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

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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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