Physical impairment and walking function required for community ambulation in patients with cervical incomplete spinal cord injury

Classification of upper-limb dysfunction severity and prediction of independence in activities of daily living after cervical spinal-cord injury

STUDY DESIGN

Prospective observational study.

OBJECTIVES

Classification of spinal-cord injury and prediction of independence in activities of daily living (ADL) based on performance evaluations such as upper-limb function have not been reported. Therefore, this study aimed to establish a severity classification and calculate cutoff values for independence in ADL using the Capabilities of Upper Extremity Test (CUE-T) for individuals with cervical spinal-cord injury (CSCI).

SETTING

A spinal-cord injury rehabilitation center in Japan.

METHODS

This study included individuals with subacute CSCI. Collected data included the CUE-T and Spinal Cord Independence Measure III (SCIM III) scores. The severity classification was used for the hierarchical cluster analysis using the CUE-T. The cutoff values of CUE-T scores for independence in ADL were calculated using an adjustment model with logistic regression analysis. The dependent variable was binary (independent/non-independent) for each SCIM III Self-care item, and the independent variable was CUE-T.

RESULTS

A total of 71 participants were included in the analysis. The severity of upper-limb dysfunction was classified into four categories using CUE-T. Significant differences in upper-limb function and ADL were observed between clusters. The cutoff values for CUE-T score for independence in ADL ranged from 37 to 91 points. All cutoff values showed good results in the internal validation, sensitivity analysis.

CONCLUSIONS

This study determined the severity of upper limb function in CSCI and the cutoff values of CUE-T scores for independence in ADL. These results may help set criteria and goals for interventions in the clinical and research fields.

SPONSORSHIP

None.

Improvement in Motor and Walking Capacity during Multisegmental Transcutaneous Spinal Stimulation in Individuals with Incomplete Spinal Cord Injury

Transcutaneous multisegmental spinal cord stimulation (tSCS) has shown superior efficacy in modulating spinal locomotor circuits compared to single-site stimulation in individuals with spinal cord injury (SCI). Building on these findings, we hypothesized that administering a single session of tSCS at multiple spinal segments may yield greater enhancements in muscle strength and gait function during stimulation compared to tSCS at only one or two segments. In our study, tSCS was applied at single segments (C5, L1, and Coc1), two segments (C5-L1, C5-Coc1, and L1-Coc1), or multisegments (C5-L1-Coc1) in a randomized order. We evaluated the 6-m walking test (6MWT) and maximum voluntary contraction (MVC) and assessed the Hmax/Mmax ratio during stimulation in ten individuals with incomplete motor SCI. Our findings indicate that multisegmental tSCS improved walking time and reduced spinal cord excitability, as measured by the Hmax/Mmax ratio, similar to some single or two-site tSCS interventions. However, only multisegmental tSCS resulted in increased tibialis anterior (TA) muscle strength. These results suggest that multisegmental tSCS holds promise for enhancing walking capacity, increasing muscle strength, and altering spinal cord excitability in individuals with incomplete SCI.

Effects of the walking independence on lower extremity and trunk muscle activity during straight-leg raising following incomplete cervical cord injury

The purpose of this study was to compare the acceleration and surface electromyography (EMG) of the lower extremity and trunk muscles during straight-leg raising (SLR) in patients with incomplete cervical cord injury according to their levels of walking independence. Twenty-four patients were measured acceleration and EMG during SLR held for 10 s. Data were analyzed separately for the dominant and nondominant sides and compared between the nonindependent (NI) and independent (ID) groups based on their levels of walking independence. Frequency analysis of the EMG showed that the high-frequency (HF) band of the contralateral biceps femoris (BF) in the ID group and bands below the medium-frequency (MF) of the BF and the HF and MF bands of the rectus abdominis in the NI group were significantly higher during dominant and nondominant SLR. During the nondominant SLR, the low-frequency band of the internal oblique and the MF band of the external oblique were significantly higher in the NI group. The ID group mobilized muscle fiber type 2 of the BF, whereas the NI group mobilized type 1 of the BF and types 2 and 1 of the trunk muscles to stabilize the pelvis. This result was more pronounced during the nondominant SLR.

Effect of Age at Injury on Walking Ability Following Incomplete Cervical Spinal Cord Injury: A Retrospective Cohort Study

Introduction

Recently, the cases of elderly individuals with spinal cord injuries are increasing in Japan. For individuals with spinal cord injury, regaining the ability to walk independently after an injury is one of the most important aspects of rehabilitation. Nevertheless, instead of age-optimized programs, uniform rehabilitation programs are currently provided to all patients because there is no information available for predicting prognosis based on age at the time of injury. This study aimed to elucidate the effect of age at the time of injury on the walking ability of patients with incomplete cervical spinal cord injury.

Methods

Of the 1,195 patients registered in the Japan single-center study for spinal cord injury database, those hospitalized within 28 days after injury, followed up for >180 days, had a cervical spinal cord injury, and had a lower extremity motor score of ≥42 points were examined. Patients were stratified into three groups according to the age at the time of injury (≤59, 60-69, or ≥70 years). The walking ability scores and independence levels of mobility were compared; these data were evaluated based on indoor mobility (item 12) and outdoor mobility (item 14) in the Spinal Cord Independence Measure III and Walking Index for Spinal Cord Injury II. All comparisons used data at discharge.

Results

The walking ability scores and independence levels of mobility were significantly lower in the group aged ≥70 years than those in the remaining two groups.

Conclusions

In patients with cervical spinal cord injuries with the same limb function, if the age at the time of injury was ≥70 years, the decline in physical function due to aging exerted a substantial effect on walking ability.

The effects of lower extremity deep sensory impairments on walking capability in patients with incomplete cervical spinal cord injury

Objective: To analyze the impact of lower extremity deep sensory impairment on the walking capability of patients with incomplete cervical spinal cord injury.Design: Retrospective cohort study.Setting: Spinal Injuries Center, Fukuoka, Japan.Participants: Patients with incomplete cervical spinal cord injury who were transferred to the Spinal Injuries Center within 2 weeks of injury and whose progress was monitored for 6 months postinjury were included. Sixty-three patients with a lower extremity motor score of 42 points or more were enrolled. They were divided into lower extremity deep sensory impairment (16 patients) and normal (47 patients) groups, and their walking capability was compared.Interventions: Not applicable.Outcome Measures: Upper and lower extremity motor scores, the presence or absence of deep sensation impairment, and walking capability indices at 6 months postinjury were evaluated.Results: The deep sensory impairment group performed significantly worse than the normal group across items in the Walking Index for Spinal Cord Injury II and in the indoor and outdoor mobility items of the Spinal Cord Independence Measure III. Indoor and outdoor mobility independence levels decreased further in the lower extremity deep sensory impairment group than in the normal group.Conclusions: The presence of lower extremity deep sensation impairments was an important factor affecting the achievement of independent walking capabilities in patients with incomplete cervical spinal cord injury. Hence, when patients with incomplete cervical spinal cord injury undergo walking training, not only their lower extremity muscle strength but also their level of deep sensation impairment must be evaluated.

Gait Training Using a Wearable Robotic Device for Non-Traumatic Spinal Cord Injury: A Case Report

Introduction

We aimed to report the clinical evaluation results of gait training with the Honda Walking Assist Device^® (HWAT) in a patient with spinal cord injury (SCI).

Patients and Methods

A 63-year-old male with SCI (grade D on the American Spinal Injury Association Impairment Scale) underwent 20 HWAT sessions over 4 weeks. The self-selected walking speed (SWS), mean step length, cadence, 6-minute walking test (6MWT), Walking Index for SCI score, SCI Functional Ambulation Inventory gait score, American Spinal Injury Association Impairment Scale grade, neurological level, upper and lower extremity motor scores, modified Ashworth Scale, Penn Spasm Frequency Scale, and Spinal Cord Independence Measure version III were measured on admission, at the start of HWAT, at 2 and 4 weeks post-HWAT, and at discharge. Three-dimensional kinematic gait analysis and electromyographic assessments were performed before and after HWAT.

Results

The patient safely completed 20 HWAT sessions. We found improvements above the clinically meaningful difference in SWS and 6MWT as well as increased hip extension, ankle plantar- and dorsi-flexion range of motion and increased hip extensor, abductor, adductor, and ankle plantar flexor muscle activity.

Discussion

The SWS improved more markedly during the HWAT intervention, exceeding the minimal clinically important difference (0.10 to 0.15 m/s) in walking speed for people with SCI until discharge. Moreover, the 6MWT results at 2 weeks after the start of HWAT exceeded the cutoff value (472.5 m) for community ambulation and remained at a similar value at discharge.

Conclusion

The walking distance (6MWT) and the walking speed (SWS) both demonstrated clinically important improvements following 20 treatment sessions which included HWAT.

Influence of Body Weight Support Systems on the Abnormal Gait Kinematic

In recent years, the Body Weight Support system has been considered to be an indispensable component in gait training systems, which be used to improve the ability to walk of hemiplegic, stroke, and spinal cord injury patients. Previous studies investigated the influence of the Body Weight Support system on gait parameters were based on the implementation with healthy subjects or patients with high assistance. Consequently, the influences of the Body Weight Support systems on gait rehabilitation in clinical practice are still unclear and need further investigation. In this study, we investigated the effects of the two Body Weight Support systems, the active body weight support system and the Counter Weight system, on an abnormal gait, which was generated by restriction of the right knee joint and 3 kg-weight on the right ankle joint. Both Body Weight Support systems improve the gait parameters of the abnormal gait such as the center of mass, the center of pressure, margin of stability, and step parameters. The active Body Weight Support system with the unloading force modulation showed more advanced and better behavior in comparison with the Counter Weight system. The results suggested the applicability of two Body Weight Support systems in clinical practice as a recovered gait intervention.

Comparison of walking quality variables between incomplete spinal cord injury patients and healthy subjects by using a footscan plantar pressure system

The main goal of spinal cord rehabilitation is to restore walking ability and improve walking quality after spinal cord injury (SCI). The spatiotemporal parameters of walking and the parameters of plantar pressure can be obtained using a plantar pressure analysis system. Previous studies have reported step asymmetry in patients with bilateral SCI. However, the asymmetry of other parameters in patients with SCI has not been reported. This was a prospective, cross-sectional study, which included 23 patients with SCI, aged 48.1 ± 14.5 years, and 28 healthy subjects, aged 47.1 ± 9.8 years. All subjects underwent bare foot walking on a plantar pressure measurement device to measure walking speed and spatiotemporal parameters. Compared with healthy subjects, SCI patients had slower walking speed, longer stride time and stance time, larger stance phase percentage, and shorter stride length. The peak pressures under the metatarsal heads and toe were lower in SCI patients than in healthy subjects. In the heel, regional impulse and the contact area percentage in SCI patients were higher than those in healthy subjects. The symmetry indexes of stance time, step length, maximum force, impulse and contact area were increased in SCI patients, indicating a decline in symmetry. The results confirm that the gait quality, including spatiotemporal variables and plantar pressure parameters, and symmetry index were lower in SCI patients compared with healthy subjects. Plantar pressure parameters and symmetry index could be sensitive quantitative parameters to improve gait quality of SCI patients. The protocols were approved by the Clinical Research Ethics Committee of Shengjing Hospital of China Medical University (approval No. 2015PS54J) on August 13, 2015. This trial was registered in the ISRCTN Registry (ISRCTN42544587) on August 22, 2018. Protocol version 1.0.

Ten Meters Walking Speed in Spinal Cord-Injured Patients: Does Speed Predict Who Walks and Who Rolls?

BACKGROUND

Walking speed is assumed to be a key factor in regaining ambulation after spinal cord injury (SCI). However, from the literature it remains unclear which walking speed usually results in independent community ambulation.

OBJECTIVE

The primary aim of this study was to determine at which walking speed SCI patients tend to walk in the community instead of using a wheelchair. The secondary aim was to investigate clinical conditions that favor independent ambulation in the community.

METHODS

Data from SCI patients were collected retrospectively from the European Multicenter Study about Spinal Cord Injury database. We determined a cutoff walking speed at which the patients tend to walk in the community by plotting a receiver operating characteristics curve, using the Spinal Cord Independence Measure for outdoor mobility. Univariate analyses investigated which factors influence independent community ambulation.

RESULTS

A walking speed of 0.59 m/s is the cutoff between patients who do and do not ambulate independently in the community, with a sensitivity of 91.6% and a specificity of 80.3%. Age, injury severity, and lower limb muscle strength have a significant influence on independent community ambulation.

CONCLUSIONS

Patients with an SCI who regain a walking speed of 0.59 m/s tend to achieve a level of walking effectiveness that allows for independent community walking. Although such patients tend to be younger and less severely injured, this walking speed can be a target for locomotor training in rehabilitation and clinical trials that lead to a meaningful outcome level of community walking.

Ambulation following spinal cord injury and its correlates

Objectives:

To assess walking ability of spinal cord injury (SCI) patients and observe its correlation with functional and neurological outcomes.

Patients and Methods:

The present prospective, observational study was conducted in a tertiary research hospital in India with 66 patients (46 males) between January 2012 and December 2013. Mean age was 32.62 ± 11.85 years (range 16-65 years), mean duration of injury was 85.3 ± 97.6 days (range 14-365 days) and mean length of stay in the rehabilitation unit was 38.08 ± 21.66 days (range 14-97 days) in the study. Walking Index for spinal cord injury (WISCI II) was used to assess ambulation of the SCI patients. Functional recovery was assessed using Barthel Index (BI) and Spinal Cord Independence Measures (SCIM). Neurological recovery was assessed using ASIA impairment scale (AIS). We tried to correlate ambulatory ability of the patients with functional and neurological recovery.

Results:

Ambulatory ability of the patients improved significantly using WISCI II (P < 0.001) when admission and discharge scores were compared (1.4 ± 3.5 vs 7.6 ± 6.03). Similarly, functional (BI: 31.7 ± 20.5 vs 58.4 ± 23.7 and SCIM: 29.9 ± 15.1 vs 56.2 ± 20.6) and neurological recovery were found to be very significant (P < 0.001) when admission vs discharge scores were compared. Improvement in WISCI II scores was significantly correlated with improvement in neurological (using AIS scores) and functional status (using BI and SCIM scores) (P < 0.001).

Conclusions:

Significant improvement was seen in WISCI II, BI, and SCIM scores after in-patient rehabilitation. Improvement in WISCI II scores also significantly correlated with functional and neurological recovery.