|
COPYRIGHT 2007 American Physical Therapy Association, Inc.
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
Patient
Information regarding the patient's injury and acute hospitalization were obtained from medical chart review in a manner that complied with the Health Insurance Portability and Accountability Act requirements for disclosure of protected health information. Both parents gave written consent for the case to be reported. The patient also signed an assent of a minor statement.
The patient was a 5-year, 10-month-old girl injured in a motor vehicle accident. Her Glasgow Coma Scale (18) score in the emergency department was 13/15. A computed tomography (CT) scan of her cervical spine revealed fractures of C4 and C5 with normal alignment. Magnetic resonance imaging of the cervical spine showed ligamentous injury with edema from C2-C6 and enlargement of the cord with edema consistent with contusion from C3-C5. A CT scan of the head revealed a mild fracture of the left frontal bone, a small left frontal pneumocephalus, and a mild left subdural hematoma. Steroids were administered and a halo brace was placed on her 3 days after injury. The patient was transferred to a pediatric inpatient rehabilitation facility 5 days after the injury with a diagnosis of SCI at C4, an ASIA A classification, and mild traumatic brain injury.
Examination, Evaluation, and Prognosis
The initial physical therapist examination occurred on the day after admission to inpatient rehabilitation. The patient was dependent for all self-care and mobility. She had full passive range of motion in all extremities except that pain limited shoulder elevation bilaterally. She tolerated elevation of the head of her bed to 45 degrees for approximately 30 minutes. She had a neurogenic bowel and bladder. Her cognition was intact. The patient was motivated and had excellent support from her family and community.
The prognosis was that upper-extremity function would improve to allow some self-care skills to be performed with adaptive equipment or assistance. According to research by Crozier and colleagues, (19) the patient's ambulatory prognosis based on sacral sensation was poor. In their review of patients classified as ASIA B 24 hours after injury, those with only light touch sensation in the sacral dermatomes had an 11% chance of becoming functional ambulators compared with 89% of those with light touch and pinprick sensation. Moreover, the patient in this case was classified as ASIA A 24 hours after injury and was not classified as ASIA B until 5 days after injury. The patient was not considered a candidate for gait training at this time due to the severity of her motor and sensory impairment.
Outcome Measures
Initial status and outcomes were assessed at all levels of the International Classification of Functioning, Disability and Health, including impairment (ASIA sensory and motor scores), activity (Functional...
Read the full article for free courtesy of your local library.
|
Bookmark this article
Print this article
Link to this article
Email this article
Digg It!
Add to del.icio.us
RSS
