2012 Annual Conference

Lauren Szot, PT, DPT, NCS

TIRR Memorial Hermann Rehabilitation Hospital, Houston, TX; Texas Woman's University; Houston, TX

The discovery of the spinal cord’s capacity for activity-dependent plasticity has caused a shift from use of compensatory to recovery-based rehabilitation approaches. Locomotor training via manual- and robotic-assisted body weight supported treadmills have been utilized by physical therapists (PTs) to promote motor learning and walking recovery by minimizing compensatory strategies. The focus on enhancing recovery may cause PTs to question whether orthoses have a positive or negative impact on motor recovery, challenging them with the decision to use orthotic devices for walking re-training. While ankle-foot orthoses (AFOs) may alter kinematics, afferent input, and ground reaction forces during walking, they have been shown to increase gait speed, step length, stability, and walking ability. The purpose of this case study is to describe the walking outcomes despite early orthotic management of an individual with an incomplete spinal cord injury (SCI) after combining compensatory and recovery intervention approaches.

A 39-year-old male with a T11 incomplete SCI

The individual with an incomplete SCI participated in task-specific interventions for recovery of walking in an outpatient program 5 months post injury.  Treatments (67 total) were 3x/week for 1 hour. Sessions included 20-30 minutes of locomotor training on a treadmill using body weight support (BWS) with 15 minutes of overground walking 2x/week and overground walking and functional training 1x/week. After 4 weeks, bilateral solid ankle AFOs were prescribed and later converted to posterior leaf spring (PLS) AFOs for running re-training. AFOs were worn during training to improve kinematics and stance stability to reduce need for BWS, upper extremity support, and manual assistance from PT in order to maximize lower extremity weight bearing during walking and functional tasks.

Improvements in walking speed, endurance, and balance as well as progression from assistive devices (ADs) and orthoses were noted. Self-selected walking speed improved from 0.63 meters/second (m/s) using lofstrand crutches to 1.37 m/s using no AFOs and no AD. Walking endurance, measured by the 6 Minute Walk Test, improved from 612 feet with a rolling walker (at 1 month) to 1,054 feet using solid ankle AFOs and lofstrand crutches (at 2 months), to 1087 feet with bilateral PLS AFOs and no AD (at 3 months), and to 1581 feet with no AFOs and no AD (at 4 months). Running overground was initiated and improved from 325 feet in 64 seconds (1.65 meters/second) to 325 feet in 45 seconds (2.23 meters/second). Balance improved from 13/30 to 26/30 on the Functional Gait Assessment.

In clinical practice the question arises of whether an orthosis reduces muscle activity, delaying motor recovery. The findings in this case demonstrate the capacity for motor learning to occur in an individual with an incomplete SCI despite use of compensatory strategies such as orthotic devices during walking re-training.

Clinical decision making regarding the use of ADs, braces, and training environments for recovery of walking after spinal cord injury differs when using a compensatory versus a recovery approach. Thus, both approaches may be beneficial for PTs practicing in clinics where treadmills with BWS or robotic assist are unavailable.