Journal Club CEU Approval
Contact Hours: 1
AR | FL CE26-803266 | ID
Impact of a limited trial of walking training using body weight support and a treadmill on the gait characteristics of an individual with chronic, incomplete spinal cord injury Physiotherapy theory and practice
JC11Q1
On-demand
$10
On-demand
$10
Webinar Description
Adult SCI Impact of a limited trial of walking training using body weight support and a treadmill on the gait characteristics of an individual with chronic, incomplete spinal cord injury Summary by Nechama Karman, PT, MS, PCS The purpose of this study was to examine the impact of a limited period of training on the gait characteristics of and individual with chronic, incomplete SCI. The subject was 59 years old, 3 years status post C3-4 incomplete (central cord) AIS C injury. At the conclusion of his post-injury episode of PT care (3 mos IP, 3 mos HHC) he was able to walk household distances with (B) platform RW + assist from PCA. He performed daily exercise with his PCA, and attended a free clinic receiving PT and OT intervention 1/wk. He reported no progress in walking ability for an extended period of time prior to the study period (baseline measurements were not taken). The subject was clearly in the chronic phase following his injury, and a brief, lower intensity episode of care was necessary due to scheduling restrictions, as is often the case in outpatient settings. The subjects was power w/c dependent, and walking was limited to “exercise performance,” of a few steps with contact guard /minimum assistance.
The intervention period was 6 weeks long, and treatment was performed twice a week during that period for a total of 10 PWB GT sessions. Support was initially set at 25% BWS, as that was the least amount of support required to elicit the best gait pattern the subject could demonstrate. With less BWS the subject had difficulty clearing during swing, which resulted in excessive frontal plane motion. His physiologic tolerance to training was closely monitored during treatment sessions, and these parameters were used to indicate a need for rest (HR, BP nearing parameters set by physician, RPE 8/10; O2 saturation). In each session the immediate goal was to walk for a total of 30 minutes with rest breaks interspersed as needed. He walked between 24 and 36 minutes per session (within 2 minutes of target for majority of sessions). Initially, manual assistance was provided for heelstrike, to prevent LE scissoring. At the 4th session facilitation shifted from the LEs to the hips, and targeted hip extension and LE loading, reducing lateral sway. Speed progressed from .089 m/s (~.2mph) to .224 m/s (.5mph): this speed was adequate for using a commercially-available treadmill to practice walking closer to home following the intervention period. He did not reach the initial target of 1 m/s which is adequate for community ambulation (~2.2 mph). Interestingly, his walking speed during training never reached the critical speeds necessary to trigger a shift to spinal control of locomotion (central pattern generators, usually 1.5-2 mph)! On day 7 he achieved .536 m/s, (1.2 mph) which became his preferred walking speed, as faster speeds resulted in an increase in toe-drag, and more effortful gait for the patient. The author reports that less conscious gait efforts (achieved with distracting conversation during gait training) yielded a better gait pattern in this individual, as one would expect once the CPGs are in control of modulating walking, however it is unlikely that this individual’s gait efforts were ever being modulated by CPGs at the slow speeds reported in this case study.
CEU Information
Overview
Outcome measures: 6 minute walk test with gait belt for assistance as needed for balance (a measure of gait efficiency), time spent walking (per session), number of rests (per session), total distance walked (per session), walking speed (per session), cadence of gait, waking speed, stride length, stride time, single limb stance time, double limb stance time, step length, step time (spatial and temporal gait characteristics measured with Vicon motion analysis system). OUTCOMES: endurance increased to 9 minutes continuous walking, @ .224 m/s for 159.4 m in 27 min total walking time, to .536 m/s preferred walking speed (plateau day 7). Tolerance continued to improve (length of time, distance before break); 965.6 m in 31 min (final day) while performing dual task (talking). Walking speed increased 284%; Cadence increased 124%; Stride length increased 70%; Stride time decreased from 6.59 to 2.94; Weight shift improvement was evidenced by: decreased stride time, step time, and DLS, indicating more continuous stepping, with decreased pause for balance check & weight shift between steps. He demonstrated an increase in symmetry of SLS time (from .1 sec difference to .04); 6 MWT (endurance) yielded an increase in speed from .172 to .317; distance increased 85%. The subject’s self-selected walking speed was faster than obtained by the motion analysis system (pre & post-test). The author reports established secondary impairments that were present pre-treatment, specifically postural compensations resulting from use of a platform walker including hip flexion, forward weight shift with arms held flexed against the trunk, and a loss of transverse plane motion. As soft tissue changes resulting from immobility may serve to passively restrain normal movement during gait, they could impede progress at this late stage, and with the lower intensity, shorter episode of care implemented in this case. In comparison to cases reported by Behrman, this subject’s functional performance prior to intervention was lower, with a longer interval since his injury, and he underwent a shorter, less intense episode of care. In Behrman’s study, the subject made more functional gains than this subject did. In Behrman’s pediatric case study, the child’s AIS LE motor score did not change despite vast improvement in his walking ability and functional performance.
Webinar Information
Contact Hours: 1
Price: $10
Instructor: Nechama Karman
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