Low level Paraplegia

Definition:
It is paralysis or weakness of both lower-limbs due to bilateral pyramidal tract lesion in the spinal 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 or 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-lished including: 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 test is done by firm passive plantar flexing of the toes and foot. This will result in spontaneous "withdrawal reflex" i.e. spontaneous flexion of the
1

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 the shock 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.
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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.

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)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:

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 twodiaphragm, 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 measurement 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 rehabilitation to document changes in ventilation (Wetzel, 1985). Patients can also be instructed to vary their breathing rate 6

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 clinician 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 performing this technique.

Postural Drainage . 7

back. Percussion is applied bilaterally, directly below the scapulae. Postural drainage with percussion and vibration may be necessary 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

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 unpleasant 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 comfortable 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 precipitated by hypoxia Passive movement and stretching Positioning: The supine position (Fig. 4.1A) 9

When supine, the patient is positioned in the following way. Lower limbs Hips extended and slightly abducted Knees extended but not hyperextended Ankles dorsiexed 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 10

 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 dorsiexed to approximately 45 Fingers slightly exed 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 necessary, 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 exed suf ciently to obtain stability with two pillows between the legs and with the upper leg lying slightly behind the lower one Ankles dorsiexed Toes extended. Upper limbs 11

 Lower arm shoulder exed 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 hipick position. In patient phase The same as icu plus Dermatome

L1 L2 L3 L4 L5 S1 S2 S3, 4, 5

Upper 1/3 front of thigh Middle 1/3 front of thigh Lower 1/3 front of thigh Antero-lateral aspect of thigh, front of knee, antero-medial aspect of leg, medial aspect of foot and big toe Lateral aspect of thigh, lateral aspect of leg, middle 1/3 of dorsum of foot and middle 3 toes Postero-lateral aspect of thigh and leg, lateral 1/3 of dorsum of foot and little toe Posterior aspect of thigh, leg and sole of foot 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 12

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 13

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 important requirements for assuming the posture need consideration. Full hip flexor ROM is necessary: if limitations exist. the patient's ability to achieve the needed hip extension 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 partiCLIlarly important given the relative anterior instability inherent in the posture. Although kneeling provides an impOltant 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 transitions into kneeling, both the patient and the therapist are initially 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 upright position as well as with moving the patient's hips toward 14

extension. The patient's hands are supp0l1ed on the therapist's shoulders, which assists in guiding the upper trunk in the desired 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. Weightshifting activities provide the important benefit of promoting the simultaneous action of synergistic muscles at more than one joint. In addition, the joint approximation and stimulation of proprioceptors further enhance joint stabilization (cocontraction). Since the kneeling posture must be stabilized 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 maintenance 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 15

is needed for adjustments in response to changes in the COM (perturbation) or changes in the SUpp011 surface (tilting). Anticipatory 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 partial 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 inhibitory 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 disassociate (break up) symmetrical limb patterns. Halfkneeling 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 osteoarthritis affecting the knee, patients with knee joint instability, 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 independent floor-to-standing transfers. b-Standing control 16

Normal Postural Synergies Normal postural strategies for maintaining upright stability and balance include: ~ Ankle strategy involves small shifts of the COM by rotating 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 exing 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

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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 ngers over the anterior superior iliac spine. With the hands in this position, the therapist can pull the pelvis back with her ngers (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. 18

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 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 shoulders. 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 ef ciency in balance, strength and control, resisted trunk exercises in the standing and lifting positions and resisted hitching are also given. 19

Passive stretch in standing Where strong spasm in the hip exors and abdominal muscles prevents the patient from assuming the erect posture, a passive stretch can be given. The therapist gives 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 nds easiest. Forwards technique Severe abdominal and/or exor spasticity which prohibits the necessary 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 disadvantage and a balanced lift is impossible. 20

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).

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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 alternative method is shown in Figure 13.10E. The short patient reaches back with his hands, releases the crutch handles and grasps the armrests. Such patients may be able to stand up in the same way. To prevent trauma, which could result in haemorrhage and bursa formation, 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 22

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.

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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. 24

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To get down and up from the oor onto crutches Crutches to oor The therapist stands behind the patient and controls the pelvis, feet and legs, as necessary: 26

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 suf ciently exed for the outstretched hand to reach the oor. 2. Balance on the right crutch, release the left crutch and put the left hand on the oor (Fig. 13.14C). 3. Balance on the left hand, release the right crutch and put the right hand on the 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 dorsiexed 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 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). 27

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.

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Gait training There are three types of gait used: swing-to gait 29

 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 rst 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 accomplished walker, it is usual to commence training with the four-point gait. It is easier to learn to use the latissimus dorsi muscles at rst 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 rst. 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). Action of the patient 1. Balance in the hyperextended position. 2. Move the hands, either separately or together, forward along the 30

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). 31

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 32

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

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(FES) STANDING SYSTEMS For the past 30 years, experiments have been undertaken to enable patients to walk using electrical stimulation of the relevant muscles. 35

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 exor withdrawal response for walking. To stimulate more muscles is impractical as it is too time-consuming. Surface stimulation 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 36

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 erectile 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 t, as energy consumption is high. Patients gain the usual benets from standing and walking with these systems, and Jaeger et al (1990) found psychological bene ts also, in that the patients self-esteem and con 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 37

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 dysreexia during treatment in patients with lesions above the splanchnic out 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, 38

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 39

 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 40

 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)

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Four-point gait This gait is the slowest and most difcult of all and is only achieved on crutches by accomplished walkers. It facilitates turning and manoeuvring in con 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 emphasizes 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. Action of the patient 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. 42

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 insuf 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 suf 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 ip the leg backwards. Swing-through gait This gait requires skilled balance, but it is the fastest and most 43

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. Action of the patient 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 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 considerable, and all patients are initially unstable and fearful. A high degree of balance skill is essential and this is only achieved with persever44

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 rst 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 abdominal muscles. Some young and active patients with lesions between T6 and T10, with or without a spinal brace, may also become ef cient and independent. Patients can climb the stairs either forwards or backwards. The forwards technique is usually taught rst 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 exor spasticity, the degree of hyperextension easily obtainable at the hip joints 45

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 technique 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 nd 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 46

(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 ick the pelvis backwards (Fig. 13.13B). 4. Drop the feet onto the stair below (Fig. 13.13A).

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