Low Level Paraplegia

7/28/2019 Low Level Paraplegia

1/48

1

Low level Paraplegia

Definition:

It is paralysis or weakness of both lower-limbs due to bilateral pyramidal tract lesion in thespinal cord(T12 to L4).

Clinical Picture of Focal Paraplegia

A.At the level of the lesion:1. Vertebral manifestations: Only present if the cause is vertebral.

- Localized pain or tenderness. - Localized deformity or swelling.

2. Radicular manifestations: Only present in extra-medullary causes.

a) Posterior root affection:

- Early pain in the back referred to the distribution of the affected root.

- Later, there is hypoesthesia or anesthesia in the dermatome supplied by the

affected root.

b) Anterior root affection: localized L.M.N. weakness in the muscles supplied by the

affected root.

B. Below the level of the lesion: (cord manifestations):

1. Motor Manifestations: They depend on whether the cause of the lesion is acute o

gradual.

a) If the cause is acute (inflammation, vascular or traumatic), the paraplegia passes

through 2 stages:

Stage of flaccidity due to neuronal shock:

there is sudden paralysis of the lower limbs, associated with complete loss of tone

and absence of reflexes.

Stage of spasticity due to recovery from the neuronal shock:

On recovery from the shock stage, the full picture of U.M.N.L. will be estab-lishedincluding: hypertonia, hyper-reflexia, positive Babinski sign & may be clonus.

b) If the cause is gradual (e.g. neoplastic): The shock stage is absent and there will

be gradual progressive weakness of LL with hypertonia and hyper-reflexia.

N.B: Piere Marie Foix testis done by firm passive plantar flexing of the toes and foot.

This will result in spontaneous "withdrawal reflex" i.e. spontaneous flexion of the


2/48

2

hip, knee and dorsiflexion of the ankle if the paraplegia is passing from extension to

flexion.

2. Sensory Manifestations:

a) If the cause of the lesion is extramedullary, encroachment on the ascending tracts

at the site of lesion results in sensory level below which, all types of sensations are

diminished. There is early loss of sensation in the saddle area (S 3, 4, 5), as the sacral

fibers lie in the outermost part of the spinothalamic tracts in the cord.

b) If the cause of the lesion is intramedullary, there will be a jacket sensory loss

(hyposthetic area with normal sensations above and below it). The sensory loss is of

a dissociated nature i.e. pain and temperature sensations are lost but touch and

deep sensations are preserved;The sensations over the saddle area are preserved

(sacral spare), as the

sacral fibers lie far from the midline lesion.

3. Sphincteric Manifestations: a. In acute lesions: There is retention of urine in theshock stage, followed by precipitancy of micturition.

b. In gradual lesions: There is precipitancy of micturation which may terminate in

automatic bladder when complete transaction of the cord occurs.

* These changes start late in extramedullary lesions and early in intramedullary

lesions as the pyramidal fibers controlling the bladder centre lie medially in the cord.

4.Sexual dysfunction.

5.Impaired sympathetic outflow.

Secondary complications of SCI:

1)Spinal instability.

2)osteoporosis and renal calculi .

3)Heterotopic ossification.

4)Respiratory complications.

5)Pressure sores.

6)Autonomic dysreflexia(hyperreflexia)

7)Orthostatic hypotension.

Physiotherapeutic assessment for traumatic spinal cord injury:

A)History

1)Personal history:

Age: occurs commonly at young age.

Sex :occurs In males more than females.


3/48

3

2)Present history:

Onset: sudden

Course: mainly regressive.

3)Past history:

Head or spinal Trauma

B)Examination:

1)Mental examination:

Mood and affect changes may occur.

2)Motor examination and sensory examination:

Designation of lesion level:

-Neurological level:

The most caudal level of the spinal cord with intact motor and sensory functions

bilaterally.-Motor level:

The most caudal level of the spinal cord with intact motor function bilaterally.

-sensory level:

The most caudal level of the spinal cord with intact sensory function bilaterally.


4/48

4

3)Respiratory assessment

Less important in low level paraplegia as respiratory muscles are free.

Chest expansion

Breathing Pattern

Cough

Vital capacity

4)Skin Examination:

Regular skin inspection should be done and teached to the patient and the family.


5/48

5

5)ADL Examination:

It must be done to determine the functional ability of the patient with cautious so as not to

stress on the fracture site.

It may be assessed by :function independence measures(FIM).

Physical therapy treatment:

Icu phase

- Respiratory management

- Posioning

- Passive range of motion exercises

- turning

respiratory management:


6/48

6

Breathing Exercises

Lateral Expansion

For those patients who have some intercostal innervation

(Tl through Tl2), lateral expansion or basilar breathing

should be emphasized. Patients are encouraged to take deep

breaths as they try to expand the chest wall laterally. PTAs

can place their hands on the patient's lateral chest wall and

can palpate the amount of movement present. Manual

resistance can eventually be applied as the patient gains

strength in the intercostal muscles. Progression to a two

diaphragm, two-chest breathing pattern is desirable.

Incentive Spirometry

Another activity that can be used to improve the function of

the pulmonary system is incentive spirometry. Blow bottles at

the patient's bedside can encourage deep breathing. A meas

urement of a patient's vital capacity can be taken with a

handheld spirometer. Vital capacity is the maximum amount

of air expelled after maximum inhalation. Measurements of

the patient's vital capacity can be taken throughout rehabil

itation to document changes in ventilation (Wetzel, 1985).

Patients can also be instructed to vary their breathing rate


7/48

7

and to hold their breath as a means to promote improved

respiratory function.

Chest Wall Stretching

Spasticity and muscle tightness within the chest wall can

develop. Manual chest stretching may be indicated to increase

chest expansion. The assistant can place one hand under the

patient's ribs and the other on top of the chest. The clini

cian then brings the hands together in a wringing type of

motion. The clinician moves segmentally up the chest. This

procedure is contraindicated in the presence of rib fractures

(Wetzel, 1985). Intervention 12-1 illustrates a clinician per

forming this technique.

Postural Drainage .


8/48

8

back. Percussion is applied bilaterally, directly below the scapulae.

Postural drainage with percussion and vibration may be nec

essary to aid in clearing secretions.

Coughs

Coughs are classified into three deterrent categories, based

on the amount of force the individual is able to generate.

Functional coughs are those that are strong enough to clear

secretions. weak functional coughs produce an adequate

amount of force to clear the upper airways. Nonfunctional

coughs are ineffective in clearing the airways of bronchial

secretions (Wetzel, 1985).

Assisted Cough Techniques


9/48

9

Percussion, vibration and shaking of the chest wall are used to improve secretion

clearance. All these interventions can potentially move the spine. For this reason they

should be used cautiously in acutely-injured patients and only with medical

approval.

Suctioning is used to move secretions from the trachea. However, this is an unpleas-

ant and invasive technique which should only be used when other interventions

fail.

cheostomies can be used. These provide direct tracheal access and are a more com-

fortable and effective way of suctioning secretions. Minitracheostomies cannot,

however, be used for other purposes (e.g. to provide invasive ventilation).

Suctioning can elicit a vagal reflex response which can cause a cardiac arrest. This

is due to loss of supraspinal control of the sympathetic nervous system and is precipi-

tated by hypoxia

Passive movement and stretching

Positioning:

The supine position (Fig. 4.1A)


10/48

10

When supine, the patient is positioned in the following way.

Lower limbs

Hips extended and slightly abducted

Knees extended but not hyperextended

Ankles dorsiflexed

Toes extended.

One or two pillows are kept between the legs to maintain abduction

and prevent pressure on the bony points, i.e. medial condyles and

malleoli.

Upper limbs (for patients with tetraplegia)

Shoulders adducted and in mid-position or protracted, but not

Retracted


11/48

11

Elbows extended; this is particularly important when the biceps

is innervated and the triceps paralysed. If the biceps is overactive,

extension can be maintained by wrapping a pillow round the

forearm, or by using a vacuum splint or making an individual

splint of suitable material.

Wrists dorsiflexed to approximately 45

Fingers slightly flexed

Thumb opposed to prevent the development of a monkey hand,

which is functionally useless.

The arms are placed on pillows at the sides. The pillows should be

high enough under the shoulders to ensure that the shoulders are not

retracted, when damage to the anterior capsule can occur. If the

shoulders are painful and protraction is required, a small sorbo

wedge can be placed behind the joint on either or both sides. If neces-

sary, two pillows should be used under the forearms and hands, as

it is important that the hands are kept higher than the shoulders to

prevent gravitational swelling in the static limbs.

The side-lying or lateral position (Fig. 4.1B)

When lying on the side, the patient is positioned in the following

manner.

Lower limbs

Hips and knees flexed suffi ciently to obtain stability with two

pillows between the legs and with the upper leg lying slightly

behind the lower one

Anklesdorsiflexed

Toes extended.

Upper limbs


12/48

12

Lower arm shoulder flexed and lying in the trough between

the pillows supporting the head and thorax to relieve pressure

on the shoulder

Elbow extended

Forearm supinated and supported either on the arm board

attached to the more sophisticated beds or on a pillow on a table

Upper arm as in the supine position, but with a pillow

between the arm and the chest wall.

For the hipflick position.

In patient phase

The same as icu plus

Dermatome

L1 Upper 1/3 front of thigh

L2 Middle 1/3 front of thigh

L3 Lower 1/3 front of thigh

L4 Antero-lateral aspect of thigh, front of knee, antero-medial aspect of leg, medial aspect

of foot and big toe

L5 Lateral aspect of thigh, lateral aspect of leg, middle 1/3 of dorsum of foot and middle 3

toes

S1 Postero-lateral aspect of thigh and leg, lateral 1/3 of dorsum of foot and little toeS2 Posterior aspect of thigh, leg and sole of foot

S3, 4, 5 Anal, peri-anal and gluteal region (saddle shaped area)

3- Training for postural control

The terms

balance,,equilibrium and and

postural control are used

as as synonyms for

concept of the mechanism

by which the human body

prevents itself from falling

or loosing balance


13/48

13

POSTURAL CONTROL

controlling the bodys position in space

for the dual purposes of stability stability and orientation

POSTURAL ORIENTATION

This involves

The ability to maintain the

appropriate alignment between

body segments

The appropriate relationship

between the body and the

environment

Requires establishing a vertical

orientation to counteract the

forces of gravity.

Creates a reference frame for

perception and action with. respect to the external world.

POSTURAL STABILITY

This involves

Maintaining the bodys centre of

mass within boundaries of space, ,referred to as referred to as stability limits.

Stability limits are boundaries of

an area of space in which the body can maintain its position

without changing its base of support

impairments of postural control in low level para plegia secondary to weakness and sensory disturbance

Good trunk control

Total control of upper extremities

Partial to full control of lower extremities

Imparirment of pelvis control


14/48

14

Impairment in standing control

Impairment in locomotion and gait

A pelvis control

Kneeling: Prerequisite Requirements

Prior to the use of kneeling as an activity, several impor-

tant requirements for assuming the posture need consider-

ation. Full hip flexor ROM is necessary: if limitations

exist. the patient's ability to achieve the needed hip exten-

sion will be compromised. Sufficient strength'of the trunk

and hip extensor muscles is necessary to keep the head

and trunk upright and the hips extended. This is partiCLI-

larly important given the relative anterior instability in-

herent in the posture. Although kneeling provides an im-

pOltant opportunity for improving posture and balance

control. adequate static postural control (ability to keep

the COM over the BOS) is needed for initial maintenance

of the upright posture.

A Kneeling, Assist-toPosition

ACTIVITIES, STRATEGIES, AND VERBAL CUES FOR KNEELING,

ASSIST-TO-POSITION FROM BILATERAL HEEL-SIDING

Activities and Strategies For assisted movement transi-

tions into kneeling, both the patient and the therapist are ini-

tially positioned in heel-sitting facing each other (Fig. 5.2A).

The therapist places one hand on the posterior upper trunk

passing under the axilla: the opposite manual contact is on

the contralateral postel;or hip/pelvis. These hand placements

allow the therapist to assist with lifting the trunk into the up-

right position as well as with moving the patient's hips toward


15/48

15

extension. The patient's hands are supp0l1ed on the therapist's

shoulders, which assists in guiding the upper trunk in the de-

sired direction of movement. The patient and therapist then

move together into a kneeling position.

Position/Activity: Kneeling, Weight Shifting

Weight shifting in kneeling is a closed-chain exercise that

involves motions in which the distal part (knees) is fixed

while the proximal segment (pelvis) is moving. Weight-

shifting activities provide the important benefit of promot-

ing the simultaneous action of synergistic muscles at more

than one joint. In addition, the joint approximation and stim-

ulation of proprioceptors further enhance joint stabilization

(cocontraction). Since the kneeling posture must be stabi-

lized while moving. weight shifting also improves dynamic

stability

Half kneeling

General Characteristics

The posture is more stable than kneeling. Half-kneeling

iJl\oh e, head. trunk. and hip muscles for upright postural

control. The head and trunk are maintained on the vertical in

midline orientation with normal spinal lumbar and thoracic

cur\'es. The peh'is is maintained in midline orientation with

the hip fully extended on the posterior stance limb. As with

kneeling. static postural col/trol is necessary for the main-

tenance of upright posture. Dynamic postural control is

necessary for control of movements performed in the posture

(e.g.. weight shifting or reaching). Reactive balance control


16/48

16

is needed for adjustments in response to changes in the COM

(perturbation) or changes in the SUpp011 surface (tilting). An-

ticipatory balance control is needed for preparatory postural

adjustments that accompany voluntary movements.

Clinical Notes:

o Holding in the posture and weight-shifting activities in the

half-kneeling position provide an early opportunity for par-

tial weightbearing on the forward foot; the position can

also be used to effectively mobilize the foot and ankle

muscles (e.g., for the patient with ankle injury).

. As in kneeling, prolonged compression provides inhibitory

influences on the stance-side quadriceps; there is no in-

hibitory pressure on the quadriceps of the forward limb.

o The asymmetrical limb positioning (one stance limb

and one limb forward with foot flat) can be used to dis-

associate (break up) symmetrical limb patterns. Half-

kneeling is a useful actiVity for the patient with spastic

diplegia (cerebral palsy).

o As with kneeling, half-kneeling may be contraindicated in

some patients, such as individuals with rheumatoid or os-

teoarthritis affecting the knee, patients with knee joint in-

stability, or patients recovering from recent knee surgery.

Position and \cth it~ : Half-Kneeling. Assist-to-Position

Assist-to-position mo\ement transitions into half-kneeling

can be effectivel) accomplished from a kneeling position.

This movement transition is an important lead-up skill to in-

dependent floor-to-standing transfers.

b-Standing control


17/48

17

Normal Postural Synergies

Normal postural strategies for maintaining upright stability

and balance include:

~ Ankle strategy involves small shifts of the COM by rotat-

ing the body about the ankle joints: there is minimal

movement of the hip and knee joints. Movements are

well within the LOS (Fig. 7.3A).

- Hip strategy involves larger shifts of the COM by flexing

or extending at the hips. Movements approach the LOS

- Change ofsupport strategies are activated when the COM

exceeds the BOS and strategies must be initiated that

reestablish the COM within the LOS. These include the

stepping strategy, which involves realignment of the BOS

under the COM achieved by stepping in the direction of the

instability. They also include UE grasp

strategies. which involve attempts to stabilize movement of

the upper trunk. keeping the COM over the BOS.

STANDING A PATIENT WITH A

KNEEANKLEFOOT ORTHOSIS

Standing between parallel bars


18/48

18

Exercises in standing

As control is gained over the upper thorax, the therapist can place

both hands around the hips to support only the pelvis. The hands

are placed along the iliac crest, with the fingers over the anterior

superior iliac spine. With the hands in this position, the therapist

can pull the pelvis back with her fingers (Fig. 13.6A), push it forward

with the heel of her hand (Fig. 13.6B), give pressure downwards

(Fig. 13.6c) or lift upwards. In this way, the therapist has complete

control of the patient and can assist or resist movement in any

direction.


19/48

19

Balance exercises

Watching his position in the mirror, the patient is taught to:

hold, move out of and regain the correct posture

maintain balance whilst lifting one hand off the bar (Fig.

13.4D). Progression is made by moving the arm in all directions,

and later by repeating this with the eyes closed

move both hands forwards and backwards along the bars.

Exercises for strength and control

Before commencing gait training, the patient must learn to tilt his

pelvis by using latissimus dorsi, and to become aware of the degree

of control he can achieve with this compensatory mechanism.

Pelvic side tilting

To hitch the left leg, place the left hand on the bar only slightly in

front of the left hip, and the right hand about half a foot length

further forward. Keeping the elbow straight, press fi rmly down on

the left hand and depress the shoulder.

The leg must be lifted upwards and not forwards.

To lift both feet off the ground and control the pelvis

Place both hands on the bars slightly in front of the hip joints. Push

down on the bars, with the elbows straight, and depress the shoul-

ders. To gain control of the pelvis, the patient should practise holding

himself at both full and partial lift, rotating the trunk and tilting the

pelvis with the feet lifted off the ground.

Resisted trunk exercises

For greater effi ciency in balance, strength and control, resisted trunk

exercises in the standing and lifting positions and resisted hitching

are also given.


20/48

20

Passive stretch in standing

Where strong spasm in the hip flexors and abdominal muscles pre-

vents the patient from assuming the erect posture, a passive stretch

can be given. The therapist gives fi rm pressure forwards with her hip

against the patients sacrum, and with her hands pulls backwards

over the front of the shoulder joints.

If the position is maintained for a few moments the spasticity

usually relaxes and the patient is able to maintain his balance.

Transfer training

To transfer from chair to crutches

An unaided exit from a chair is essential if crutch walking is to be

functional. There are three techniques used to get into and out of the

chair with crutches:

forwards technique

sideways technique

backwards technique.

All three methods are taught where possible, and the patient chooses

that which he finds easiest.

Forwards technique

Severe abdominal and/or flexor spasticity which prohibits the neces-

sary hyperextension at the hips, or excessive height, may prevent a

patient accomplishing this technique. When the patient is well over

average height with the extra length primarily in the legs, the elbows

are higher than the shoulders with the crutches in position for the

lift. Latissimus dorsi and triceps are thus at a mechanical disadvan-

tage and a balanced lift is impossible.


21/48

21

The therapist

The therapist stands in front of the patient astride the legs and ready

to give support with her hands around the scapula region (Fig.

13.9AD).


22/48

22

Action of the patient

1. Check the position of the chair and swing away or remove the

footplates. During early training, when the weight distribution

may be incorrect, a feeling of stability is given if the chair is

backed against a wall.

2. Sit well back in the chair (Fig. 13.10A).

3. Place the crutches midway between the front and rear wheels,

level with each other and equidistant from the sides of the

chair (Fig. 13.10B). To avoid rotation during the lift, the

position of the crutches must be accurate.

4. Lean forward over the crutches and balance.

5. Lift on the crutches, adducting and extending the shoulders.

6. The feet are lifted backwards, and as the weight goes onto

them, hyperextend the hips and retract the shoulders (Fig.

13.10C).

7. When balanced, move the crutches forward and assume the

correct standing position (Fig. 13.10D).

To sit down, reverse the procedure, as in Figures 13.10DA.

If the physical proportions of the patient are suitable, an alterna-

tive method is shown in Figure 13.10E. The short patient reaches

back with his hands, releases the crutch handles and grasps the arm-

rests. Such patients may be able to stand up in the same way. To

prevent trauma, which could result in haemorrhage and bursa forma-

tion, sitting down should be done slowly without bumping on the

chair.

Sideways technique

Some patients of below average height are able to get out of the chair


23/48

23

using one crutch and an armrest:

1. Put the left arm through the forearm support, position the left

crutch and grasp the armrest.

2. Turn through 45 towards the left armrest.

3. Place the right crutch in front and to the left of the midline of

the chair.

4. Lift on both arms (Fig. 13.11A, B).

5. With the weight on the feet, balance on the right crutch and

grasp the left crutch handgrip.

Reverse the procedure to sit down.


24/48

24

Backwards technique

The therapist stands in front of the patient ready to control the pelvis

or legs as necessary.

To turn to the left:

1. Cross the right leg over the left (Fig. 13.12A).

2. Lift the buttocks to the right side of the chair (Fig. 13.12B).

3. Turn the trunk to the left, moving the left hand to the right

armrest and the right hand to the left armrest (Fig. 13.12C).

4. Push on both armrests to stand (Fig. 13.12D) facing the chair.

5. Hitch the feet to the left (Fig. 13.12E).

6. Put each hand through the crutch forearm supports and return

to holding the armrests (Fig. 13.12F).

7. Grasp the handgrips in turn.

8. Walk backwards away from the chair (Fig. 13.12G).

Reverse the procedure to sit down.


25/48

25


26/48

26

To get down and up from the floor onto crutches

Crutches to floor

The therapist stands behind the patient and controls the pelvis, feet

and legs, as necessary:


27/48

27

1. From the standing position on the mat (Fig. 13.14A), walk the

crutches forward one by one (Fig. 13.14B) until the hips and

trunk are suffi ciently fl exed for the outstretched hand to reach

the floor.

2. Balance on the right crutch, release the left crutch and put the

left hand on the fl oor (Fig. 13.14C).

3. Balance on the left hand, release the right crutch and put the

right hand on the fl oor (Fig. 13.14D).

4. Walk forward on the hands until lying prone (Fig. 13.14E).

Floor to crutches

The therapist may need to assist the patient to get the weight over

his feet initially:

1. Lying prone, make sure the ankles and toes are dorsiflexed so

that the feet are vertical (Fig. 13.14F).

2. Position the crutches, tips forward, well in front of the body

and put both forearms through the forearm supports.

3. Press up on the hands, and at the same time use the abdominal

muscles to pull the pelvis towards the hands and so prevent the

legs being pushed backwards.

4. Maintaining the action of the abdominal muscles, walk the

hands towards the feet, trailing the crutches (Fig. 13.14G) until

the weight is over the feet (Fig. 13.14H).

5. Balance on the left hand, grasp the right crutch handgrip and

place the crutch on the fl oor (Fig. 13.14I).

6. Balance on the right crutch and take hold of the left

crutch in a similar manner. Balance on both crutches (Fig.

13.14J).


28/48

28

7. Walk the crutches towards the feet until standing erect (Fig.

13.14K).

To get out of a car onto crutches

1. Turn to face the open door and lift the legs out of the car.

2. Lock the knee joints.

3. With the window open, use the window ledge and the back of

the seat, or the seat and a crutch, to lift into standing.

4. Balance with the hips hyperextended and take hold of each

crutch in turn.


29/48

29

Gait training

There are three types of gait used:

swing-to gait


30/48

30

four-point gait

swing-through gait.

Controlled walking is achieved only through perseverance, perfect

timing, rhythm and coordination. The patient is taught always:

1. to move the hands first

2. to walk slowly and place his feet accurately

3. to take the weight through the feet and so ensure that the

hands can relax between each step

4. to lift the body upwards and not to drag the legs forwards.

An accurate technique must be achieved in bars if crutch walking is

to be successful.

Where it is anticipated that the patient will become an accom-

plished walker, it is usual to commence training with the four-point

gait. It is easier to learn to use the latissimus dorsi muscles at first

separately and then together than vice versa.

GAIT TRAINING IN THE BARS

Swing-to gait

This is the universal gait because it is both the simplest and the safest.

All patients with lesions above T10 are normally taught this gait

first.

The therapist

The therapist stands behind the patient with her hands over the iliac

crests. Assistance is given to lift, to control the tilt of the pelvis and

to transfer weight as necessary (Fig. 13.6AC).


1. Balance in the hyperextended position.

2. Move the hands, either separately or together, forward along the


31/48

31

bars approximately half a foot length in front of the toes.

3. Lean forward, with the head and shoulders over the hands (Fig.

13.6D), and lift the legs, which will swing forward to follow the

position of the head and shoulders. The step is short and the feet

must drop just behind the level of the hands (Fig. 13.6E). To

achieve this, the lift must be released quickly, otherwise the feet

will travel too far and land between or in front of the hands.

When on crutches, it is unstable and therefore dangerous to have

the feet and hands in line. It must therefore be avoided in the

bars. The swing-to gait is a staccato gait with no follow through:

lift and drop.

The patient should also be taught to swing backwards along the

bars.

To turn in the bars

The turn is achieved in two movements by turning through 90 each

time.

To turn to the right:

1. Place the left hand forward about a foot length along the bars and

the right hand either level with or a little behind the trunk.

2. Lift and twist the shoulders and upper trunk to the right. The

feet land facing the bar to the right (Fig. 13.7A).

3. Balance in this position and move the left hand across to the

right bar (Fig. 13.7B).

4. Twisting the upper trunk to the right, place the right hand on

the opposite bar.

5. Lift the feet round to a central position between the bars (Fig.

13.7C).


32/48

32

Benefits of Body Weight Support (BWS) and a Treadmill

Locomotor interventions may be implemented earlier

in the episode of care (compared to more conventional

approaches).

Loading of the UEs is minimized or eliminated owing to

maximal loading of the LEs.

LE loading can be varied based on the patient's ability

to support weight.

Compensatory movement strategies are reduced or

eliminated.

Learned nonuse may be eliminated secondary to

weightbearing and "forced" stepping movements of

more involved segments.

Normal gait kinematics and phase relationships of the

full gait cycle are promoted (e.g., limb loading in

midstance; unweighting and stepping during swing).

The fear of falling is reduced or eliminated.

I :e- and intra-limb locomotor timing and rhythm can

be Dromoted without the demands of supporting the

, 11 body weight.

R m'c input from the constant speed of the TM


33/48

33

he ps 0 reestablish or reinforce coordinated reciprocal

LE patterns.

Using greater BWS and 10wTM velocity, gait

deviations may be addressed early.

Dynamic balance training can be practiced by

decreasing BWS and increasing the TM speed.

Sensory inputs facilitate muscle activation.

Coordinated kinematics of the trunk, pelvis, and limbs

specific to the locomotor task are promoted.

Walking speed and distance improve.

Muscular and cardiovascular endurance improves.

GAIT USING FUNCTIONAL ELECTRICAL STIMULATION


34/48

34


35/48

35

(FES) STANDING SYSTEMS

For the past 30 years, experiments have been undertaken to enable

patients to walk using electrical stimulation of the relevant muscles.


36/48

36

Surface, nerve cuff and deep muscle electrodes have been used. FES

is applied to the intact lower motoneurone pathways and is therefore

only suitable for upper motoneurone paralysis, as with stimulation

of the phrenic nerve (Ch. 5). Initially, FES is used to improve the

condition and bulk of the paralysed muscles. When the state of the

muscles has improved, electronic implants can be used to activate

muscles in functional sequence. Interestingly, 50 years ago Sir Ludwig

Guttmann showed that muscle bulk could be improved in rabbits

(Guttmann & Guttman 1942) and later in humans using galvanic

stimulation (Guttmann & Guttman 1944).

Surface stimulation

Root stimulation gives access to the whole motor output, whilst

surface stimulation reaches only part of it. Usually the gluteal and

hamstring muscles are stimulated for standing, and quadriceps and

the flexor withdrawal response for walking. To stimulate more

muscles is impractical as it is too time-consuming. Surface stimula-

tion is wasteful of current and requires assiduous attention to skin

care, and the stimulation varies with movement of the limbs (Rushton

Three types of implanted electrodes are used:

Percutaneous wires are inserted through the skin and focused on a

motor point. Any number of wires may be used. Formal surgery is not

required and the wires are inserted easily by a practised operator.

This procedure has a high risk of electrode failure and a high

incidence of infection. Cosmesis is unacceptable (Barr et al 1995).

The nerve cuff electrode is placed around peripheral nerves in a

formal surgical procedure.

The epimysial electrode (disc type of electrode) is placed near the


37/48

37

motor point of large muscles. Less dissection is required than for the

cuff type but multichannel lower limb systems still require extensive

surgery and the cabling also has to be implanted in the limb. As cable

connectors tend to fracture, further surgery is often required.

A sacral anterior root stimulator implant (SARSI) has been widely

used to restore bladder control in male and female patients and erec-

tile function in male patients (Brindley & Rushton 1990). A lumbar

anterior root stimulator implant (LARSI) has been used to stimulate

lumbar and sacral roots (L2S2) to restore lower limb function in

two patients. These systems are now commercially available, as are

some surface and upper limb motor locomotor systems.

Stringent criteria are necessary for the selection of patients for any

FES system, which will include psychological as well as physical

assessments. For example, joints must have full range of movement

and be free of osteoporosis and the patient must be physically fit, as

energy consumption is high. Patients gain the usual benefits from

standing and walking with these systems, and Jaeger et al (1990)

found psychological benefi ts also, in that the patients self-esteem and

confi dence appeared to increase. To use a surface system long term

is impractical, but surface stimulation as a non-invasive means of

assessment and training is necessary for an implant system (Barr et

al 1995). Both systems are useful and in many ways complementary

FES does not restore functional gait. It is a form of exercise and

remains experimental. Whatever the technique used, walking speed

is slow and, together with energy consumption, is a limiting factor.

Major technical problems continue to be encountered, for example

in the selection and control of stimulation, failure of equipment and


38/48

38

muscle fatigue.

To replace the intricate mechanism of normal gait is an enormous

task. It is not surprising that progress is slow. Research continues in

many centres worldwide.

In a study to examine the safety of FES, Ashley et al (1993) found

evidence to suggest that there was a danger of autonomic dysreflexia

during treatment in patients with lesions above the splanchnic

outfl ow, i.e. above T6. Extra caution should therefore be employed

with these patients.

Hybrid Assistive Limb 5

While this device has a long list of tasks that will greatly impact fields across all professions, it is being looked at in

hospitals and in medical care for patients who are suffering from illness that make them weak and unable to perform

daily tasks. It is also being used for workers in facilites to help lift items (or humans) that are overweight.

This device is currently on the market, but the thing that will most certainly revolutionize modern medicine which is still

in development is cognitive responses, in the hopes that one day wheelchair-bound individuals may be able to walk.

Lokomat

This leads to an intensive rehabilitation regiment, which dispite the patients hard work can produces limited results.

This is why researchers in Switzerland designed Lokomat, which combines medical and engineering approaches to help

patients regain mobility faster, with less pain. The Lokomat uses a robot to automate treadmill training, giving patients

longer and more frequent sessions and resulting in a faster and improved return to mobility. The robot intelligently

adapts its behavior to the patients individual capabilities.

The walking with Lokomat is said to improve pelvis and hip actuation as the walking is more natural, and the virtual

training environments can increase patients motivation and engagement.

Gait training in different environments

Walking Surfaces

Practice walking on a variety of indoor and outdoor

surfaces.

Indoor surfaces: tile, linoleum, low- and high-pile

carpet, and hardwood and laminate flooring

Outdoor surfaces: sidewalks, concrete, gravel,


39/48

39

asphalt, and grassy terrains

Stair Climbing

Practice stair climbing using a handrail; progress to

stair climbing without the use of a handrail.

Practice stair climbing one step at a time; progress to

step over step; alter requirements for step height and

number of steps.

Obstacles

Practice walking while avoiding or contending with

obstacles in the environment such as the following:

Walking over and around a static obstacle course

created with objects of varying heights and widths

(e.g., step stool, chair, cans, yardstick, stacking cones,

books, and so forth); altering requirements for foot

clearance, step length, step time, and walking

speed

Walking with dynamic (moving) obstacles in the path

(e.g., revolving door, elevator, or escalator)

Walking on varying paths (e.g., changing environment)

Walking with two individuals navigating the same

obstacle course (collision avoidance)

Slopes or Ramps

Practice walking on ramps and slopes of varying

heights.

Gradual incline: using smaller steps

Steep incline: smaller steps using a diagonal, zigzag

pattern (step length decreases with increasing slope


40/48

40

Requirements for navigating slopes or ramps include

the following:

Descent is associated with increased knee flexion

(stance) and increased ankle and hip motions (s ' g;

during descent, peak moments and powers are

higher at the knees.

Ascent is associated with decreased speed, cadence,

and step length.

Open Environments

Practice walking in busy, open, community

environments (e.g., a busy hallway, hospital lobby,

shopping mall, or grocery store).

Practice finding solutions to real-life functional

problems, such as the following:

Pushing or pulling open doors

Pushing a grocery cart

Car transfers: getting into and out of a car

Getting on and off a bus or other public

transportation vehicle

Carrying a bag of groceries

Practice walking and traversing unfamiliar routes and

unfamiliar places.

Practice stepping up and down curbs.

Time Requirements

Practice walking with anticipatory timing requirements,

such as the following:

Crossing at a stoplight


41/48

41

Moving on and off moving walkways

Moving on and off an escalator

Walking through automatic revolving doors

Visual Conditions

Practice walking in varying visual conditions, such as

the following:

Full lighting with progression to reduced and low

lighting

With dark glasses to alter visual conditions

Varied lighting conditions (e.g., outside to inside

lighting)


42/48

42

Four-point gait

This gait is the slowest and most difficult of all and is only achieved

on crutches by accomplished walkers. It facilitates turning and

manoeuvring in confi ned spaces. It also provides an excellent training

exercise in strength, balance and control.

The therapist. The therapist holds the pelvis in the usual way. Both

by instruction and by correction with her hands, the therapist empha-

sizes each move, ensuring that the patient achieves it correctly. Only

when the patient consistently makes a single movement correctly does

the therapist stop correcting that component. The patient needs to

see and feel the correct posture at each move, and therefore constant

repetition is necessary.


To take a step forward with the left leg

1. Place the right hand forward about half a foot length along the

bar and the left one just in front of the hip joint.

2. Take the weight on the right leg, so that the hip is over the

right foot and the knee and ankle in a vertical line.


43/48

43

3. With the left shoulder slightly protracted, push on the left

hand and depress the shoulder (Fig. 13.6F, p. 227). The effort

is to lift the leg upwards.

4. As the left leg is lifted, it swings forward to follow the

shoulder. The lift is released when a large enough step has

been made. (Small steps should be taken initially, but the foot

must always land in front of the hand.)

5. Take the weight over the left leg.

6. Move the left hand forward along the bar in preparation for

moving the right leg. Pelvic rotation must be avoided.

The following are possible reasons for an inadequate lift:

some weight remains on the moving leg

the hands are too far forward

the weight may be over the toes and not back over the heels, in

which case the trunk may be hyperextended and the legs

consequently inclined too far forward

insuffi cient depression of the shoulder girdle on the side of the

moving leg

the bars are too high or too low

the lift is not held for suffi cient time to allow the leg to swing

forward.

To take a step backward with the left leg

1. Place the left hand slightly behind the hip joint.

2. Lift the leg and at the same time lean forward on that side.

3. Bend the elbow and flip the leg backwards.

Swing-through gait

This gait requires skilled balance, but it is the fastest and most


44/48

44

useful.

The therapist

The therapist gives assistance where necessary with her hands

controlling the pelvis until the patient can accurately and slowly

perform the movements. The forward thrust of the pelvis to push the

weight over the feet usually needs to be emphasized.


1. Place the hands forward along the bars as for the swing-to gait.

2. Lean forward and take the weight on the hands.

3. Push down on the bars, depress the shoulder girdle and lift both

legs. The lift must be sustained until the legs have swung forward

to land the same distance in front of the hands as they were

originally behind. Considerably more effort is required than for

the swing-to gait.

4. As the weight is lifted and the legs swing forward, hyperextend

the hips, extend the head and retract the shoulders.

5. To move the trunk forward over the feet, push on the hands,

extending the elbows and adducting the shoulders. When the

weight is fi rmly on the feet, move the hands along the bars for

the next step.

GAIT TRAINING ON CRUTCHES

Progression is made to crutch walking only when the technique

between the bars is good. The height of the elbow crutches is checked

as for the bars.

The change from walking in bars to crutch walking is considera-

ble, and all patients are initially unstable and fearful. A high degree

of balance skill is essential and this is only achieved with persever-


45/48

45

ance and much practice.

Balance exercises

Balance on crutches is trained in the same way as when balancing in

the bars (Fig. 13.8A). Resisted work is also given to enable the patient

to gain adequate control over the trunk and pelvis.

Walking on crutches

Swing-to and four-point gaits are taught first and progression is made

to swing-through (Fig. 13.8B, C). Until the new postural sense is

established training is again carried out in front of a mirror.

Progression in the four-point gait may be made by using one bar

and one crutch if preferred. Otherwise, progression is directly onto

two crutches, as there is less tendency to trunk and pelvic rotation.

The technique for each gait is the same as already described for

walking in bars. Much greater skill is required and several weeks of

practice will be needed to acquire the necessary balance and

coordination.

Stairs

Climbing stairs is normally functional for patients with good abdom-

inal muscles. Some young and active patients with lesions between

T6 and T10, with or without a spinal brace, may also become effi -

cient and independent.

Patients can climb the stairs either forwards or backwards. The

forwards technique is usually taught first because it has the advantage

that the patient can see where he is going. Most agile patients with

good abdominal muscles will learn both methods and make their

own choice. Where there is severe abdominal and/or hip flexor spas-

ticity, the degree of hyperextension easily obtainable at the hip joints


46/48

46

may be too limited for the forwards technique.

Two rails are used initially, progression being made to one rail and

one crutch. Finally, the second crutch must be carried, usually in the

crutch hand, as illustrated in Figure 13.13.

The therapist. The therapist always stands behind the patient. She

holds the trouser band or a therapeutic belt with one hand and grasps

the patient round the waist with the other. After the initial attempts,

both hands should be placed around the pelvis in the usual position

for greater control. Assistance is given, as necessary, until the tech-

nique is mastered.

Forwards technique using one rail and one crutch

To walk upstairs

1. Standing close to the rail, grasp it approximately half a foot

length in front of the toes.

2. Place the right crutch on the stair above, level with the hand

on the rail (Fig. 13.13A). The hands must be level to avoid

trunk rotation when lifting. The tendency to grasp the rail too

far forward and pull must be avoided.

3. Lean over the hands and lift as high as possible, keeping the

trunk and pelvis in the horizontal plane (Fig. 13.13B).

4. As soon as the feet land on the stair above, hyperextend the

hips to find the balance point (Fig. 13.13C).

To walk downstairs

1. Standing close to the rail and keeping the body in the

horizontal plane, place the right crutch close to the edge of the

same stair.

2. Place the left hand down the rail on a level with the crutch


47/48

47

(Fig. 13.13D).

3. Lift and swing the feet down to the stair below (Fig. 13.13E).

4. Hyperextend the hips and retract the shoulders as soon as the

feet touch the ground (Fig. 13.13F).

Very short patients may need to put the crutch on the stair below

the feet and lift down to the crutch.

Backwards technique using one rail and one crutch

To walk upstairs

1. Balance in hyperextension whilst placing the left hand higher

up the rail and the crutch on the stair above, keeping the

hands level (Fig. 13.13F).

2. Lift backwards (Fig. 13.13E).

3. Regain the balance (Fig. 13.13D).

To walk downstairs

1. Place the crutch on the edge of the same stair as the feet, with

the hands level (Fig. 13.13C).

2. Lift the feet backwards to the edge of the stair.

3. Lean forward on the hands, lift and fl ick the pelvis

backwards (Fig. 13.13B).

4. Drop the feet onto the stair below (Fig. 13.13A).


48/48

Documents

Low Level Paraplegia