Gait Post Spinal Cord Injury
Original Editor - Prit Shah
Top Contributors - Prit Shah, Naomi O'Reilly, Kim Jackson and Nikhil Benhur Abburi
Introduction[edit | edit source]
The recovery or improvement of ambulation after a Spinal cord injury (SCI) is an important goal because people who can walk independently are more likely to be able to participate in expected social roles and desired recreational activities, have a higher quality of life, and have improved health status.
The ability to walk after a Spinal cord injury (SCI) depends on many factors including your:
- Level of injury.
- Severity of injury.
- Time since injury.
- Age.
- Level of fitness.
- Level of sensation
- Other related problems such as spasticity and joint problems (contractures).
- Level of pain. [1]
Therefore, it is difficult to predict if a patient will ever regain his walking ability and especially at what point of time in his rehabilitation. Some patients take a few months up to a year and some take many years.
Identifying the Level of Lesion[edit | edit source]
The designation of level of lesion in the spinal cord and the extent of motor and sensory function after injury has a large impact on the medical and rehabilitation needs of the individual.
ASIA Impairment Scale[edit | edit source]
The American Spinal Injury Association (ASIA) created the International Standards for Neurological Classification of Spinal cord injury (ISNCSCI) which provides a standardized examination method to determine the extent of motor and sensory function loss after a spinal cord injury (SCI) for establishing prognosis and is also an important tool for clinical research trials.[2]
It is explained in detail right here - American Spinal Cord Injury Association (ASIA) Impairment Scale
Complete And Incomplete Injuries and Zones of Preservation[edit | edit source]
The International Standards for Neurological Classification of Spinal cord injury (ISNCSCI) defines a complete injury as having no sensory or motor function in the lowest sacral segments (S4 and S5). Sensory and motor function at S4 and S5 are determined by anal sensation and voluntary external anal sphincter contraction. An incomplete injury is classified as having motor and/or sensory function below the neurological level including sensory and/or motor function at S4 and S5. If an individual has motor and/or sensory function below the neurological level but does not have function at S4 and S5, then the areas of intact motor and/or sensory function below the neurological level are termed zones of partial preservation.[3]
Gait Analysis[edit | edit source]
A spinal cord injury (SCI) can create weakness and spasticity in the feet, legs, hips, and trunk, as well as in the hands and arms. It is known that people with an incomplete SCI have more potential to regain walking than those with a complete SCI, but people with both types of SCI may have gait training included in their therapy plans.[1]
In a study to find out the effects of injury level and spasticity on Gait, it was found that - Subjects with thoracic injures demonstrated reduced cadence, forward velocity, and knee angular velocity, whereas lumbar injuries resulted in reduced stride length and ankle velocities. Gait in individuals with cervical injuries was not significantly different.[4]
A combination of studies show that –
- Individuals with complete (ASIA A) UMN injuries are not likely to regain the functional LE strength required to become independent ambulators.
- In patients with incomplete SCI (ASIA B, C, and D) the prognosis for recovery of walking ability is more complex.
- For individuals with ASIA B (sensory incomplete) the preservation of pinprick sensation is an important prognostic indicator of the recovery of walking ability.
- Most patients with ASIA D and C, SCI will regain some ability to walk.
- Lower extremity ASIA motor score, quadriceps strength in particular, can be a useful predictor of functional walking ability in people with motor incomplete injuries.[5][6][7][8][9]
Preparation for Gait Training[edit | edit source]
Assessment[edit | edit source]
The physician will test your strength, sensation, ability to stand up, transfers, bed mobility, balance while standing, spasticity or stiffness, and range of motion at your hips, knees, ankles, and trunk and accordingly plan out the training planner.
The therapist may also provide you assistive devices and/or braces to give you better balance, protect your joints, and ensure your safety as you walk. He/ she may then test your walking speed, endurance, and balance with these devices and braces to keep track of your therapy progress. [1]
The patient is made to understand the steps involved in the training, it’s potential benefits as well as the complications if not done right. For example, if a patient using a wheelchair, trains to walk and eventually regains overground balance, coordination, the strength and does not risk falling in all environments (indoors and outdoors) completely, the use of wheelchair then should be slimmed to none or he will become dependent on it and the muscles will regress back into weakness and spasticity.
A study found that at the end of one year post-injury, people who were discharged from therapy trying to walk, but returned to using a wheelchair, had greater pain and more depression. [10]
Most individuals, those who are very old or are with complete SCI will rely on a wheelchair as their primary means of locomotion at home and in the community. Thus, it is important to assess patient’s wheelchair skills which can be done using the Wheelchair Skills Test (WST) [11][12][13]
Locomotor Training[edit | edit source]
Overview[edit | edit source]
It becomes necessary to assess and document the patient’s walking ability, function, ambulation speed, endurance, capacity and so on before beginning the training to compare from time to time so that his progression can be noted. The most commonly used tests are :-
1. Walking Index for Spinal cord injury (WISCI) or (WISCI II) [14][15][16][17]
2. 10 Metre Walk Test (10MWT) [16][17]
3. 6 Minute Walk Test (6MWT) [16][17]
4. Spinal Cord Injury Functional Ambulation Inventory (SCI-FAI) [18]
References[edit | edit source]
- ↑ 1.0 1.1 1.2 1. Spinal Cord Injury and Gait Training. Available at - https://msktc.org/sci/factsheets/Gait-Training-and-SCI
- ↑ O'sullivan, S.B, Schmitz , T.J, Fulk, G.D. Physical Rehabilitation. (6th ed.). Philadelphia: FA Davis Company; c2014.
- ↑ Kirshblum SC, Biering-Sorensen F, Betz R, Burns S, Donovan W, Graves DE, Johansen M, Jones L, Mulcahey MJ, Rodriguez GM, Schmidt-Read M. International standards for neurological classification of spinal cord injury: cases with classification challenges. The journal of spinal cord medicine. 2014 Mar 1;37(2):120-7
- ↑ Krawetz P, Nance P. Gait analysis of spinal cord injured subjects: effects of injury level and spasticity. Archives of physical medicine and rehabilitation. 1996 Jul 1;77(7):635-8.
- ↑ Crozier KS, Graziani V, Ditunno JF, Herbison GJ. Spinal cord injury: prognosis for ambulation based on sensory examination in patients who are initially motor complete. Archives of physical medicine and rehabilitation. 1991 Feb 1;72(2):119-21.
- ↑ Burns SP, Golding DG, Rolle Jr WA, Graziani V, Ditunno Jr JF. Recovery of ambulation in motor-incomplete tetraplegia. Archives of physical medicine and rehabilitation. 1997 Nov 1;78(11):1169-72.
- ↑ Alander DH, Parker J, Stauffer ES. Intermediate-term outcome of cervical spinal cord-injured patients older than 50 years of age. Spine. 1997 Jun 1;22(11):1189-92.
- ↑ Crozier KS, Cheng LL, Graziani V, Zorn G, Herbison G, Ditunno JF. Spinal cord injury: prognosis for ambulation based on quadriceps recovery. Spinal Cord. 1992 Nov;30(11):762-7.
- ↑ Waters RL, Adkins R, Yakura J, Vigil D. Prediction of ambulatory performance based on motor scores derived from standards of the American Spinal Injury Association. Archives of physical medicine and rehabilitation. 1994 Jul 1;75(7):756-60.
- ↑ Riggins MS, Kankipati P, Oyster ML, Cooper RA, Boninger ML. The relationship between quality of life and change in mobility 1 year postinjury in individuals with spinal cord injury. Archives of physical medicine and rehabilitation. 2011 Jul 1;92(7):1027-33.
- ↑ Kirby RL, Dupuis DJ, MacPhee AH, Coolen AL, Smith C, Best KL, Newton AM, Mountain AD, MacLeod DA, Bonaparte JP. The wheelchair skills test (version 2.4): measurement properties. Archives of physical medicine and rehabilitation. 2004 May 1;85(5):794-804.
- ↑ Kirby RL, Swuste J, Dupuis DJ, MacLeod DA, Monroe R. The Wheelchair Skills Test: a pilot study of a new outcome measure. Archives of Physical Medicine and Rehabilitation. 2002 Jan 1;83(1):10-8.
- ↑ Lindquist NJ, Loudon PE, Magis TF, Rispin JE, Kirby RL, Manns PJ. Reliability of the performance and safety scores of the wheelchair skills test version 4.1 for manual wheelchair users. Archives of physical medicine and rehabilitation. 2010 Nov 1;91(11):1752-7.
- ↑ Ditunno JF, Ditunno PL, Graziani V, Scivoletto G, Bernardi M, Castellano V, Marchetti M, Barbeau H, Frankel HL, Greve JD, Ko HY. Walking index for spinal cord injury (WISCI): an international multicenter validity and reliability study. Spinal cord. 2000 Apr;38(4):234-43.
- ↑ Ditunno JF, Scivoletto G, Patrick M, Biering-Sorensen F, Abel R, Marino R. Validation of the walking index for spinal cord injury in a US and European clinical population. Spinal Cord. 2008 Mar;46(3):181-8.
- ↑ 16.0 16.1 16.2 Jackson A, Carnel C, Ditunno J, Read MS, Boninger M, Schmeler M, Williams S, Donovan W. Outcome measures for gait and ambulation in the spinal cord injury population. The journal of spinal cord medicine. 2008 Jan 1;31(5):487-99.
- ↑ 17.0 17.1 17.2 van Hedel HJ, Wirz M, Dietz V. Assessing walking ability in subjects with spinal cord injury: validity and reliability of 3 walking tests. Archives of physical medicine and rehabilitation. 2005 Feb 1;86(2):190-6.
- ↑ Field-Fote EC, Fluet GG, Schafer SD, Schneider EM, Smith R, Downey PA, Ruhl CD. The spinal cord injury functional ambulation inventory (SCI-FAI). Journal of rehabilitation medicine. 2001 Jul 1;33(4):177-81.
