Innovative spinal cord injury rehabilitation in the context of a middle-income country: a pilot randomised control study investigating physiological and psychological effects

dc.contributor.advisorAlbertus, Yumna
dc.contributor.advisorWest, Sacha
dc.contributor.advisorDerman, Wayne
dc.contributor.authorEvans, Robert William
dc.date.accessioned2022-01-31T07:56:08Z
dc.date.available2022-01-31T07:56:08Z
dc.date.issued2021
dc.date.updated2022-01-26T12:57:00Z
dc.description.abstractA spinal cord injury (SCI) is life-altering, resulting in neurological deficits and a multitude of secondary complications. South Africa holds one of the highest traumatic SCI incidence rates in the world, where the social need for SCI prevention and rehabilitation is immense. Robotic locomotor training (RLT) is a novel rehabilitation technique that may improve health and wellbeing after SCI. A systematic review was conducted across 27 studies and 308 participants to explore the systemic effects of RLT. This review demonstrated that RLT shows promise as a tool for improving neurological rehabilitation outcomes; providing individuals with a SCI the ability to walk safely while improving their walking performance, as well as potentially improving cardiovascular outcomes and psychosocial factors. However, the studies reviewed were non-controlled with small, heterogenous sample sizes. Further high-powered, randomised controlled trials, with homogenous samples, are required to investigate these effects. If widespread adoption of these new technologies is to occur, sound evidence demonstrating efficacy and long-term cost saving is required. This dissertation aimed to explore some of these under-researched areas in a sample of sixteen persons with incomplete tetraplegia. Areas of focus included, 1) rehabilitation feasibility, adherence, and research challenges in an under-resourced environment 2) cardiovascular functioning and adaptation to a rehabilitation programme, and 3) psychological well-being. We implemented two interventions, robotic locomotor training (RLT) and activity-based training (ABT), over a 24-week pilot randomised control trial. Adherence to the interventions was high (93.9 ± 6.2%). Challenges to the study's feasibility included: ethical approval, medical clearance, transport and limited human/financial resources. Cardiovascular parameters demonstrated that efficiency of exoskeleton walking improved during the intervention. RLT may be more effective than ABT in improving cardiac responses to orthostatic stress, with standing heart rate at 24-weeks being significantly lower in the RLT group (75.1 ± 15.0 beats/min) compared to the ABT group (95.6 ± 12.6 beats/min). Standing and RLT had similar effects on the parasympathetic nervous system, whilst both interventions were limited in their effect on brachial and ankle blood pressure. Despite experiencing past trauma, participants possessed psychological resources including resilience, self-efficacy and post-traumatic growth which contributed to high perceptions of quality of life. The use of an exoskeleton may have had a greater positive impact on subjective psychological well-being. Expectations of participants entering the study centred around regaining the ability to walk again, despite past experiences and medical advice suggesting otherwise. Hope aids in buffering against negative emotions, however, a thin line exists between supporting high expectations and confronting unrealistic hope. Initial high expectations of recovery decreased and became more realistic during the intervention. This dissertation demonstrates potential physiological and psychological benefits that RLT provides. Despite this potential, barriers exist in the use of RLT in low- and middle-income countries such as South Africa, primarily due to a lack of financial and human resources. The development of lower-cost exoskeletons would lessen the burden of conducting large-scale trials and increase the likelihood of adopting these innovative rehabilitation tools into current standard of care practices.
dc.identifier.apacitationEvans, R. W. (2021). <i>Innovative spinal cord injury rehabilitation in the context of a middle-income country: a pilot randomised control study investigating physiological and psychological effects</i>. (). ,Faculty of Health Sciences ,Division of Exercise Science and Sports Medicine. Retrieved from http://hdl.handle.net/11427/35613en_ZA
dc.identifier.chicagocitationEvans, Robert William. <i>"Innovative spinal cord injury rehabilitation in the context of a middle-income country: a pilot randomised control study investigating physiological and psychological effects."</i> ., ,Faculty of Health Sciences ,Division of Exercise Science and Sports Medicine, 2021. http://hdl.handle.net/11427/35613en_ZA
dc.identifier.citationEvans, R.W. 2021. Innovative spinal cord injury rehabilitation in the context of a middle-income country: a pilot randomised control study investigating physiological and psychological effects. . ,Faculty of Health Sciences ,Division of Exercise Science and Sports Medicine. http://hdl.handle.net/11427/35613en_ZA
dc.identifier.ris TY - Doctoral Thesis AU - Evans, Robert William AB - A spinal cord injury (SCI) is life-altering, resulting in neurological deficits and a multitude of secondary complications. South Africa holds one of the highest traumatic SCI incidence rates in the world, where the social need for SCI prevention and rehabilitation is immense. Robotic locomotor training (RLT) is a novel rehabilitation technique that may improve health and wellbeing after SCI. A systematic review was conducted across 27 studies and 308 participants to explore the systemic effects of RLT. This review demonstrated that RLT shows promise as a tool for improving neurological rehabilitation outcomes; providing individuals with a SCI the ability to walk safely while improving their walking performance, as well as potentially improving cardiovascular outcomes and psychosocial factors. However, the studies reviewed were non-controlled with small, heterogenous sample sizes. Further high-powered, randomised controlled trials, with homogenous samples, are required to investigate these effects. If widespread adoption of these new technologies is to occur, sound evidence demonstrating efficacy and long-term cost saving is required. This dissertation aimed to explore some of these under-researched areas in a sample of sixteen persons with incomplete tetraplegia. Areas of focus included, 1) rehabilitation feasibility, adherence, and research challenges in an under-resourced environment 2) cardiovascular functioning and adaptation to a rehabilitation programme, and 3) psychological well-being. We implemented two interventions, robotic locomotor training (RLT) and activity-based training (ABT), over a 24-week pilot randomised control trial. Adherence to the interventions was high (93.9 ± 6.2%). Challenges to the study's feasibility included: ethical approval, medical clearance, transport and limited human/financial resources. Cardiovascular parameters demonstrated that efficiency of exoskeleton walking improved during the intervention. RLT may be more effective than ABT in improving cardiac responses to orthostatic stress, with standing heart rate at 24-weeks being significantly lower in the RLT group (75.1 ± 15.0 beats/min) compared to the ABT group (95.6 ± 12.6 beats/min). Standing and RLT had similar effects on the parasympathetic nervous system, whilst both interventions were limited in their effect on brachial and ankle blood pressure. Despite experiencing past trauma, participants possessed psychological resources including resilience, self-efficacy and post-traumatic growth which contributed to high perceptions of quality of life. The use of an exoskeleton may have had a greater positive impact on subjective psychological well-being. Expectations of participants entering the study centred around regaining the ability to walk again, despite past experiences and medical advice suggesting otherwise. Hope aids in buffering against negative emotions, however, a thin line exists between supporting high expectations and confronting unrealistic hope. Initial high expectations of recovery decreased and became more realistic during the intervention. This dissertation demonstrates potential physiological and psychological benefits that RLT provides. Despite this potential, barriers exist in the use of RLT in low- and middle-income countries such as South Africa, primarily due to a lack of financial and human resources. The development of lower-cost exoskeletons would lessen the burden of conducting large-scale trials and increase the likelihood of adopting these innovative rehabilitation tools into current standard of care practices. DA - 2021_ DB - OpenUCT DP - University of Cape Town KW - Exercise Science &amp KW - Sports Medicine LK - https://open.uct.ac.za PY - 2021 T1 - Innovative spinal cord injury rehabilitation in the context of a middle-income country: a pilot randomised control study investigating physiological and psychological effects TI - Innovative spinal cord injury rehabilitation in the context of a middle-income country: a pilot randomised control study investigating physiological and psychological effects UR - http://hdl.handle.net/11427/35613 ER - en_ZA
dc.identifier.urihttp://hdl.handle.net/11427/35613
dc.identifier.vancouvercitationEvans RW. Innovative spinal cord injury rehabilitation in the context of a middle-income country: a pilot randomised control study investigating physiological and psychological effects. []. ,Faculty of Health Sciences ,Division of Exercise Science and Sports Medicine, 2021 [cited yyyy month dd]. Available from: http://hdl.handle.net/11427/35613en_ZA
dc.language.rfc3066eng
dc.publisher.departmentDivision of Exercise Science and Sports Medicine
dc.publisher.facultyFaculty of Health Sciences
dc.subjectExercise Science &amp
dc.subjectSports Medicine
dc.titleInnovative spinal cord injury rehabilitation in the context of a middle-income country: a pilot randomised control study investigating physiological and psychological effects
dc.typeDoctoral Thesis
dc.type.qualificationlevelDoctoral
dc.type.qualificationlevelPhD
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