Clinical view on ambulation in patients with Spinal Cord Injury

Transcription

1 Clinical view on ambulation in patients with Spinal Cord Injury Sasa Moslavac Spinal Unit, Special Medical Rehabilitation Hospital, Varazdinske Toplice,, Croatia 1

2 Spinal Cord Injury (SCI) to walk again this is among most important issues for SCI patients and the symbol of regaining control and of former lifestyle multisystem dysfunction,, not only paralysis clinical point: evaluate patient, neurological level and completeness of injury and walking capacity community ambulation? 2

3 neurological classification of SCI for lesion level NLI <T11 ( T7?) increased potential for ambulation L2 (hip flexion) and L3 (knee extension) for community ambulation orthotic assistance, aids KAFO, AFO, walker, crutches proprioception toleration to high-energy consumption 3

4 ASIA (American Spinal Injury Association) impairment scale for lesion completeness no complete tetraplegic patient regains ability to walk almost half of incomplete tetraplegics and 75% of incomplete paraplegics do % initially incomplete patients will recover to walk again 4

5 Lower extremities motor score (LEMS) Uses the ASIA key muscles in both lower extremities, with a total possible score of 50 LEMS of 20 or less indicates that the patient is likely to be a limited ambulator LEMS of 30 or more suggests that the individual is likely to be a community ambulator 5

6 Gait training or not? motivation, age, strength limitations: co-morbidity, complications, pain, contracture. 6

7 Goals carefully set and realistic to estimate the use of gait and benefits for every patient to prevent further injury (e.g. neuroarthropathy) gait training vs community ambulation b770 Gait pattern functions d410-d429 d429 Changing and maintaining body position d430-d449 d449 Carrying, moving and handling objects d450-d469 d469 Walking and moving d810 Informal education d840 Apprenticeship (work preparation) d9100 Informal associations d9200 Play 7

8 Rehabilitation interventions gradual training scheme verticalisation from tilt-table table exercise caution in lesion >T6 (early, incomplete) standing in frames use of walkers and braces in selected patients ambulation as functional gain (eg community ambulators) 8

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12 interventions kinesiotherapy hydrokinesiotherapy gait training bracing,, aids, orthoses, reciprocal gait orthoses, parawalker... treadmill (BWSTT) functional electro stimulation neuroprotheses isokinetic exercises 12

13 kinesiotherapy posture balance range of motions strengthening 13

14 hydrokinesiotherapy 14

15 balance, transfer and gait training 15

16 isokinetic exercises 16

17 bracing,, aids, orthoses, reciprocal gait orthoses, parawalker... AFO KAFO HKAFO. long-leg braces may facilitate the ability of people with subacute or chronic complete paraplegia to stand independently and to achieve some functional ambulation skills, although slower than optimal community ambulation speed (1.1 m/s) enhanced home or indoor mobility, for general exercise and health benefits, and psychological benefits from attaining upright posture and standing hardly on significant level, or everyday or community use 17

18 BWSTT stepping on a motorized treadmill while unloading some body weight with harness system, with guided legs and various speed of walking according to patients tolerance afferent feedback body image and locomotion incomplete injury 18

19 BWSTT replaces PTs increases duration of training while extensive assistance is still needed greater improvement in locomotor ability, motor function and balance than conventional techniques (manual assisted BWSTT)? BWSTT has equivalent effects to conventional rehabilitation consisting of an equivalent amount of overground mobility practice (Dobkin et al. 2006) still under debate 19

20 FES surface electrodes quadriceps, peroneal nerve, gluteal muscles T4-T12 T12 NLI 20

21 FES of the common peroneal nerve in assisting foot clearance during the swing phase to stimulate the ankle plantarflexor muscles to assist push-off at the end of stance and enhance the initiation of the swing phase more complex systems that involve several channels of stimulation that support proper extension as well as foot clearance during swing stimulation of thigh extensor muscles (quadriceps, gluteal muscles) to support extension and standing, as well as stimulation of the common peroneal nerve to assist with swing phase movements. problems: skin irritation, displacement of electrodes implanted electrodes regular use of FES in gait training or activities of daily living can lead to improvement in walking 21

22 combined FES/robotic systems in favour with few studies treatment of postural instability and balance combination with drugs (eg for spasticity).. the human hand will (not) be replaced? 22

23 measured by standardized outcome measures movement/gait analysis SCIM FIM MBI Walking Index for Spinal Cord Injury (WISCI) 10-m m walk test (10MWT) 6-min walk test (6MWT) 23

24 Spinal Cord Independence Measure promoted by ISCoS mobility indoors - 8 mobility for moderate distances ( m) - 8 mobility outdoors (>100 m) - 8 stair management 3 27 /100 24

25 Level Description Client is unable to stand and/or participate in assisted walking. Ambulates in parallel bars, with braces and physical assistance of two persons, less than 10 meters. Ambulates in parallel bars, with braces and physical assistance of two persons, 10 meters. Ambulates in parallel bars, with braces and physical assistance of one person, 10 meters. Ambulates in parallel bars, no braces and physical assistance of one person, 10 meters. Ambulates in parallel bars, with braces and no physical assistance, 10 meters. Ambulates with walker, with braces and physical assistance of one e person, 10 meters. Ambulates with two crutches, with braces and physical assistance of one person, 10 meters. Ambulates with walker, no braces and physical assistance of one person, 10 meters. Ambulates with walker, with braces and no physical assistance, meters. Ambulates with one cane/crutch, with braces and physical assistance of one person, 10 meters. Ambulates with two crutches, no braces and physical assistance of one person, 10 meters. Ambulates with two crutches, with braces and no physical assistance, 10 meters. Ambulates with walker, no braces and no physical assistance, 10 meters. Ambulates with one cane/crutch, no braces and physical assistance e of one person, 10 meters. Ambulates with one cane/crutch, with braces and no physical assistance, stance, 10 meters. Ambulates with two crutches, no braces and no physical assistance, 10 meters. Ambulates with no devices, no braces and physical assistance of one person, 10 meters. Ambulates with no devices, with braces and no physical assistance, 10 meters. Ambulates with one cane/crutch, no braces and no physical assistance, ance, 10 meters. Ambulates with no devices, no braces and no physical assistance, 10 meters. PL Ditunno*,1 and JF Dittuno Jr2 Walking index for spinal cord injury (WISCI II): scale revision, Spinal Cord (2001) 39,

26 10-m m walk test (10MWT) 6-min walk test (6MWT) -? van Hedel HJ, Wirz M, Dietz V. Assessing walking ability in subjects with spinal cord c injury: validity and reliability of 3 walking tests. Arch Phys Med M Rehabil 2005; 86: van Hedel HJ, Dietz V, Curt A. Assessment of walking speed and distance in subjects with an incomplete spinal cord injury. Neurorehabil Neural Repair 2007; 21:

27 PRM specialist in charge of SCI rehabilitation to assess and lead gait training in SCI patient who may profit from it but also to direct rehabilitation goals away from ambulation efforts if it is not achievable or even harmful for the patient difficult decision 27

28 Thank you 28