Introduction to Gait Rehabilitation in Spinal Cord Injury

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Introduction

The walking recovery for patients with spinal cord injury is a target of various rehabilitative approaches. The understanding of prognostic factors influencing the recovery is necessary when choosing the most appropriate therapeutic intervention.This article discusses two approaches in gait rehabilitation and factors that help to predict ambulation recovery for patients with a spinal cord injury.

Plasticity-Based Approach

The plasticity-based approach in gait rehabilitation in spinal cord injury (SCI) arises from the research on activity-dependent neural adaptation and training. The afferent input influences activity-dependent plasticity of the spinal cord which affect the neurobiological control of walking. The examples can be found in the studies by Sherrington, Grillner and Rossignol who looked at the input of hip position and the effect of load on retraining walking after SCI. As the result of these studies, the rehabilitation strategies to regain the ability to ambulate by the patient with a spinal cord injury focused on hip extension, load and other sensory elements to facilitate walking.

In plasticity-based approach a specific task, like locomotion undergoes intensive practice in a specific training environment, while an appropriate sensory input is provided. The training environment may include treadmill with body-weight support (BWS), lokomat, or Exoskeleton. The sensory input can be offered in a form of limb loading and unloading, trunk posture, hip extension, or limb kinematics.

Example: Locomotor training using a Lokomat.

• The goal is to generate stepping in response to specific afferent input associated with the task of walking
• The general guidelines focus on maximising loading of the lower limbs through body-weight support systems or overground walking with assistive devices

Compensatory-Based Approach

Compensation is "a rehabilitation strategy for non-remediable deficits of strength (force-generating capacity), voluntary motor control, sensation, and balance."It is based on the principles that patients use their remaining abilities (compensate) to complete the task, or the task or environment are modified to achieve the established goal.

In compensatory-based approach a task of walking is accomplished with the use of orthosis and assistive devices, and the outcome depends on the degree of motor and sensory loss.

Definitions of Walking Recovery in Spinal Cord Injury

General Definitions

Community ambulation is defined as “independent mobility outside the home, which includes the ability to confidently negotiate uneven terrain, private venues, shopping centres, and other public venues.”

Eight dimensions of community ambulation include the following:

• Ability to manage distances
  • Walk distance from 16 to 677m, depending on the community destination.
• Temporal characteristics
  • Gait velocity, cadence, step length, and step time
• Speed
  • crosswalk speed requirements range from .44 to 1.32m/s, appear to vary by country, and increase with increasing population size.
• ambient conditions
• terrain
• physical load
• attentional demands
• postural transitions
• density (the number of people and objects in the immediate surroundings)

Definitions of Ambulation in Spinal Cord Injury Research

There is no consistency definition of walking recovery after spinal cord injury. The following definitions are used in the publications that discuss predictors for functional outcome of walking:

• Walking recovery is defined as "regained ability to walk independently in the community, with or without the use of devices and braces."
• Functional walking is defined as "the capacity to walk reasonable distances both in and out of home unassisted by another person".
• Outdoor walking is defined "as the self-reported ability to walk more than 100 m outside using one cane, leg orthosis only, or no assistive devices."

Predictors for Functional Outcome of Walking

Motor and Sensory Loss

• Moon et al. have found that hip flexors strength followed by knee extensors are the most important contributors to regain an independent walking in patients with incomplete SCI.
• A clinical prediction rule for ambulation outcomes after traumatic spinal cord injury include motor scores of the quadriceps femoris (L3), gastrocsoleus (S1) muscles, and light touch sensation of dermatomes L3 and S1.
• The score greater than 33 for the motor scores of the quadriceps (L3), big toe extensors (L5), and the light touch sensory score (S1) indicate the likehood of the patient to regain outdoor walking ability one year after spinal cord injury.
• According to Cathomen and colleagues the motor score of the myotomes L2 and L3 allow to differentiate between walkers and non-walkers. The motor score of myotomes L4-S1 are considered prognostic factors for indoor versus outdoor walkers (with and without aids).

Severity of the Lesion

The first examination of the patient with the SCI is performed using The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI). It allows to determine the neurological level of injury, and the severity of the lesion. The ASIA Impairment Scale (AIS) A through D defines the complete and incomplete lesions.

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