Walking-related outcomes for individuals with traumatic and non-traumatic spinal cord injury inform physical therapy practice

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.

Development of Wheeled Mobility indicators to advance the quality of spinal cord injury rehabilitation: SCI-High Project

Background: Wheeled mobility is critical for individuals with Spinal Cord Injury or Disease (SCI/D) related paralysis. The World Health Organization (WHO) developed guidelines highlighting eight steps in wheelchair service delivery: (1) referral and appointment; (2) assessment; (3) prescription; (4) funding and ordering; (5) product preparation; (6) fitting; (7) user training; and, (8) follow-up maintenance/repairs. This article describes the processes used to develop structure, process and outcome indicators that reflect the WHO guidelines within the Domain of Wheeled Mobility rehabilitation for Canadians. Methods: Wheeled mobility experts within the SCI-High Project Team used the WHO guideline to inform the Construct refinement and development of a Driver diagram. Following seven meetings, the Driver diagram and review of outcome measures and literature synthesis regarding wheelchair service delivery informed indicator selection and group consensus. Results: The structure indicator examines the proportion of SCI/D service providers within a rehabilitation program who have specialized wheelchair training to ensure prescription, preparation, fitting, and maintenance quality. The process indicator evaluates the average number of hours of wheelchair service delivery provided per patient during rehabilitation. The intermediary outcome indicator (rehabilitation discharge), is a target capacity score on the Wheelchair Skills Test Questionnaire (WST-Q). The final outcome indicators (at 18 months post rehabilitation admission) are the Life Space Assessment (LSA) and the Wheelchair Use Confidence Scale (WheelCon) short form mean scores. Conclusion: Routine implementation of the selected Wheeled Mobility structure, process and outcome indicators should measurably advance care within the Wheeled Mobility Domain for Canadians living with SCI/D by 2020.

Feasibility of predicting improvements in motor function following SCI using the SCAR outcome measure: a retrospective study

STUDY DESIGN

A retrospective study.

OBJECTIVES

To assess improvement in volitional motor function after SCI, using The Spinal Cord Ability Ruler (SCAR) as a metric and investigate participant characteristics and recovery of motor functioning.

SETTING

A highly-specialized SCI rehabilitation unit (Spinal Cord Injury Centre of Western Denmark, SCIWDK).

METHODS

Retrospectively, data on all SCI patients admitted to SCIWDK between 1 January 1997 and 1 November 2018 were extracted from a database. The SCAR score (range: 0-100) was calculated by combining items from ISNCSCI and SCIM.

RESULTS

Mean (95%CI) improvement in volitional motor function was of 17.2 (CI: 14.5-19.9) equal to an improvement of 43% from baseline after median 155 days in-hospital rehabilitation. Individuals with tetraplegia exerted larger improvement (mean difference of 8.9 (CI: 3.6-14.2) points) as compared to paraplegia. Male gender predicted better improvement (p < 0.03), as did no need for mechanical ventilation with a gain of 8.5 (CI: 1.8-15.3) points as compared to those in need.

CONCLUSIONS

Overall mean improvement of 43% in volitional motor function was found in 84 in-hospitalized patients using SCAR as a metric at a highly-specialized SCI unit. Following factors; level-of-injury, gender, age, need of ventilation support predicted improvement in volitional motor function after a rehabilitation period. Results should be cautiously interpreted as a majority of hospitalized patients did not fulfill criteria for SCAR scoring. Prospectively designed studies with better internal validation and external validations are needed to confirm these findings.

Prognostic validity of a clinical trunk control test for independence and walking in individuals with spinal cord injury

Objective: The objective of the present work was to determine the prognostic validity of the trunk control test for walking and independence in individuals with SCI.Design: A cohort, prospective study was carried out in all individuals with sub-acute SCI.Setting: All inpatients at the Mexico City based National Rehabilitation Institute (INR).Participants: Ninety individuals with a clinical diagnosis of sub-acute SCI, American Spinal Injury Association Impairment Scale (AIS) A-D, and that have not participated in a rehabilitation program were included. Thirty-five individuals had good initial trunk control and the remaining 55 had poor trunk control. All individuals participated in a standard rehabilitation program subsequently.Interventions: N/AOutcome Measures: The trunk control test was performed at baseline. At 1, 3, 6, 9 and 12 months after the first evaluation, walking and independence were assessed.Results: Survival Analysis revealed that 62.5% and 100% individuals with good trunk control at baseline assessment were respectively walking and independent in ADL at 12 months and 14% and 48% individuals with poor trunk control were walking and independent in ADL. Cox regression analysis revealed that individuals with good trunk control were 4.6 times more likely to walk independently at 12 months and 2.9 times more likely to be independent in activities of daily living.Conclusion: The present study revealed that the trunk control test is useful for providing a prognosis of independence and walking at 1 year in individuals with SCI, independently of the neurologic level and the severity of the injury.

Trunk strength and function using the multidirectional reach distance in individuals with non-traumatic spinal cord injury

CONTEXT

Trunk control is essential to engage in activities of daily living. Measuring trunk strength and function in persons with spinal cord injury (SCI) is difficult. Trunk function has not been studied in non-traumatic SCI (NTSCI).

OBJECTIVES

To characterize changes in trunk strength and seated functional reach in individuals with NTSCI during inpatient rehabilitation. To determine if trunk strength and seated reach differ between walkers and wheelchair users. To explore relationships between trunk and hip strength and seated functional reach.

DESIGN

Observational study.

SETTING

Two SCI rehabilitation facilities.

PARTICIPANTS

32 subacute inpatients (mean age 48.0 ± 15.4 years).

OUTCOME MEASURES

Isometric strength of trunk and hip and function (Multidirectional Reach Test: MDRT) were assessed at admission and within 2 weeks of discharge. Analysis of variance was conducted for admission measures (MDRT, hip and trunk strength) between walkers and wheelchair users. Changes in MDRT, hip and trunk strength were evaluated using parametric and non-parametric statistics. The level of association between changes in values of MRDT and strength was also examined.

RESULTS

Significant differences between walkers and wheelchair users were found for strength measures (P < 0.05) but not for MDRT. Left- and right-sided reaches increased in wheelchair users only (P < 0.05). Associations between changes in hip strength, trunk strength, and reach distance were found (R = 0.67-0.73).

CONCLUSION

In clinical settings, it is feasible and relevant to assess trunk, hip strength, and MRDT. Future studies require strategies to increase the number of participants assessed, in order to inform clinicians about relevant rehabilitation interventions.

Who is going to walk? A review of the factors influencing walking recovery after spinal cord injury

The recovery of walking function is considered of extreme relevance both by patients and physicians. Consequently, in the recent years, recovery of locomotion become a major objective of new pharmacological and rehabilitative interventions. In the last decade, several pharmacological treatment and rehabilitative approaches have been initiated to enhance locomotion capacity of SCI patients. Basic science advances in regeneration of the central nervous system hold promise of further neurological and functional recovery to be studied in clinical trials. Therefore, a precise knowledge of the natural course of walking recovery after SCI and of the factors affecting the prognosis for recovery has become mandatory. In the present work we reviewed the prognostic factors for walking recovery, with particular attention paid to the clinical ones (neurological examination at admission, age, etiology gender, time course of recovery). The prognostic value of some instrumental examinations has also been reviewed. Based on these factors we suggest that a reliable prognosis for walking recovery is possible. Instrumental examinations, in particular evoked potentials could be useful to improve the prognosis.