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Walking after Spinal Cord Injury:
The first question that arises in the patient’s mind while he/she is on bed is:
Will I ever walk again?
Inability to walk is the major disability a patient of SCI has. The patient experiences immense social pressure to attain his upright posture and to walk again. Patients having complete lesion above T10 are generally unsuitable for locomotion and they are considered for wheel chair mobility. Whereas patient having lower level lesion or patient with incomplete lesion who has some strength in one or both hip flexors and or quadriceps are more likely to achieve a successful ambulation with the help of some kind of orthosis.
Walking after spinal cord injury leads to large number of physiological benefits in the patient. Some of these are:
Walking after spinal cord injury should be initiated in the patient as soon as patient has mastered in transfer, bed, mat and wheel chair activities. The main aim of Walking after spinal cord injury is to teach functional ambulation to the patient. But there are many physical factors which determine whether a patient can achieve functional Walking after spinal cord injury or not. The first and the foremost, being the level of lesion.
Spasticity, spinal and limb deformities, coordination, stability, renal abnormalities and pressure sores.
Patient’s age, weight, intelligence and motivation also determine his ability to walk. To become a functional ambulatory, patient must possess adequate muscular strength, postural alignment, ROM and sufficient cardiovascular endurance. Patient with high level lesion cannot achieve ambulation because of their inability to stabilize the trunk and pelvis.
A normal walking after spinal cord injury comprises of three basic components. These are:
Walking in SCI patient is assisted with the help of orthosis. The use of orthosis varies according to the level of lesion. For i.e.:
Maintenance of posture is very important before teaching walking after spinal cord injury. The patient must learn to pay attention to sensations in the upper trunk and also learn to compensate for loss of equilibrium reactions in legs and lower trunk.
Prior to ambulatory training balance exercises are taught to the patient to locate his point of balance, learn control of body segments and master in body weight shifting. Balance exercises while standing are taught first in parallel bars and then on mat. Before making patient to stand on parallel bar from wheel chair, putting and removing of orthosis is taught. Putting on and of the orthosis is usually done in sitting and supine position. While standing the locks of the orthosis should be properly locked to prevent falling and maintain stability.
After the fitting of orthosis patient is given appropriate training to stand from the wheel chair with the help of parallel bars and then progression is made with the use of crutches.
Once in upright position between parallel bars, training for different activities such as balancing, co-ordination and strengthening are taught to the patient.
The parallel bar activity can be graded as:
b) Weight transference laterally:
Patient stands with parallel bars and shifts the body weight on one foot the other by alternately pushing over bar. This alternate weight transfer may be done rhythmically causing the moving leg to react repeatedly.
c) Weight transference backward:
d) Weight transference forward:
e) Arm raising forward:
f) Arm raising sideward:
In this procedure, activities are performed, same as above but the arms are raised at sides.
g) Arm swinging:
This activity requires significant upper limb strength.
b) Stepping forward and backward:
This is alternated with stepping backward with one leg, shifting the body weight posteriorly on the backward leg and return to start position
c) Dipping activity:
a) Patient standing between parallel bars distributes his weight on both lower limb and then raises both upper limbs forwards and sideward’s, again forwards and then to starting position.
b) Hip hiking: Patient shifts his body weight to one side and by pushing over parallel bar of same side, raises the hip of other side. Return to starting position.
c) Leg swinging: Patient rises his one leg in the same manner described above and swings the raised leg forward and backward for several counts.
In advanced parallel bar activities, patients are given initial gait training to teach basic fundamentals of gait and to develop proper gait patterns and habits.
a) Drag to gait:
b) Swing to gait:
All the activities performed is same as above, except lifting body of the floor and swinging forward instead of dragging it.
c) Swing through gait:
Same as above, except the body is swing forward and feet are kept beyond the line of hand.
d) Four point gait:
The rest of the distance is covered in same manner.
Another option to use with or instead of braces is electrical stimulation. Functional electrical stimulation (FES) (also called neuroprosthesis) stimulates certain muscles in the legs to do the same job as a brace during walking. For example, a cuff with electrodes (material that transfers an electric current) may be placed around the lower leg that stimulates the muscle that picks up the foot as you take a step. If it works well for you, this may be used in place of a plastic AFO.
The electrodes for electrical stimulation may also be on separate small pads (without the cuff) on the skin or be surgically implanted.
Patient stands between parallel bar facing one bar with both hands on same bar. This activity is performed actively. Progression is made by applying manual resistance at pelvis and thigh
Sideward progression facilitates active abduction of moving limb. It also helps in controlled mobility and weight bearing of opposite supporting limb.
All the activities in this progression is same as that of 4 point forward progression except that all the movements are made in backward direction instead of forward direction. This activity also combines hip extension with knee flexion.
Throughout the regime described above, physiotherapist must assist or guard the patient. Guarding of the patient develops psychological confidence, prevents instability and helps to built rapport.
After that, the patient’s mastery over parallel bar activities progression is made with other devices. Before continuing with the progression of gait training activities outside the parallel bar, emphasis is given over:
Generally in patient of paraplegia, gait training is started with the help of axillary crutches and then progression is made for forearm crutches is that it increases the functional capacity of person during stair climbing.
A crutch given to a patient should properly fit according to his body and for this purpose proper measurement can be done either in standing position or in supine position.
Prior to walking after spinal cord injury with the help of crutches balancing and co-ordination activities, as performed in parallel bars should be practiced with the crutches. When patient becomes master in these activities, gait training with the help of crutches is given. The gait pattern on level surface is taught with the help of axillary crutches. For ascending and descending stairs, forearm crutches are preferred.
If you are eventually walking after spinal cord injury with assistive devices or braces, you may still continue gait training on a body-weight support device to help increase your speed and improve your balance and the timing, coordination, and symmetry of your steps. This is performed without using walking devices or braces. You will receive verbal instructions and manual assistance from your therapist and team.
All levels of gait training activities can be practiced safely in the harness of the body-weight support device, because you cannot fall.
Continued gait training with your therapist will hopefully improve your balance and strength so that you can rely less on devices or braces.
Gait pattern are selected on the basis of patient’s balance, co-ordination, muscle function and weight bearing status. Before giving training for specific gait pattern, some points must be considered.
Gait patterns are taught to the patient according to their level of injury. Progression is made from easier one to harder one.
a) Drag to gait:
b) Swing to gait:
In this gait pattern, all the activities are some as that of drag to gait except that the feet are lifted from the floor and swing to the line of crutches instead of dragging them.
c) Swing through gait:
d) Four point gait:
This pattern provides a slow, stable gait. In this gait, weight is borne on both lower extremities. During ambulation, first one crutch is advanced forward from starting position and then the opposite lower extremity is moved. Progression is made by other crutch and leg.
For e.g. if right crutch is moved first then the left lower limb will advance and then left crutch followed by right lower limb.
e) Two point gait:
This gait is usually not performed by paraplegic patient. Only those patients who have great stability can perform this gait pattern. This gait provides less stability as compared to 4-point gait.
In this gait the opposite crutch and limb are advanced forward together from the starting position and then movement is continued in similar manner. The patient with their orthosis performed this entire gait pattern. A gradual emphasis should be placed on improved timing and speed.
After giving these training, patient should become master of walking after spinal cord injury on the leveled surface. Once the patient gains confidence on level surface, gait training progression is made for stair climbing. During stair climbing training patient are always advised to use the railing if it is present.
For stair climbing, using a railing both crutches are held in one hand. Forearm crutches should always be preferred for stair climbing because these crutches improve function by allowing unrestricted movement at the shoulder.
The easiest pattern of ascending stair is usually to climb the stairs backwards i.e. patient facing the lower step. Steps with handrail must always be preferred, as it gives extra confidence to the patient. While climbing, one hand is over handrail and other crutch in hand, as hands are free in forearm crutch.
Position of patient:
• Patient standing on stairs with one forearm crutch and facing downward.
Action of Patient:
Patient can move upstairs either by four point gait or by swinging both legs upwards together. Four point gait pattern is slower and more stable.
Four point gait pattern:
4 Point Gait:
Same as ascending but movement is done in downward direction.
Position of patient-
Patient standing on step with crutch, facing the lower step.
Action of patient: