LOCOMOTOR TRAINING AND AQUATIC THERAPY IN COMBINATION WITH ACTIVITY-BASED RESTORATIVE THERAPIES TO IMPROVE THE EFFICIENCY OF GAIT IN SPINAL CORD INJURY: A SINGLE CASE STUDY
Kelly M. Joslyn*, Albert Recio
ICSCI-Physical Therapy, Kennedy Krieger Institute
PURPOSE: The purposes of this case report were to 1) describe the outcomes of a 32 year old female with SCI whose primary goal was to improve her ambulation, 2) determine the effects of a combination of locomotor training, aquatic therapy, and ABRT as a strategy to improve gait.
BACKGROUNDS/SIGNIFICANCE: In individuals with a SCI, regaining locomotor function is typically a primary goal. Locomotor training involves partial body weight supported treadmill training consisting of manual cues for muscle activation and proper gait mechanics. Aquatic therapy can be used in the treatment of SCI. Current research has shown aquatics to be beneficial in the treatment of spasticity, stroke, cerebral palsy, and numerous other diagnoses. Spasticity is a major health problem for the SCI population because it not only limits mobility and affects independence, but it leads to pain, decreased range of motion, and impaired ambulation. ABRT is a rehabilitation intervention with scientific premises based on activity-dependent neural plasticity proven to exist at both brain and spinal cord level, where changes in the neurons and muscular system are driven by repetitive activation of the neuromuscular system below injury level. Currently no studies exist that focus on the combination of locomotor training, aquatic effects of buoyancy and ABRT to improve gait. It is proposed that the combination of these three interventions will produce better results than any one intervention alone in improving gait in the adult SCI population.
SUBJECTS: A 32 year old African American female diagnosed with C4 ASIA D spinal cord injury secondary to transverse myelitis in April of 2000. Her primary goal was to walk without any assistive devices and to regain anormal gait pattern.
METHODS AND MATERIALS: A retrospective single subject case report examining the effects of locomotor training, aquatic therapy and ABRT on improving efficiency of gait. A rehabilitation program was designed to strengthen muscles weakened by the diagnosis, improve range of motion in the major muscles responsible for gait, and to improve overall gait mechanics through treadmill training both on land and in water.
Patient was prescribed ABRT to facilitate neuronal recovery with stimulation of central pattern generators. ABRT includes: overground and treadmill gait training, neuromuscular electrical stimulation for trunk and lower extremity strengthening, range of motion, tone management, and proprioceptive neuromuscular facilitation to retrain normal patterns of movement.
Patient was evaluated and reassessed on a monthly basis. Initial evaluation revealed the following impairments: Bilateral LE spasticity with MAS scores between 2-3/4, diffuse LE weakness, decreased standing balance, right hip pain, foot drop, decreased ROM most noted in the hamstrings, hip flexors, hip adductors and plantarflexors. Her activity limitations included requiring walker for ambulating, having pain and fatigue with ADLs and community ambulation, and frequent falls. She participated in land therapy three days a week for two months consisting of locomotor training and ABRT interventions. Then added aquatic therapy was added making a total of five days of therapy a week for two months. Objective measures assessed were: visual posture and gait analysis, lower extremity tone and manual muscle test, berg balance scale, six minute walk test, 10 meter walk test, tinetti assessment, dynamic gait index (DGI), and ASIA scores.
ANALYSES: The patient completed 64 of 83 of skilled physical therapy sessions. The monthly measurements were not only compared against each other but also to the measurements pre-study. ROM in the lower extremities increased by 5.5% at the right popliteal fossa assessing hamstrings ROM. At the completion of the study patient reported having increased safety in gait as evidenced by 100% reduction on the number of her falls. There was also a 100% improvement in her report of right hip and knee pain which improved from 8/10 pain to 0/10 pain.
Over a period of 3 months of therapy, patient’s ASIA classification improved from C4 ASIA D to C5 ASIA D. Motor scores improved by 15%. She progressed from being ambulatory with a walker to ambulating with two straight canes over various surfaces and ambulating without assistive device within her home environment. Patient has demonstrated improvement in ADL’s and outlook in life.
RESULTS: Normal gait speed without upper extremity support improved from 42.9 to 64.8 cm/second. Fast gait speed, in which the patient was instructed to ambulate as fast as safely possible, without an assistive device improved from 34.7 to 90.5 cm/second. Ten meter walk performance improved from 20.31 seconds without an assistive device to 12.87 seconds signifying an improvement in gait speed. Step length equalized at normal and fast gait speeds with and without assistive devices. Berg balance test scores improved from 43/56 to 50/56 decreasing her risk for falls. Six Minute Walk Test scores improved from a continuous 364 feet without an assistive device to a continuous 590 feet without an assistive device signifying improvements in endurance. Ten meter walk test scores improved from 20.31 seconds with no assistive device to 12.87 seconds signifying an improvement in gait speed. DGI score improved from a 9/24 to 18/24 and Tinetti assessment improved from 20/28 to 25/28 signifying improvements in balance and gait efficiency. The patient also subjectively saw great improvements in her independence and confidence with ambulating in the community.
CONCLUSIONS: Improvements can be seen in the efficiency and safety of gait following an intensive program that combines locomotor training, aquatics, and ABRT.
FUNDING SOURCE: Not applicable
KEYWORDS: Spinal Cord Injury, Aquatic Therapy, Locomotor Training
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