Inventory(LBMSI) was used to assess mat mobility skills.
Participants were observed while assuming,
maintaining, and performing closed-chain
activities in various positions for 25 mat mobility
skills (eg, prone on elbows, sitting, hands andknees, kneeling and standing). Physical assistance(PA) required during the performance of each mat
skill was recorded using a 7-point ordinal scale(FIM PA scale). From initial examination (IE)
to discharge (DC) examination, all 23 subjects
demonstrated significant improvement (Z = -4.1;
P < .005) in total LBMSI scores (Wilcoxon signed
ranks test), and in the assume, maintain, andclosed-chain subscores (P < .005). Figure 2 showschanges in LBMSI scores for each participant oversubsequent 30-day test intervals.
The Satisfaction with Life Scale (SWLS) wasused to measure life satisfaction and the CHART
was used to measure physical independence(paid and unpaid care needed, assistance neededActivity-based Therapies

39

Table 2. Demographic and baseline information

Age, years
GenderTime postinjury, months
Tetraparesis/paraparesis
AIS Classification
ASIA Motor
ASIA LEMS
SCIM II

Experimental(n = 11)

Control(n = 15)P

44.9 ± 13.6
M = 11 / F = 0
107.0 ± 158.7
11/0
C=4/D=7
60.4 ± 16.7
26.6 ± 12.8
59.0 ± 19.4

32.6 ± 11.9
M=7/F=849.2 ± 56.0
13/2
C=8/D=7
59.6 ± 17.3
25.9 ± 11.8
66.7 ± 21.9

.02
<.01
.21
.21
.39
.91
.88
.36

Note: Values are mean ± SD or number of participants. AIS = ASIA Impairment Scale; LEMS = lower
extremity motor score; SCIM II = Spinal Cord Independence Measure (version II).

for grocery shopping, laundry, housekeeping,or medical needs), mobility (frequency of social
interactions, in-home and transportation access,and assistance needed), and occupation (timespent on job, school, recreational, volunteer
activities). From IE to DC examination, there was anonsignificant trend (P = .06) for the group (n=21)
to improve in SWL scores. From IE to DC, CHART
physical independence subscores improved (P =.03), mobility subscores improved (P = .05), andoccupation subscores did not improve (P = .59).
Six of the 23 participants succeeded in obtaining
ambulation overground (4 paraplegic, 2 tetraplegic;
5 incomplete and 1 complete SCI). For participants
who ambulated, 3- or 6-minute walk tests13,14 wereadministered every 30 days. Ambulation velocity
did not improve (Z = -1.2; P = .25), but distance
did improve (Z = -2.2; P = .02) over the courseof therapy (Wilcoxon signed ranks test). Distanceincreased, on average, 16.7 ± 10.8 m every 30 days.
Three of the 6 ambulatory participants progressed
to a less restrictive assistive or orthotic device,
and 4 of 6 decreased in the amount of physicalassistance (PA) required.
In late 2008, Shepherd Center initiated aprospective, randomized clinical trial to evaluate
empirically the effects of participation in an
intensive, ABT program for individuals withchronic (> 1 year postinjury), motor incomplete
SCI (AIS C or D). To date, 45 individuals havebeen enrolled in the trial, which is examining theeffectiveness of an intensive (9 h/wk), 24-week

ABT program targeting locomotor recovery.
Individualized treatment and progression intreatment was provided based on the parameterspresented in Table 1. Preliminary findings for the
first 26 participants to complete the program arepresented here. Table 2 presents basic demographic
and baseline clinical information for this sample.
The experimental and control groups varied
significantly in age and gender but were essentiallyequivalent in baseline ASIA Motor and Spinal
Cord Independence Measure (version II) scores.
A multitude of outcome measures have beencollected for the trial. For experimental participants,
outcome measures were collected before and after
the 24-week intervention. For control participants,
measures were collected before and after a 24-week
delay in starting the intervention. During the delay,
they were allowed to continue with any exercise or
therapy activities they were already conducting.
Several participants reported training to “getready” for participation in the trial.
Presented in this preliminary analysis are preand posttest differences in motor function (ASIA
Motor Score and LEMS), functional independence(SCIM II), and walking (10-Meter Walk, 6-MinuteWalk, and Timed Up & Go tests). An adaptationof the Spinal Cord Injury Functional Ambulation
Inventory (SCI-FAI)15 was used to account forchanges in the use of assistive devices during
walking and to assess qualitative aspects of gait.
Video clips of participants taken during pre- andpostwalking tests were simultaneously viewed and40

Topics in Spinal Cord Injury Rehabilitation/Winter 2012

Table 3. Changes in primary outcome measures

ASIA Motor
ASIA LEMS
SCIM II
10- Meter Walk (m/min)
6-Minute Walk (ft)Timed Up & Go (sec)SCI-FAI (max = 34)

Experimental(n = 11)

Control(n = 15)P

5.7 ± 7.3
3.7 ± 5.9
2.7 ± 6.4
2.4 ± 7.4
68.0 ± 108.8-27.6 ± 86.5
3.9 ± 6.9

1.7 ± 4.6
0.3 ± 3.4
0.9 ± 4.5
0.6 ± 6.9
0.6 ± 90.2
-1.1 ± 5.9-0.5 ± 3.0

.10
.08
.39
.53
.10
.24
.11

Note: Values are mean ± SD. AIS = ASIA Impairment Scale; LEMS = lower extremity motor score;
SCIM II = Spinal Cord Independence Measure (version II); SCI-FAI = Spinal Cord Injury Functional
Ambulation Inventory.

independently rated by 2 raters who were blinded
to the timing of the video (pre- or posttest). The
Walking Parameters (weight shift, step width,
step rhythm, step height, foot contact, step
length) and Assistive Devices (upper extremity
balance/weightbearing; lower extremity orthosis)
components of the SCI-FAI were used and scores
summed for left and right side, for a maximum
score of 34.
Table 3 presents pre- to posttest differenceson each outcome measure. Although greater
improvements were noted for experimental versus
control participants on all measures, none of themean differences were statistically significant
and only changes in ASIA LEMS approachedsignificance. Several factors contribute to the lackof significance noted thus far including limited
sample size (about half of the final n needed basedon our preliminary power analysis) and highvariability in scores among participants.
Discussion
Differing in intensity and scope, the programs
presented here share similar therapeutic approaches
and modalities to promote functional recovery inindividuals with chronic SCI. Taken together,results from preliminary analyses of effectivenessoffer encouragement that ABT programs may be
useful to improve functional status after SCI. Gains
were noted in ASIA Motor scores, particularly
lower extremity motor scores, which might be

expected given the emphasis on walking recovery
that is integral to these programs. Improvements
in physical independence (SCIM II and CHART)and mobility (LBMSI) were noted, and modest
improvements in walking were observed amonga subset of program participants. Improvements
in muscle strength and bone density were also
reported, but participation in an ABT intervention
had little effect on perceived health and life
satisfaction.
Although the impact of ABT on functional
recovery – and particularly walking – appears to
be modest, it is important to note that these results
are for individuals with chronic SCI. Conventional
thinking is that functional recovery after the firstyear postinjury is limited. For example, Kirschblum
et al16 reported that 27% of their sample classified
as ASIA A and 58% classified ASIA B, C, or D
showed an increase in ASIA Motor score fromtheir 1-year to 5-year follow-up exam. The degreeof improvement was modest, however, with anaverage increase of 1.38 ± 6.22. This is comparablewith improvements noted by control group
participants presented here and substantially lower
than improvements noted for ABT participants.
Gauging efficacy of ABT is encumbered inpart by the high variability noted in participants’
response to therapy. Preliminary results from the
Beyond Therapy trial, for example, suggest that
there are clear responders and nonresponders.
Project Walk results suggest there may be a dose
effect (Figure 1), whereas results from the CSCIRActivity-based Therapies

program (Figure 2) suggest there may also be an
upper limit, beyond which therapeutic gains arediminished.
These findings point to the need to identify
factors that predict response to ABT and also
the optimal dosing “window” – the therapeutic
threshold as well as point of diminishing returns.
Failure to identify these parameters and establish
clear expectations for ABT clients may lead toa loss in credibility of these nascent therapeutic
programs. This is particularly important given thetenuous nature of funding for ABT. Because it is
not considered to be a medical necessity by mosthealth insurers, many ABT clients must pay outof pocket or seek funding from nonconventionalsources such as fundraising; all the more reason
to ensure that reasonable expectations forrecovery are established and maintained. The
work by Winchester and colleagues17 to establish a
predictive model of responsiveness to locomotor
training in SCI provides a useful blueprint for
future research needed in this area.
Even for individuals who do achieve meaningful
functional recovery from participation in an ABT
program, there is little information available about
the durability of outcomes achieved or what isneeded to maintain gains. Do those who gain somedegree of walking ability after participation in
ABT continue to walk and progress in other areasof function? Do these gains translate into more41

meaningful participation, better health, fewer
secondary complications, and improved perceptionof life satisfaction? Long-term follow-up studies
are needed to determine the lasting impact of ABTparticipation and the active lifestyle needed toensure longevity of outcomes.
Acknowledgments
Rehabilitation Institute of Michigan: Del Harder
Rehabilitation Grant. Thank you to the following
individuals who assisted in this project during
their DPT studies at Oakland University: Lisa
Dotson, PT, Ella Kishelova, PT, Tygre Whittington,
PT, Nicole Wargo, PT, Lauren Yeomans, PT,
Melanie Bevins, PT, Cassandra Ianni, PT, andStefanie Collins Brewer, PT.
Shepherd Center: This work was funded in partby a grant (H133G080031) from the National
Institute on Disability and Rehabilitation Research(NIDRR), US Department of Education. The
opinions contained in this paper are those of theauthors and do not necessarily reflect those of the
US Department of Education or NIDRR. Sincere
thanks are extended to Rebecca Washburn, Sarah
Morrison, PT, Deborah Backus, PT, PhD, Keith
Tansey, MD, PhD, and Jennifer Coker, MPH, forassistance in planning and execution of the study
and initial analysis of findings.

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