Locomotor training within an inpatient rehabilitation program after pediatric incomplete spinal cord injury.(Case Report)(Case study)

Over the past decade, spinal t cord injury (SCI) rehabilitation research has provided physical therapists with guidelines for locomotor training with patients following incomplete SCI. (1-6) These studies used partial-body-weight suspension and treadmill gait training with adults with acute (1-3,5) and chronic (3,6) injuries, with tetraplegia (1-5) and paraplegia, (2,3,5,6) and with various levels of ambulatory capability. Treadmill training is often followed by overground gait training. (l-3,6) The greatest improvements in function and participation have been reported in individuals with an initial American Spinal Injury Association (ASIA) Impairment Scale (7) classification of C and D, (1-6) and the majority of these participants had chronic injuries. When applied to individuals with acute (5) or chronic (8) ASIA B injuries, training did not result in improvements in overground mobility.

A recent multicenter, randomized clinical trial compared 12 weeks of locomotor training using bodyweight-supported treadmill walking with 12 weeks of overground mobility training, including standing or stepping training, or both, during inpatient rehabilitation in individuals with acute incomplete SCI. (9) At the end of the intervention and at follow-up 3 months later, no differences were demonstrated between groups in Functional Independence Measure (FIM) locomotor walking scores for participants with an initial ASIA classification of B or C or in walking speed for participants with an initial ASIA classification of C or D. (9,10) However, overground walking speed was greater in both groups than traditionally achieved after incomplete SCI, with medians of 1.1 m/s (interquartile range=0.8-1.4 m/s) for the treadmill walking group and 1.0 m/s (interquartile range= 0.7-1.5 m/s) for the mobility training group. These results may suggest an important effect of the intensity of training in both groups. Time from injury to initiation of either type of training also was important, with those beginning either intervention within 4 weeks of injury demonstrating better outcomes on all measures at both the 12-week and follow-up assessments than those beginning training 4 to 8 weeks after injury. (9,10)

Children under the age of 16 years accounted for 3.7% of traumatic SCIs reported by the Model Spinal Cord Injury Systems (MSCIS) between 1973 and 2003. (11) This percentage, however, likely underestimates the percentage of children in the total population, as young children are frequently treated in pediatric facilities instead of in MSCISs. There is no evidence of the effectiveness of intensive locomotor training in young children following incomplete SCI. Neuromaturation of the central motor pathways is known to continue until adolescence, (12-15) yet little is known of the potential for these processes to interact with the training-induced plasticity of the nervous system that occurs with locomotor training. (16,17)

The primary purpose of this case report is to describe and report outcomes of a comprehensive inpatient rehabilitation program with a locomotor training component in a child with a severe incomplete SCI. A secondary purpose is to demonstrate the feasibility of implementing such a program in the clinical rehabilitation setting, as measured by patient tolerance, use of personnel, and cost.

Case Description