This is a case of 65 years old healthy woman who fell from seven steps and had a loss of consciousness for few minutes almost a year and a half ago.
Learning to walk again after SCI
The patient sustained C7 cervical spinal cord injury (SCI) from a fall. Her injury was classified as ASIA A SCI and she had to undergo cervical spinal fusion after the injury. She received basic rehabilitation at the hospital and had few complications like PNA and UTI during her hospitalization. She came to our facility for neurorehabilitation. Gait training was the most difficult task for my patient to achieve after her injury. And of course, gait training was one of her main goals. This article summarizes her progress in rehab and the creative ideas I had to use during her gait training.
Her status at the time of evaluation was as below:
|Bed mobility||Max A 2|
|Functional transfer||Totally dependent|
|Upper Body Dressing||MOD A|
|Lower Body Dressing||Max A|
|Toileting and Hygiene||Totally dependent|
|Feeding||Min A with adaptive equipment|
She went through aggressive physical and occupational therapy for 5 to 7 days a week for almost a year and a half after her injury. The plan of care included increasing and normalizing tone of BLE and BUE, neuro facilitatory techniques to facilitate active movements, improving the strength of muscles of intact muscle fibers, and neurodevelopmental techniques like mat exercises, weight bearing, and joint approximation techniques, stretching etc.
This patient was improving greatly with the plan of care. She was showing better improvements in upper extremities than lower extremities. Also, the left leg was weaker and had less voluntary control out of all four extremities. After eight months of aggressive rehab, her functional status was as below:
|Bed mobility||MOD A|
|Functional transfer||MAX A 2 with FWW|
|Ambulation||Started pre gait training, still no functional ambulation|
|Upper Body Dressing||Supervision after setup|
|Lower Body Dressing||Max A mainly on left lower extremity.|
|Toileting and Hygiene||Totally dependent|
|Feeding||Independent with adaptive equipment.|
For my patient, gait training was the most difficult task after her SCI. The MMT on left leg showed following results:
- Hip Abductors: 1/5
- Hip flexor (group): 2+/5
- Hip extensors: ⅕
- Knee extensors: ⅗
- Knee flexors: 3+/5
- Ankle Dorsi flexors: 0/5
- Ankle Plantar flexors: ⅗, resulted in foot drop while pre gait training.
Putting it all together for functional ambulation:
As you see, the main muscles that act during our gait cycle on the same side, are either very weak or not acting ( in other words, these muscles are not firing or generating enough force that is needed for gait cycle or to advance the leg). The right leg demonstrated at least ⅗ on MMT for all major muscle group. So in reality, when my patient stood up with a walker, she could advance her right leg with me supporting her left knee (to prevent sudden buckling) but was not able to perform any movement afterward. At that point, I had to put her on a mat again, and start with basic neuro facilitatory techniques to activate hip flexors, extensors, and hip abductors. The initial stage was to start with gravity eliminated plane at first. I also used neuro re-education with electrical stimulation to activate those big and bulky muscles passively (hams, quads, glutes etc). I concentrated on activating those muscles for another two weeks. Along with this, my patient was doing home exercises to strengthen quadriceps and to activate hip extensors very diligently (at least I like to think she was doing it!!).
After two weeks for this regime, when she got back on her feet with a walker, I did not have to support the left knee when she is advancing the right leg. But she could still not advance the left leg independently. I could feel her activating hip extensors and abductors. She was unable to perform hip flexion, knee extension, and ankle dorsiflexion simultaneously to advance the leg for heel strike. She could only perform hip flexion and knee flexion and ankle plantar flexion.
Use of Wrap, Brace, and Splint – Being Creative!!
Now, I started wrapping her knee to prevent knee flexion and applied tubigrip ( small sock-like material on top of a gripped sock) to “slide” the heel easier with her foot drop. Then, I passively perform hip flexion (ACE wrap will keep the knee in extension, and Tubigrip will allow me to slide the heel on the floor easily) to advance the leg!! We performed around 10 feet with my patient advancing right leg independently and me advancing the left leg. There was a visible sign of happiness and satisfaction on her face. We continued to do the same almost daily after all strengthening and mat exercise in PT session. In a week or so, she was able to get to 50 feet with me just “pushing/sliding” hip a little bit to initiate the flexion. Overall, I was providing Moderate assistance for gait training with a walker.
Since my patient was more stable on her feet, I started applying knee brace (it was double upright drop lock) on her left leg. With the use of knee brace, she was able to perform hip flexion with little hip hiking while keeping knee extended and clear the floor to advance the left leg. My patient did not have heel strike response of gait cycle due to her foot drop (the foot drop was not severe, she can bring the ankle in a neutral position actively but cannot perform any dorsiflexion). In PT session, we achieved 75 feet with MIN A with walker and knee brace for the first time!! This was a huge accomplishment for my patient. Now as a clinician, I just need to keep strengthening hip abductors, extensors, and try to activate ankle dorsiflexors on the left side to increase independence with functional ambulation. Also, repetition of gait cycle daily helped to strengthen the neural connection to reproduce the same movement easily. By December of 2016, this patient was able to ambulate 150 feet with walker, and supervision of a skilled physical therapist.
Currently, this patient is not receiving any skilled physical therapy but ambulates with supervision with nursing staff with FWW. She does not need any brace or support to perform ambulation! This was a great achievement for my patient who was not able to move her legs after her injury and was not sure if she could ever stand up on her feet!! With aggressive and consistent skilled physical therapy, the magical results were achieved. We just needed to be patient, consistent and provide a holistic approach.
After SCI (especially ASIA A), it is very difficult to maintain positivity and believe that you are going to be able to get back on your feet. You need to work with different approaches and find out what works for your patient and believe in yourself. That is the most important thing because your patient believes in you! Sometimes it can be depressing and patient will want to give up. As a clinician, you are not sure if you are going to achieve your patient’s goals or not but you are providing the best PT you can think of. You, as a therapist, also need to provide your patient with psychological support, positive thoughts, and keep your patient motivated. Communicate with other team members like social workers, and nursing to get your patient necessary help. When you and your patient are working as a team for the same goal, it becomes “easier” to be a therapist and think critically to achieve “that goal”.