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Dr Jeff Tubbs4/16/14
James S. Krause, PhD, Holly Wise, PhD; PT, and Elizabeth Walker, MPA have disclosed a research grant with the National Institute of Disability and Rehabilitation Research
The contents of this presentation were developed with support from an educational grant from the Department of Education, NIDRR grant number H133B090005. However, those contents do not necessarily represent the policy of the Department of Education, and you should not assume endorsement by the Federal Government.
The Medical University of South Carolina is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The Medical University of South Carolina designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
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Dr. Jeffrey Tubbs does not have any financial disclosures.
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Identify factors associated with the ability to ambulate after SCI
Discuss the prognosis of ambulation based on injury level and functional impairments.
Identify methods for aiding ambulation and gait training following SCI.
Ambulation is an important goal for many with acute SCI
Combat osteoporosis Reduced urinary
calcinosis Reduced spasticity/ROM Improved
digestion/bowel function Prevent pressure ulcers Access items not
accessible at wheelchair level
Psychological
High energy demand Increased weight
bearing through UEs Muscle atrophy Ability to don
orthosis Fracture risk May not be a priority
in acute Inpatient Rehab setting
BENEFITS
Can help slow bone loss…. Standing alone not sufficient to
reverse bone loss after SCI Potentially decreased
spasticity/contracture Bowel/bladder Improvement in orthostatic
hypotension Improved
self-concept/depression Skin Health
(Kirshblum 2011)
CAUTIONS
Fracture risk LE edema No firm recommendations
regarding degree of bone loss at which standing is contraindicated.
Standing FramesTilt TablesOrthotics
Non-ambulatoryExercise
Can stand and take few steps with orthoticsRequires assistance (person, parallel bars…)
HouseholdAmbulate I-Mod I in homeUse WC for longer distances
CommunitySitstandDon/doff orthotics Walk ≥ 150 ft
Requirements (Hussey,
Stauffer 1973)
Bilat hip flexor strength + unilateral Knee Ext ≥ 3/5
Maximum bracing = ▪ 1 long leg brace (KAFO)
+ 1 short leg brace (AFO)
Proprioception ▪ At least hip and ankle
SpasticityROMProprioceptionVisionCognitive statusAerobic capacityUpper body/trunk strengthMuscle AtrophyMotivation(Barbeau et al. 2006)
Depends on… Energy cost Level of independence Cosmesis Orthotic function/reliability Finances
▪ Orthosis, assistive devices, fitting, training, maintanance
Ambulating at Rehab discharge▪ AIS A < 1%▪ AIS B = 1-15%▪ AIS C = 28-40%▪ AIS D = 67-75%
▪ Tetraplegia vs Paraplegia did not significantly affect walking in AIS C-D
(Kay et al. 2007, Burns et al. 1997)
T12 and above (complete injury) Do not expect community or household ambulation
L2 and below Best prognosis for community ambulation
Community ambulation at 1 year Complete Paraplegia = 5% Incomplete tetraplegia = 46% Incomplete Paraplegia = 76%
20-50% AIS B recover ability to walk at 1 year Pinprick preservation more important prognostic ally
(Alekna et al. 2008, Stauffer et al. 1978, Oleson et al. 2005, Waters & Mulroy 1999)
Prognosis for community ambulation at 1 yr based on exam 30 days post injury (Waters et al. 1992, 1994, 1994,1998)
Complete paraplegia▪ LEMS = 0 < 1% LEMS = 1-9 45%
Incomplete paraplegia▪ LEMS = 0 33% LEMS = 1-9 70%▪ LEMS >10 100%
Incomplete tetraplegia▪ LEMS = 0 0% LEMS = 1-9 21%▪ LEMS = 10-19 63% LEMS > 20 100%
Based on LE motor scores hip flexors, hip abductors, hip
extensors, knee extensors, knee flexors
Each muscle graded 0-3 (max score = 30)
AMI = % of max Higher scores associated with…
Faster gait Increased cadence Decreased oxygen cost Decreased force on UE assistive
devices
AMI ≥ 60% required for community ambulation Correlated with maximum of 1 long
leg brace (Waters et al. 1989)
Anyone who wants to… First, do no harm Keeping in mind co-morbidities Setting appropriate, clear goals
Thoracic, Complete injuries Focus on being independent at WC level
first
Reciprocal (alternating) Requirements
▪ Hip flexion ≥ 3/5▪ …or able to compensate
(lifting hip + post pelvic tilt to advance leg)
LEMS is the main determinant of …▪ Speed, cadence, oxygen
consumption
Swing-through (with crutches) Typically used by those with complete injuries
▪ Bilat KAFO▪ Arm strength needed to lift/swing body
Compared to normal ambulation… (Rosman & Spira 1974,
Waters & Mulroy 1999)
▪ 64% slower▪ 38% additional oxygen requirement
KAFO (long leg brace)
Conventional▪ Double metal upright AFO attached to shoes▪ Knee joint▪ Thigh uprights with thigh band
Thermoplastic▪ Lighter, better cosmesis, no shoe attachment▪ More difficult to modify▪ Potential for skin breakdown
▪ Not accommodating for edema, tone, decreased sensation
Swivel WalkerChildrenCaudal to C6Allows ambulation
w/out walking aidsRocking to
alternative sides foot lifted off ground brace swivels due to gravity
Ambulation is slowOnly on level surface
Reciprocating Gait Orthosis (RGO)
Bowden cablesExtension of 1 hip causes
flexion of the otherExtension of trunk
causes extension of stance hip
Gait is slow3-4x energy cost of
normal slow walking10-58% abandonment
rate
Hip Guidance Orthosis (HGO) -Orlau Parawalker
Used in thoracic paraplegia▪ Reciprical gait with crutches
Rigid body brace connected to bilat KAFO
Hips resists adduction/abduction
Uses gravity for swing phase
ParastepTranscutaneous FES
Quads, common peroneal (for hip flex reflex), glut max/paraspinals
Reciprocal gaitControl switches on
walkerCandidates
Complete thoracic SCIIntact lumbo/sacral cord
“The Loco-Motion” 1962 – Little Eva
(#1) 1974 – Grand Funk
Railroad (#1) 1988 – Kylie
Migonue (#3)
Activity based training Repetitive stepping
overground/treadmill while connected to body weight supported system
Variable loading of body weight
Spinal cord can generate rhythmic movements resulting in locomotion w/out supraspinal input (Barbeau et al. 1998)
The basic neuronal circuitries responsible for generating efficient stepping patterns are embedded within the lumbosacral spinal cord.
General scheme of the normal control of locomotion.
Rossignol S Phil. Trans. R. Soc. B 2006;361:1647-1671
©2006 by The Royal Society
However, a CPGs alone not sufficient for overground walking Feedback from other
systems (touch, proprioception, visual, vestibular, cortical…)
Modulation of muscle activity based on the environment
Plasticity of spinal neuronal circuits is largely task specific and use-dependent
Spinal neuronal circuits learn the sensorimotor task that is specifically practiced and trained
Practice walking better walking Practice standing better standing Practice walking ≠ better standing
(Hubli and Dietz, 2013)
C00rdination lower limb muscles in stepping is present in the human lumbosacral spinal cord, however… Cats full weight-bearing stepping with
step training Humans w/complete SCI at the thoracic
level only partial weight-bearing steps
(Edgerton, Harkema and Roy, 2010)
Motor complete and incomplete SCI coordinated leg muscle activation pattern in both legs can be
induced following partial unloading standing on a moving treadmill
Successive reloading might be an important stimulus for leg extensor activation during locomotion in cats and humans
Afferent input is important for shaping locomotor output
(Hubli and Dietz, 2013)
May recognize the “gestalt” pattern of input Feed-forward control
State-Dependent Processing Complete SCI activation of extensor
muscles increases as load bearing increases
(Edgerton, Harkema and Roy 2010)
Concept that spinal cord is not just a relay center Experience dependent
information processing/decision making
All input may provide info to cord in order to recognize temporal events and anticipate what to do next Muscle spindles, GTO, free nerve
endings in muscles/joints/skin(Edgerton, Harkema and Roy 2010)
Implications for anything that reduces afferent input to the spinal cord
Objectives
Progressive loading of LES Timing Leg kinematics Step speed Strength
Types Body Weight Supported Suspension
▪ BWSTT – treadmill Combo with FES Robotic
▪ Exoskeleton
Parachute Harness or Pneumatic Harness Pneumatic closer to normal loading/unloading
gait pattern
Over ground/treadmill LiteGait (2 point attachment) Biodex (1 point attachment)
Robomedica Pneumatic lift, elevated treadmill
Therastride Hardware-software interface for treadmill and
BWS control
LITEGAIT BIODEX
ROBOMEDICA THERASTRIDE
ADVANTAGES Therapist can
perceive level of assistance needed
Higher volume of repetitions per treatment period compared to non-BWS gait training
Therapist can guide the support needed Prevent “bad habits”
DISADVANTAGES
Labor intensive, multiple therapists
Non-ergonomic for therapists
Difficult to control trajectory of joints consistently
Stimulation Quads Hamstrings Gluteal Peroneal N
▪ To get flexion withdrawl response (hip/knee flex, dorsiflex)
Treadmill Lokomat
Footplates Gait Trainer GT-1, HapticWalker, G-EO,
LokoHelpExoskeleton
ReWalk, Ekso, Indego,Tibion Bionic Leg
Active control hip and knee position
Passive control of ankles.
Sensors track force generated at each joint
“guidance control” feature can provide some variability in walking
Goal = Consistent bilat coordinated stepping pattern with normal kinetics
Limited to repetitive walking on level surface
© 2012 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc. 4
FIGURE 3
Robotic-Assisted Gait Training and Restoration.Esquenazi, Alberto; Packel, Andrew; PT, NCS
American Journal of Physical Medicine & Rehabilitation. 91(11) Supplement 3:S217-S231, November 2012.DOI: 10.1097/PHM.0b013e31826bce18
FIGURE 3 . Photo of LokoHelp, courtesy of the manufacturer.
Haptic Walker (commercially available as G-EO
System)
Unconstrained hip/knee joints “adaptive mode” allows for some
kinematic variability during walking
© 2012 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc. 5
FIGURE 4
Robotic-Assisted Gait Training and Restoration.Esquenazi, Alberto; Packel, Andrew; PT, NCS
American Journal of Physical Medicine & Rehabilitation. 91(11) Supplement 3:S217-S231, November 2012.DOI: 10.1097/PHM.0b013e31826bce18
FIGURE 4 . Photo of G-EO in use by a patient with a stroke, courtesy of MossRehab.
Locomotor training trials
Historically▪ Largely nonrandomized▪ No control group▪ Various outcome measures▪ Various training duration/intensity
Wirz et al. 2005, multisite trial▪ N = 20, chronic (>2 yr) motor
incomplete▪ 16 could ambulate
overground (>10m) @ baseline
▪ Up to 45 min, 3-5x/week, x8 weeks
▪ Improved overground walking speed/endurance
▪ No change in walking aids, orthoses, physical assistance
FIELD-FOTE ET AL. 2005
Walking outcomes for chronic, motor incomplete SCI (n = 27)
BSWTT with manual assistance, BWSTT w/FES, BWS overground w/FES, Lokomat
0% became community ambulators
Improvement in walking speed in each group, improved household ambulation
No significant difference b/w groups
FIELD-FOTE AND ROACH, 2011 Single-blind, randomized N= 74 (64 completed
training), chronic motor incomplete SCI
5x/week, 12 weeks Treadmill training with
manual assistance, treadmill/FES, overground/FES, treadmill with robotic assist
Walking speed improved with overground and treadmill-based training
Walking distance improved more with overground training
Cochrane Review (Mehroholz et al. 2008)
Insufficient evidence that any one LT strategy improves walking recovery more than any other
Tefertiller et al. 2011 Review of locomotor training after SCI, CVA,
MS, TBI, Parkinson Supported LT with robotic assistance for
improving walking function after SCI and CVA Gait speed/endurance not significantly
different b/w LT approaches in motor incomplete SCI
Additional potential benefits Metabolism Body composition Attenuating bone loss Cardiovascular Bowel Care/reduced time Pressure ulcer
▪ Increased muscle mass, increased peripheral blood flow, less seating pressure
(Kirshblum 2011)
Full body unloading during robotic assisted walking does not lead to significant leg muscle activation Ground contact is key
Hubli and Dietz, 2013
© 2012 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc. 6
FIGURE 5
Robotic-Assisted Gait Training and Restoration.Esquenazi, Alberto; Packel, Andrew; PT, NCS
American Journal of Physical Medicine & Rehabilitation. 91(11) Supplement 3:S217-S231, November 2012.DOI: 10.1097/PHM.0b013e31826bce18
FIGURE 5 . Photo of ReWalk in use by a patient with complete spinal cord injury, courtesy of MossRehab.
Walking robot, Patient controlled Intended for patients with motor complete
paraplegia
Zeilig et al. 2012, pilot study for safety N = 6 Avg 13-14 training sessions no adverse safety events
Esquenazi et al. 2012 Study of safety and performance Motor complete SCI After training 100% (n = 11) , could transfer and walk
atleast 50-100 m continuously over 5-10 min Self reported improvement in bowel function (n = 5/11),
and spasticity (n = 3/11)
Fineburg et al. 2013 Chronic motor complete (n=6) 1.5-14 yr post injury (5 AIS A, 1 AIS B)
▪ Able bodied controls (n=3) with their normal gait no exoskeleton
Outcomes▪ F-scan in shoe pressure monitoring system to measure
ground reactive force Results
▪ those in ReWalk who could ambulate w/out assistance had vGRF that were similar to able bodied controls (no exoskeleton)▪ If needed min A to ambulate, ~50% compared to able bodied
Parker-Hannifin design concept for the commercial version of the exoskeleton. (Courtesy of Parker-Hannifin)
Esquenazi A, Packel A. Robotic-assisted gait training and restoration. Am J Phys Med Rehabil. 2012 Nov;91(11 Suppl 3):S217-31. Good Review “seek to provide intensive, task-specific
training with high numbers of repititions.” Identify and address underlying components
that are interfering with walking Overground walking would be most “task-
specific” activity for household/community ambulation▪ Consider robotic assisted gait training if cannot
achieve the desired intensity/volume overground
Still unanswered questions regarding locomotor training in SCI: How early to start therapy? How intense should it be? Duration of training?
In general, locomotor training should be challenging with only minimal support by therapists/robot
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2. Barbeau H, Nadeau S, Garneau G. Physical determinants, emerging concepts, and training approaches in gait of individuals with spinal cord injury. J Neurotrauma 2006;23(3-4):571-85.
3. Barbeau H, Pepin A, Norman KE, et al. Walking after spinal cord injury: control and recovery. Neuroscientists 1998;4(1):14-24
4. Burns SP, Golding DG, Rolle WA Jr, et al. Recovery of ambulation in motor-incomplete tetraplegia. Arch Phys Med Rehabil 1997;78:1169-1172.
5. Edgerton VR, Harkema SJ, Roy RR (2010). Retraining the Human Spinal Cord: Exercise Interventions to Enhance Recovery after a Spinal Cord Injury. In Lin VW (2nd Ed), Spinal Cord Medicine: Principles and Practice (939-949). New York, NY. Demos Medical Publishing.
6. Esquenazi A, Packel A. Robotic-assisted gait training and restoration. Am J Phys Med Rehabil. 2012 Nov;91(11 Suppl 3):S217-31.
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8. Field-Fote EC, Lindley SD, Sherman AL. Locomotor training approaches for individuals with spinal cord injury: a prelimary report of walking-related outcomes. J Neurol Phys Ther 2005;29(3):127-137.
9. Field-Fote EC, Roach KE. Influence of a locmotor training approach on walking speed and distance in people with chronic spinal cord injury: a randomized clinical trial. Phys Ther. 2011 Jan;91(1):48-60.
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26. Zeilig G, Weingarden H. Zwecker M. Dudkiewicz I, Bloch A, Esquenazi A. Safety and tolerance of the ReWalk exoskeleton suit for ambulation by people with complete spinal cord injury: a pilot study. J Spinal Cord Med. 2012 Mar;35(2):96-101.