NEURO PHYSIOTHERAPY ASSESSMENT & TREATMENT PROTOCOL

Patient: Dakshaben Naishadkumar Prajapati | F/46 yrs (approx) | CMPP Neuro OPD

SECTION A: CASE SYNTHESIS FROM REPORTS

SECTION B: PG-LEVEL NEURO PHYSIOTHERAPY ASSESSMENT FORMAT

I. PATIENT PROFILE & DEMOGRAPHIC DATA

• Name, Age, Sex, Occupation, Handedness, Contact details
• Address, Referral source (Neuro OPD)
• Date of assessment, Assessor name + designation

II. CHIEF COMPLAINT (in patient's own words)

1. Difficulty in walking
2. Difficulty maintaining balance
3. Difficulty in sit-to-stand
4. Difficulty climbing stairs
5. Severity & duration of each complaint (VAS/NRS for any associated pain)

III. HISTORY OF PRESENT ILLNESS (HOPI)

• Onset, duration, mode (insidious/acute post-fall)
• Progression: Static / Progressive / Fluctuating
• Aggravating & relieving factors
• Functional impact: ADLs, IADLs, social participation

IV. PAST MEDICAL / SURGICAL HISTORY

• 2013: Spinal intramedullary subependymoma Grade I (C3/4-D3/4) - posterior excision
• Post-op physiotherapy received - nature & duration
• 2014: Fall - L5-S1 fracture - conservative management
• 2017: Follow-up MRI - residual/recurrent tumor D1-D3, myelomalacia
• 2021: Fall - annular tear L5-S1 - no physiotherapy

V. DRUG HISTORY

• Tab. Liofen (Baclofen) - previously prescribed (spasticity management)
• Note any current medications: antispasmodics, analgesics, neuroprotectives

VI. FAMILY & SOCIAL HISTORY

• Socioeconomic status, home environment (stairs/ramps), caregiver support, compliance barriers

VII. REVIEW OF SYSTEMS

• Bladder/bowel function (important in myelopathy - note any neurogenic bladder/bowel)
• Sensory disturbances: numbness, tingling, dermatomal distribution
• Sexual dysfunction (if applicable)
• Fatigue levels
• Sleep quality

VIII. GENERAL PHYSICAL EXAMINATION

• Vitals: BP, PR, SpO2, RR
• Build, BMI, nutritional status
• Posture analysis: anterior/posterior/lateral views (standing or sitting as tolerated)
• Skin integrity: pressure points, scars (post-laminectomy scar C7-D3 region - document location, length, mobility)
• Oedema, trophic changes

IX. NEUROLOGICAL EXAMINATION

A. MENTAL STATUS

• Consciousness, Orientation (time/place/person)
• Cognitive screening: Mini-Mental State Examination (MMSE) or Montreal Cognitive Assessment (MoCA)

B. CRANIAL NERVE SCREENING

• Quick screen CN II, V, VII, IX, X, XI, XII (relevant since C3-4 level was involved)

C. MOTOR EXAMINATION

• Modified Ashworth Scale (MAS) - document for each muscle group:

• Also apply Modified Tardieu Scale for dynamic spasticity differentiation

• Manual Muscle Testing (MRC grading 0-5) for all key muscle groups:
  • Upper limb: shoulder abductors, elbow flexors/extensors, wrist extensors, finger flexors (UE involvement likely given C3-4 level)
  • Lower limb: hip flexors, extensors, abductors; knee flexors/extensors; ankle dorsiflexors/plantarflexors; big toe extensors

• C5: Deltoid/biceps | C6: Wrist extensors | C7: Triceps | C8: Finger flexors
• L2-L3: Hip flexors | L3-L4: Knee extensors | L4: Ankle dorsiflexors | L5: Big toe extensors | S1: Ankle plantarflexors

• Apply International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI/ASIA) - recommended even in non-traumatic SCI per PMC rehabilitation in spine tumors
• Determine: Motor level, Sensory level, Neurological level, AIS grade (A-E)

D. SENSORY EXAMINATION

• Light touch (cotton wool) - dermatomal mapping
• Pin prick (sharp/blunt) - spinothalamic
• Proprioception + vibration (128 Hz tuning fork) - dorsal column function (critical given myelomalacia C6-D1)
• Temperature sensation
• Document using ISNCSCI sensory scoring (0/1/2 for each key sensory point)

E. REFLEXES

• Biceps (C5-6), Triceps (C7-8), Brachioradialis (C5-6)
• Knee/Patellar (L2-4) - Grade 3+ (documented in your case = hyperreflexia, confirms UMN)
• Ankle/Achilles (S1-2)
• Grade using: 0 (absent), 1+ (diminished), 2+ (normal), 3+ (brisk), 4+ (clonus)

• Babinski sign - POSITIVE (documented) = confirms UMN lesion
• Hoffman's sign (upper limb UMN sign) - important given C3-C5 involvement
• Clonus: ankle clonus, knee clonus (document beats and sustainability)
• Inverted radial reflex (C5-6 lesion)
• Crossed adductor reflex

• Abdominal reflexes (upper T6-9, lower T10-12)
• Cremasteric reflex (L1-2)
• Anal wink reflex (S3-4-5)

F. COORDINATION TESTS

• Finger-nose test, Diadochokinesis (upper limb)
• Heel-knee-shin test (lower limb)
• Romberg's test (assess proprioceptive vs. cerebellar component)
• Tandem gait / Tandem Romberg
• Past pointing

G. BALANCE ASSESSMENT

• Standing balance: bilateral stance, semi-tandem, tandem, unilateral stance (time with eyes open/closed)

• Berg Balance Scale (BBS) - 14 items, 0-56 score, validated for neurological conditions; <45 = fall risk
• Tinetti Performance Oriented Mobility Assessment (POMA) - gait + balance subscales; PMID [35201709]
• Functional Reach Test - anterior reach distance (< 25 cm = fall risk)

H. GAIT ANALYSIS

• Gait pattern: spastic gait / steppage / scissor gait / ataxic gait / combined pattern
• Walking aids currently used
• Step length, step width, cadence, symmetry
• Arm swing, trunk stability, head position

• 10-Metre Walk Test (10MWT) - comfortable + fast speeds; record time and steps
• 6-Minute Walk Test (6MWT) - functional endurance
• Timed Up and Go (TUG) - mobility + fall risk; >12 sec = high fall risk
• Dynamic Gait Index (DGI) - 8 items, assesses gait under changing demands; <19/24 = fall risk
• Functional Ambulation Category (FAC) - 0-5, determines level of walking independence

I. FUNCTIONAL ASSESSMENT

• Spinal Cord Independence Measure (SCIM-III) - most sensitive for SCI population; covers self-care, respiration/sphincter, mobility
• Barthel Index (BI) - for basic ADL function
• Functional Independence Measure (FIM) - 18 items; motor + cognitive domains

• Five Times Sit-to-Stand Test (FTSTS) - time to complete 5 STS; >12 sec = impaired

J. PAIN ASSESSMENT

• Numeric Rating Scale (NRS) 0-10 for back pain / radicular pain
• Pain map (body chart)
• Nature: nociceptive vs. neuropathic
• DN4 Questionnaire - for neuropathic pain screening (given annular tear L5-S1 + nerve root compression)
• Visual Analogue Scale (VAS) for pain during specific activities

K. RANGE OF MOTION (ROM) ASSESSMENT

• Passive ROM: hamstrings (popliteal angle), hip adductors, hip flexors (Thomas test), calf (ankle DF)
• Note presence of contractures (high risk in this patient due to prolonged immobility)
• Document: which joints, degree of limitation, end-feel

L. SPASTICITY-SPECIFIC TOOLS

• Modified Ashworth Scale (MAS) - muscle tone
• Modified Tardieu Scale (MTS) - differentiates spasticity from contracture (catch angle R1 vs. full ROM R2)
• Spasticity Assessment Tool for Spastic Reflexes (SCATS) - clonus, flexor spasms, extensor spasms (each 0-3) per SCI Guidelines 2024
• Penn Spasm Frequency Scale - patient-reported spasm frequency

M. PSYCHOLOGICAL ASSESSMENT

• Hospital Anxiety and Depression Scale (HADS) - depression is prevalent in chronic myelopathy
• Brief Pain Inventory (BPI) - pain interference with function

N. QUALITY OF LIFE

• SF-36 or WHOQOL-BREF - both validated in neurological populations

SECTION C: PROBLEM LIST (from Assessment)

1. Spasticity - bilateral lower limbs (hamstrings, quadriceps, adductors, calf muscles) - UMN pattern
2. Muscle weakness - bilateral lower limbs, possibly bilateral UE weakness
3. Impaired balance - static and dynamic (BBS likely < 45)
4. Gait impairment - likely spastic/scissor gait + ataxic component
5. Reduced flexibility/ROM - hamstrings, adductors, calf, hip flexors (shortened due to spasticity)
6. Myelomalacia C6-D1 - proprioceptive deficit, sensory ataxia
7. L5-S1 disc herniation with annular tear - possible radicular pain, neural tension
8. Activity limitation - STS difficulty, stair climbing, ADL dependence
9. Fall risk - high (Babinski +ve, hyperreflexia, 3+ DTR, gait/balance deficits + history of 2 falls)
10. Deconditioning - prolonged immobility, incomplete physiotherapy compliance

SECTION D: EVIDENCE-BASED PHYSIOTHERAPY TREATMENT PROTOCOL

GOALS

• Reduce spasticity to MAS ≤1 in major muscle groups
• Improve static standing balance
• Improve STS with minimal assistance
• Educate patient + family on home program and fall prevention

• Independent safe ambulation (FAC ≥ 3)
• BBS ≥ 45 (reduce fall risk)
• TUG < 12 seconds
• Stair negotiation with rail support
• Independence in ADLs

PHASE 1: ACUTE/SUBACUTE PHASE (Weeks 1-2)

1. SPASTICITY MANAGEMENT

• Prolonged static stretching - 20-30 minutes per session for tight muscle groups (hamstrings, adductors, calf, hip flexors); evidence from a 2026 RCT confirms sustained stretch reduces spasticity in SCI
• Positioning and posture correction - anti-spasticity positioning (ankle dorsiflexion splints at night, hip neutral positioning)
• Rhythmic passive movements - rotational patterns, slow rhythmic rocking to inhibit hypertonicity (Bobath approach)
• Transcutaneous Electrical Nerve Stimulation (TENS) - for pain + adjunct spasticity reduction; same 2026 RCT (Afridi et al. PMID 41646570) showed TENS comparable to baclofen for SCI spasticity
• Cold therapy / Cryotherapy - prior to stretching to reduce dynamic spasticity

2. STRENGTHENING - WEAK ANTAGONISTS

• Active-assisted exercises - hip flexors, knee extensors, ankle dorsiflexors
• Antigravity position exercises per MRC grade:
  • MRC 0-1: Electrical muscle stimulation (EMS/NMES)
  • MRC 2: Gravity-eliminated active exercises
  • MRC 3-4: Against gravity, then progressive resistance

3. SENSORY RE-EDUCATION

• Proprioceptive training: joint repositioning, vibration therapy
• Textured surfaces for foot sensory stimulation
• Weight-shifting exercises in supported standing

PHASE 2: ACTIVE REHABILITATION (Weeks 2-6)

1. BALANCE TRAINING (evidence level: Systematic Review - PMID 38705999)

• Progressive standing balance program:
  • Bilateral stance → narrow base → semi-tandem → tandem
  • Eyes open → eyes closed (to challenge proprioception)
  • Stable surface → foam → wobble board
• Weight shifting exercises - anterior/posterior/lateral in standing
• Perturbation training - therapist-applied manual perturbations
• Dual-task balance training - standing + cognitive task (counting, ball toss)

2. GAIT REHABILITATION

• Task-specific gait training (neuroplasticity principle - most important)
• Body Weight Supported Treadmill Training (BWSTT) - if available; high evidence for incomplete SCI; start with 30-40% body weight support, reduce progressively
• Overground gait training with parallel bars → frame → stick
• Gait pattern correction:
  • Hip hiking reduction
  • Knee hyperextension management (stance phase stability)
  • Foot clearance improvement (AFO if persistent foot drop)
• Backward walking training - improves knee control and proprioception

3. SIT-TO-STAND TRAINING

• Practice STS from progressively higher to lower seat heights
• Weight forward before rise (correct pattern)
• Eccentric control training for sit-down phase
• FTSTS as outcome measure

4. STAIR CLIMBING TRAINING

• Start with single step, lower riser height
• Rail-assisted, monitor for fatigue and falls
• Step-over-step vs. marking time progression

5. CORE AND TRUNK STABILIZATION

• Bridging, pelvic tilts, draw-in maneuver
• Sitting balance challenges
• Trunk rotation in sitting

PHASE 3: FUNCTIONAL & COMMUNITY REINTEGRATION (Weeks 6-12+)

1. ADVANCED BALANCE & FUNCTIONAL TRAINING

• Community ambulation simulation: uneven surfaces, curbs, slopes
• Obstacle course training (DGI-based)
• Fall recovery training: safe falling technique, floor-to-chair transfer

2. UPPER LIMB REHABILITATION

• Given C3-C5 involvement: assess for fine motor deficits, grip strength
• NMES/FES for weak upper limb muscles if MRC <3
• Task-specific training: writing, buttoning, utensil use

3. TECHNOLOGY-ASSISTED REHABILITATION

• Robotic-assisted gait training (RAGT) - Meta-analysis 2025 (Liu et al. PMID 40442684) shows RAGT significantly improves gait speed and balance over conventional training in SCI
• Exoskeleton-based gait training - Systematic review 2024 (Nepomuceno et al. PMID 38705999) provides dosage guidelines: minimum 20 sessions, 45-60 min/session recommended
• Virtual reality balance training - emerging evidence in spinal conditions
• Transcutaneous Spinal Cord Stimulation (tSCS) - pilot evidence (PMID 39998450) for activity-based therapy combined with tSCS shows safe and effective for improving motor function

PHYSICAL MODALITIES

HOME EXERCISE PROGRAM (HEP) - KEY FOR COMPLIANCE

• Simple 3-4 exercise home program in written/visual format
• Caregiver-assisted stretching routine
• Daily log sheet
• Weekly telehealth check-in if possible
• Graded progression with clear goals for motivation

PRECAUTIONS / CONTRAINDICATIONS

1. No aggressive cervical/thoracic manipulation - post-laminectomy, residual cord lesion
2. Monitor for autonomic dysreflexia signs (though T-level lesion - lower risk than cervical; still monitor during bowel/bladder procedures)
3. Assess orthostatic hypotension before standing activities (especially early phase)
4. Avoid activities that increase spinal flexion load at L5-S1 (loaded forward flexion) due to annular tear
5. Fall prevention - supervise all gait and balance training, non-slip footwear, home hazard assessment
6. Monitor for signs of tumor recurrence or neurological deterioration - any new weakness, sensory changes, or bladder/bowel changes = urgent neurosurgical referral

OUTCOME MEASURES SUMMARY TABLE

KEY EVIDENCE REFERENCES

1. Neurorehabilitation in intradural spinal cord tumors: Khalid et al., Pak J Med Sci 2025 [PMID 41522397] - retrospective analysis confirming functional gains with structured neurorehab
2. Role of rehabilitation in spine tumors: PMC 2025 review - recommends ISNCSCI, SCIM, FIM as standard assessment tools; physiatry + physiotherapy team approach
3. Spasticity management in SCI - TENS vs. sustained stretch: Afridi et al., Cureus 2026 [PMID 41646570] - RCT showing both TENS and sustained stretch effective
4. Robotic-assisted gait in SCI: Liu et al., J Neuroeng Rehabil 2025 [PMID 40442684] - Meta-analysis confirming superior outcomes with RAGT
5. Exoskeleton dosage for gait/balance: Nepomuceno et al., J Neuroeng Rehabil 2024 [PMID 38705999] - Systematic review on dosage parameters
6. Post-stroke spasticity physiotherapy (applicable principles): Brusola et al., NeuroRehabilitation 2023 [PMID 36806522] - umbrella review confirming stretching + TENS + positioning
7. Ependymoma surgery and recovery: Alhalabi et al., J Neurosurg Spine 2024 [PMID 37922542] - early surgery and absence of pre-op ataxia predicts full recovery; relevant for prognosis counseling
8. SCI spasticity management guidelines: UAMS IDHI SCI Guidelines 2024 - standardized MAS, SCATS, SCIM, Modified Tardieu protocols

PG Tip: In your presentation, frame this case as "Post-excision Intramedullary Subependymoma with residual myelopathy (AIS classification pending clinical examination) with concurrent L5-S1 posterior disc herniation presenting as progressive UMN syndrome with balance and gait dysfunction." This shows clinical reasoning linking pathology - impairment - activity limitation - participation restriction (ICF model), which is expected at PG level.The full assessment and protocol above is comprehensive and ready for clinical use. Here is a quick summary of what is covered and why each section matters for your PG presentation:

• Image 1 (Civil Hospital 2017 MRI): Residual/recurrent intramedullary lesion D1-D3 (11x14x38 mm), myelomalacia C6-D1, post-laminectomy C7-D3 - this is why you see UMN signs
• Image 2 (Sterling Hospital discharge 2013): Confirmed Subependymoma Grade I, posterior excision performed 28.05.2013 - benign tumor, good prognosis with rehab
• Image 3 (Gujarat Imaging Centre 2013 pre-op MRI): C3-C4 to D3-D4 intramedullary lesion with cord expansion - establishes extent of original tumor
• Image 4 (Lions General Mehsana 2021 MRI): Posterior disc herniation with annular tear L5-S1 compressing thecal sac and nerve roots - this adds a second level of pathology

ICF FRAMEWORK & PHYSICAL FUNCTIONAL DIAGNOSIS

Patient: Dakshaben Naishadkumar Prajapati | F/~46 yrs | Post-op Intramedullary Subependymoma + Myelopathy + L5-S1 Disc Herniation

PART 1: ICF (International Classification of Functioning, Disability and Health)

COMPONENT 1: HEALTH CONDITION (Diagnosis)

Post-surgical residual cervico-dorsal intramedullary Subependymoma Grade I (C3-D4) with myelopathy and myelomalacia (C6-D1) + L5-S1 posterior disc herniation with annular tear causing thecal sac and nerve root compression

COMPONENT 2: BODY STRUCTURE & FUNCTION IMPAIRMENTS

BODY STRUCTURES AFFECTED:

BODY FUNCTIONS AFFECTED:

COMPONENT 3: ACTIVITY LIMITATIONS

COMPONENT 4: PARTICIPATION RESTRICTIONS

COMPONENT 5: CONTEXTUAL FACTORS

ENVIRONMENTAL FACTORS (Barriers - negative qualifier; Facilitators - positive qualifier)

PERSONAL FACTORS (Not coded in ICF but clinically significant)

PART 2: PHYSICAL FUNCTIONAL DIAGNOSIS

FORMAT USED: Pathology → Impairments → Functional Limitations → Disability

PHYSICAL FUNCTIONAL DIAGNOSIS STATEMENT:

Mrs. Dakshaben Prajapati, a 46-year-old female, presents with post-surgical residual myelopathy secondary to intramedullary subependymoma Grade I (C3-D4) with myelomalacia at C6-D1 and concurrent L5-S1 posterior disc herniation with annular tear, resulting in:

(1) Bilateral lower limb spasticity (UMN pattern) with hyperreflexia (knee DTR 3+) and a positive Babinski sign;

(2) Severe tightness and reduced flexibility of bilateral hamstrings, quadriceps, calf, and adductor muscles;

(3) Impaired proprioception and sensory function below the lesion level;

(4) Compromised static and dynamic balance;

(5) Gait impairment (likely spastic/ataxic pattern) with reduced speed, safety, and endurance;

manifesting as significant activity limitations in walking on level ground, stair climbing, sit-to-stand, and transfer activities; with participation restrictions in domestic, occupational, social, and community roles; further compounded by prolonged deconditioning, poor rehabilitation compliance, and a high risk of falls.

STRUCTURED ICF SUMMARY DIAGRAM:

HEALTH CONDITION
Post-op Intramedullary Subependymoma Grade I (C3-D4)
+ Myelomalacia (C6-D1) + L5-S1 Disc Herniation
          |
     _____|_____________________________
    |                                   |
BODY FUNCTION/STRUCTURE          ACTIVITY LIMITATIONS
- Spasticity (UMN)               - Walking ↓↓
- Hyperreflexia (3+)             - Balance ↓↓
- Babinski +ve                   - Sit-to-Stand ↓↓
- Proprioception ↓               - Stair climbing ↓↓
- Muscle tightness               - ADL performance ↓
- Weakness BLE                   - Transfer ↓
- Pain (L5-S1 radicular)
          |                                   |
     _____|___________________________________| 
                        |
             PARTICIPATION RESTRICTIONS
             - Unable to work
             - Domestic dependence
             - Social isolation
             - Community ambulation absent
                        |
         _______________|_______________
        |                               |
ENVIRONMENTAL FACTORS           PERSONAL FACTORS
Barriers:                       - Fear of falling
- No assistive device           - Poor compliance
- Home not adapted              - Demoralization
- Poor healthcare follow-up     - Avoidance coping
Facilitators:
- Family support
- Tertiary care access

ICF QUALIFIER SUMMARY (for documentation):

• 0 = No impairment (0-4%)
• 1 = Mild (5-24%)
• 2 = Moderate (25-49%)
• 3 = Severe (50-95%)
• 4 = Complete (96-100%)

PG Tip: In your case presentation, always write the ICF before your treatment goals. Each SHORT-TERM goal should target a Body Function/Activity impairment and each LONG-TERM goal should target a Participation restriction. This shows the examiner that your treatment reasoning is goal-directed and patient-centered, not just modality-based. The ICF model is the backbone of modern neurological physiotherapy practice and is now mandatory in clinical documentation at tertiary centers.

BALANCE TRAINING - EVIDENCE ARTICLES

For: Post-op Intramedullary Subependymoma with Myelopathy (Incomplete SCI equivalent)

EVIDENCE HIERARCHY AT A GLANCE

DETAILED ARTICLE SUMMARIES

ARTICLE 1 - MOST RELEVANT (Meta-Analysis) ⭐⭐⭐

• Standalone BWST - weak evidence for standing balance in iSCI
• BWST + Neurostimulation = best results (large effect size -0.98)
• VR-based balance training = significant BBS improvement (+4.22 points)
• Further high-quality RCTs needed

ARTICLE 2 - Technology-Assisted Balance (Systematic Review) ⭐⭐⭐

• Technology-assisted rehab (treadmill devices, exoskeletons, tilt table) showed significant balance improvements
• However, improvements were not superior to conventional therapy in head-to-head comparisons
• Recommendation: Technology = adjunct to, not replacement of, conventional balance training

ARTICLE 3 - Suspension Exercise Training (Meta-Analysis, 2025) ⭐⭐⭐

ARTICLE 4 - RAGT + Spinal Stimulation RCT (2026) ⭐⭐⭐

ARTICLE 5 - Walking Adaptability RCT (Multicenter, 2024) ⭐⭐

• Significant improvements in walking speed, functional ambulation, balance confidence, participation - both interventions worked

ARTICLE 6 - Virtual Reality RCT (Indian data) ⭐⭐

ARTICLE 7 - Immersive VR vs. FES RCT ⭐⭐

SYNTHESIS FOR YOUR CASE - WHAT THE EVIDENCE SAYS

BALANCE TRAINING APPROACH          EVIDENCE LEVEL    KEY FINDING
─────────────────────────────────────────────────────────────────
BWST + Neurostimulation            Meta-Analysis     SMD = -0.98 (large effect)
Suspension Exercise Training (SET)  Meta-Analysis     BBS +6.15 points
RAGT + tSCS                        RCT (2026)        BBS +7.67 points, TUG -10.91s
VR + Conventional PT               RCT x2 (Indian)   Significant BBS/MFRT gains
Conventional PT (task-specific)    Multicenter RCT   Equally effective as VR-treadmill
─────────────────────────────────────────────────────────────────

1. Phase 1-2: Conventional task-specific balance training (evidence = multicenter RCT, PMID 38661122) - this is the most accessible and equally effective
2. Add VR (Xbox Kinect/low-cost) when available - Indian RCT directly supports this (PMID 36412376)
3. BWST + NMES/TENS combination when partial body weight support is available - strongest meta-analytic evidence (PMID 37235196)
4. RAGT if the centre has a Lokomat/ReWalk - 2026 BMC Medicine RCT (PMID 41803851) is the most current high-quality evidence supporting this

PG Exam Tip: Always quote PMID numbers + journal + year when presenting evidence at PG level. For balance training in this patient, cite Walia et al. 2023 (Meta-Analysis, Topics in SCI Rehabil) as your primary reference - it is the highest-quality article directly addressing standing balance in incomplete SCI with a pooled quantitative effect size.

ARTICLE DETAILS

STUDY DETAILS

• Databases searched: CINAHL Complete, Embase, Emcare Nursing, Medline ALL, Web of Science
• Total studies screened: 2,108 studies identified
• Final included: 19 studies (adults with subacute and/or chronic SCI/disease)
• Inclusion criteria: must report dose + dosage parameters AND at least one gait/balance outcome measure

KEY FINDINGS

Evidence-Based Dosage Recommendations:

• Great heterogeneity was found in dose, dosage, and indications across studies
• Despite heterogeneity, a clear pattern of 60 min / 3x per week emerged as best practice

CONCLUSION

"This review provides evidence-based best practice recommendations for overground exoskeleton training among individuals with spinal cord injury/disease based on individual therapeutic goals - functional restoration or cardiorespiratory rehabilitation."

HOW TO USE THIS IN YOUR CASE

• Goal = Functional restoration → prescribe exoskeleton/RAGT at 60 min sessions, 3x per week, for 8 weeks (24 sessions total)
• This is your evidence-based dosage justification when a PG examiner asks "how many sessions did you plan and why?"
• Cite directly: "As per Nepomuceno et al. (2024), J Neuroeng Rehabil, PMID 38705999 - functional restoration protocol recommends 60 min, 3x/week for 8 weeks/24 sessions"