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Ambulation after SCI Dr Jeff Tubbs 4/16/14 Ambulation after SCI Dr Jeff Tubbs 4/16/14

Disclosure of PI-RRTC Grant James S. Krause, Ph. D, Holly Wise, Ph. D; PT, Disclosure of PI-RRTC Grant James S. Krause, Ph. D, Holly Wise, Ph. D; PT, and Elizabeth Walker, MPA have disclosed a research grant with the National Institute of Disability and Rehabilitation Research The contents of this presentation were developed with support from an educational grant from the Department of Education, NIDRR grant number H 133 B 090005. However, those contents do not necessarily represent the policy of the Department of Education, and you should not assume endorsement by the Federal Government.

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Disclosure of Presenter Dr. Jeffrey Tubbs does not have any financial disclosures. Disclosure of Presenter Dr. Jeffrey Tubbs does not have any financial disclosures.

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Objectives Identify factors associated with the ability to ambulate after SCI Discuss the prognosis Objectives Identify factors associated with the ability to ambulate after SCI Discuss the prognosis of ambulation based on injury level and functional impairments. Identify methods for aiding ambulation and gait training following SCI.

Introduction Ambulation is an important goal for many with acute SCI Introduction Ambulation is an important goal for many with acute SCI

Potential Benefits Combat osteoporosis Reduced urinary calcinosis Reduced spasticity/ROM Improved digestion/bowel function Prevent pressure Potential Benefits Combat osteoporosis Reduced urinary calcinosis Reduced spasticity/ROM Improved digestion/bowel function Prevent pressure ulcers Access items not accessible at wheelchair level Psychological

Difficulties High energy demand Increased weight bearing through UEs Muscle atrophy Ability to don Difficulties High energy demand Increased weight bearing through UEs Muscle atrophy Ability to don orthosis Fracture risk May not be a priority in acute Inpatient Rehab setting

Standing Standing

Standing - Benefits BENEFITS Can help slow bone loss…. Standing alone not sufficient to Standing - Benefits BENEFITS Can help slow bone loss…. Standing alone not sufficient to reverse bone loss after SCI Potentially decreased spasticity/contracture Bowel/bladder Improvement in orthostatic hypotension Improved self-concept/depression Skin Health (Kirshblum 2011) CAUTIONS Fracture risk LE edema No firm recommendations regarding degree of bone loss at which standing is contraindicated.

Standing Frames Tilt Tables Orthotics Standing Frames Tilt Tables Orthotics

Levels of Ambulation Non-ambulatory Exercise Household Community Can stand take few steps with orthotics Levels of Ambulation Non-ambulatory Exercise Household Community Can stand take few steps with orthotics Requires assistance (person, parallel bars…) Ambulate I-Mod I in home Use WC for longer distances Sit stand Don/doff orthotics Walk ≥ 150 ft

Community Ambulation Requirements (Hussey, Stauffer 1973) Bilat hip flexor strength + unilateral Knee Ext Community Ambulation Requirements (Hussey, Stauffer 1973) Bilat hip flexor strength + unilateral Knee Ext ≥ 3/5 Maximum bracing = ▪ 1 long leg brace (KAFO) + 1 short leg brace (AFO) Proprioception ▪ At least hip and ankle

Other Factors Spasticity ROM Proprioception Vision Cognitive status Aerobic capacity Upper body/trunk strength Muscle Other Factors Spasticity ROM Proprioception Vision Cognitive status Aerobic capacity Upper body/trunk strength Muscle Atrophy Motivation (Barbeau et al. 2006)

Functional Gait Depends on… Energy cost Level of independence Cosmesis Orthotic function/reliability Finances ▪ Functional Gait Depends on… Energy cost Level of independence Cosmesis Orthotic function/reliability Finances ▪ Orthosis, assistive devices, fitting, training, maintanance

Prognosis Prognosis

Walking during Acute Rehab Ambulating at Rehab discharge ▪ ▪ AIS A < 1% Walking during Acute Rehab Ambulating at Rehab discharge ▪ ▪ AIS A < 1% AIS B = 1 -15% AIS C = 28 -40% AIS D = 67 -75% ▪ Tetraplegia vs Paraplegia did not significantly affect walking in AIS C-D (Kay et al. 2007, Burns et al. 1997)

Gait determination by NLOI T 12 and above (complete injury) Do not expect community Gait determination by NLOI T 12 and above (complete injury) Do not expect community or household ambulation L 2 and below Best prognosis for community ambulation Community ambulation at 1 year Complete Paraplegia = 5% Incomplete tetraplegia = 46% Incomplete Paraplegia = 76% 20 -50% AIS B recover ability to walk at 1 year Pinprick preservation more important prognostic ally (Alekna et al. 2008, Stauffer et al. 1978, Oleson et al. 2005, Waters & Mulroy 1999)

Gait Determination by LEMS Prognosis for community ambulation at 1 yr based on exam Gait Determination by LEMS Prognosis for community ambulation at 1 yr based on exam 30 days post injury (Waters et al. 1992, 1994, 1998) Complete paraplegia ▪ LEMS = 0 < 1% Incomplete paraplegia ▪ LEMS = 0 33% ▪ LEMS >10 100% Incomplete tetraplegia ▪ LEMS = 0 0% ▪ LEMS = 10 -19 63% LEMS = 1 -9 45% LEMS = 1 -9 70% LEMS = 1 -9 21% LEMS > 20 100%

Ambulatory Motor Index (AMI) Based on LE motor scores hip flexors, hip abductors, hip Ambulatory Motor Index (AMI) Based on LE motor scores hip flexors, hip abductors, hip extensors, knee extensors, knee flexors Each muscle graded 0 -3 (max score = 30) AMI = % of max Higher scores associated with… Faster gait Increased cadence Decreased oxygen cost Decreased force on UE assistive devices AMI ≥ 60% required for community ambulation Correlated with maximum of 1 long leg brace (Waters et al. 1989)

Who Should Undergo Gait Training? Anyone who wants to… First, do no harm Keeping Who Should Undergo Gait Training? Anyone who wants to… First, do no harm Keeping in mind co-morbidities Setting appropriate, clear goals Thoracic, Complete injuries Focus on being independent at WC level first

Gait Patterns Reciprocal (alternating) Requirements ▪ Hip flexion ≥ 3/5 ▪ …or able to Gait Patterns Reciprocal (alternating) Requirements ▪ Hip flexion ≥ 3/5 ▪ …or able to compensate (lifting hip + post pelvic tilt to advance leg) LEMS is the main determinant of … ▪ Speed, cadence, oxygen consumption

Gait Patterns Swing-through (with crutches) Typically used by those with complete injuries ▪ Bilat Gait Patterns Swing-through (with crutches) Typically used by those with complete injuries ▪ Bilat KAFO ▪ Arm strength needed to lift/swing body Compared to normal ambulation… (Rosman & Spira 1974, Waters & Mulroy 1999) ▪ 64% slower ▪ 38% additional oxygen requirement

Orthotics KAFO (long leg brace) Conventional ▪ Double metal upright AFO attached to shoes Orthotics KAFO (long leg brace) Conventional ▪ Double metal upright AFO attached to shoes ▪ Knee joint ▪ Thigh uprights with thigh band Thermoplastic ▪ Lighter, better cosmesis, no shoe attachment ▪ More difficult to modify ▪ Potential for skin breakdown ▪ Not accommodating for edema, tone, decreased sensation

Orthotics Swivel Walker Children Caudal to C 6 Allows ambulation w/out walking aids Rocking Orthotics Swivel Walker Children Caudal to C 6 Allows ambulation w/out walking aids Rocking to alternative sides foot lifted off ground brace swivels due to gravity Ambulation is slow Only on level surface

Orthotics Reciprocating Gait Orthosis (RGO) Bowden cables Extension of 1 hip causes flexion of Orthotics Reciprocating Gait Orthosis (RGO) Bowden cables Extension of 1 hip causes flexion of the other Extension of trunk causes extension of stance hip Gait is slow 3 -4 x energy cost of normal slow walking 10 -58% abandonment rate

Orthotics Hip Guidance Orthosis (HGO) Orlau Parawalker Used in thoracic paraplegia ▪ Reciprical gait Orthotics Hip Guidance Orthosis (HGO) Orlau Parawalker Used in thoracic paraplegia ▪ Reciprical gait with crutches Rigid body brace connected to bilat KAFO Hips resists adduction/abduction Uses gravity for swing phase

Orthotics Parastep Transcutaneous FES Quads, common peroneal (for hip flex reflex), glut max/paraspinals Reciprocal Orthotics Parastep Transcutaneous FES Quads, common peroneal (for hip flex reflex), glut max/paraspinals Reciprocal gait Control switches on walker Candidates Complete thoracic SCI Intact lumbo/sacral cord

Locomotor Training “The Loco-Motion” 1962 – Little Eva (#1) 1974 – Grand Funk Railroad Locomotor Training “The Loco-Motion” 1962 – Little Eva (#1) 1974 – Grand Funk Railroad (#1) 1988 – Kylie Migonue (#3)

Locomotor Training Activity based training Repetitive stepping overground/treadmill while connected to body weight supported Locomotor Training Activity based training Repetitive stepping overground/treadmill while connected to body weight supported system Variable loading of body weight Spinal cord can generate rhythmic movements resulting in locomotion w/out supraspinal input (Barbeau et al. 1998)

Central Pattern Generators The basic neuronal circuitries responsible for generating efficient stepping patterns are Central Pattern Generators The basic neuronal circuitries responsible for generating efficient stepping patterns are embedded within the lumbosacral spinal cord.

General scheme of the normal control of locomotion. Rossignol S Phil. Trans. R. Soc. General scheme of the normal control of locomotion. Rossignol S Phil. Trans. R. Soc. B 2006; 361: 1647 -1671 © 2006 by The Royal Society

CPGs However, a CPGs alone not sufficient for overground walking Feedback from other systems CPGs However, a CPGs alone not sufficient for overground walking Feedback from other systems (touch, proprioception, visual, vestibular, cortical…) Modulation of muscle activity based on the environment

Training Plasticity of spinal neuronal circuits is largely task specific and usedependent Spinal neuronal Training Plasticity of spinal neuronal circuits is largely task specific and usedependent Spinal neuronal circuits learn the sensorimotor task that is specifically practiced and trained Practice walking better walking Practice standing better standing Practice walking ≠ better standing (Hubli and Dietz, 2013)

Weight Bearing C 00 rdination lower limb muscles in stepping is present in the Weight Bearing C 00 rdination lower limb muscles in stepping is present in the human lumbosacral spinal cord, however… Cats full weight-bearing stepping with step training Humans w/complete SCI at the thoracic level only partial weight-bearing steps (Edgerton, Harkema and Roy, 2010)

Muscle Activation Motor complete and incomplete SCI coordinated leg muscle activation pattern in both Muscle Activation Motor complete and incomplete SCI coordinated leg muscle activation pattern in both legs can be induced following partial unloading standing on a moving treadmill Successive reloading might be an important stimulus for leg extensor activation during locomotion in cats and humans Afferent input is important for shaping locomotor output (Hubli and Dietz, 2013)

Sensory Input May recognize the “gestalt” pattern of input Feed-forward control State-Dependent Processing Complete Sensory Input May recognize the “gestalt” pattern of input Feed-forward control State-Dependent Processing Complete SCI activation of extensor muscles increases as load bearing increases (Edgerton, Harkema and Roy 2010)

Spinal Cord is Smart Concept that spinal cord is not just a relay center Spinal Cord is Smart Concept that spinal cord is not just a relay center Experience dependent information processing/decision making All input may provide info to cord in order to recognize temporal events and anticipate what to do next Muscle spindles, GTO, free nerve endings in muscles/joints/skin (Edgerton, Harkema and Roy 2010)

Sensory Input Implications for anything that reduces afferent input to the spinal cord Sensory Input Implications for anything that reduces afferent input to the spinal cord

Locomotor Training Objectives Progressive loading of LES Timing Leg kinematics Step speed Strength Locomotor Training Objectives Progressive loading of LES Timing Leg kinematics Step speed Strength

Locomotor Training Types Body Weight Supported Suspension ▪ BWSTT – treadmill Combo with FES Locomotor Training Types Body Weight Supported Suspension ▪ BWSTT – treadmill Combo with FES Robotic ▪ Exoskeleton

BWSTT BWSTT

BWSTT Parachute Harness or Pneumatic Harness Pneumatic closer to normal loading/unloading gait pattern Over BWSTT Parachute Harness or Pneumatic Harness Pneumatic closer to normal loading/unloading gait pattern Over ground/treadmill Lite. Gait (2 point attachment) Biodex (1 point attachment) Robomedica Pneumatic lift, elevated treadmill Therastride Hardware-software interface for treadmill and BWS control

LITEGAIT BIODEX LITEGAIT BIODEX

ROBOMEDICA THERASTRIDE ROBOMEDICA THERASTRIDE

Zero. G Zero. G

BWSTT ADVANTAGES DISADVANTAGES Therapist can perceive level of assistance needed Higher volume of repetitions BWSTT ADVANTAGES DISADVANTAGES Therapist can perceive level of assistance needed Higher volume of repetitions per treatment period compared to non-BWS gait training Therapist can guide the support needed Prevent “bad habits” Labor intensive, multiple therapists Non-ergonomic for therapists Difficult to control trajectory of joints consistently

Functional E-Stim Stimulation Quads Hamstrings Gluteal Peroneal N ▪ To get flexion withdrawl response Functional E-Stim Stimulation Quads Hamstrings Gluteal Peroneal N ▪ To get flexion withdrawl response (hip/knee flex, dorsiflex)

Bioness L 300 plus Bioness L 300 plus

Robotic-Assisted Treadmill Lokomat Footplates Gait Trainer GT-1, Haptic. Walker, G-EO, Loko. Help Exoskeleton Re. Robotic-Assisted Treadmill Lokomat Footplates Gait Trainer GT-1, Haptic. Walker, G-EO, Loko. Help Exoskeleton Re. Walk, Ekso, Indego, Tibion Bionic Leg

Lokomat Active control hip and knee position Passive control of ankles. Sensors track force Lokomat Active control hip and knee position Passive control of ankles. Sensors track force generated at each joint “guidance control” feature can provide some variability in walking

Lokomat Goal = Consistent bilat coordinated stepping pattern with normal kinetics Limited to repetitive Lokomat Goal = Consistent bilat coordinated stepping pattern with normal kinetics Limited to repetitive walking on level surface

FIGURE 3 Robotic-Assisted Gait Training and Restoration. Esquenazi, Alberto; Packel, Andrew; PT, NCS American FIGURE 3 Robotic-Assisted Gait Training and Restoration. Esquenazi, Alberto; Packel, Andrew; PT, NCS American Journal of Physical Medicine & Rehabilitation. 91(11) Supplement 3: S 217 -S 231, November 2012. DOI: 10. 1097/PHM. 0 b 013 e 31826 bce 18 FIGURE 3. Photo of Loko. Help, courtesy of the manufacturer. © 2012 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc. 4

Robotic Haptic Walker (commercially available as G-EO System) Unconstrained hip/knee joints “adaptive mode” allows Robotic Haptic Walker (commercially available as G-EO System) Unconstrained hip/knee joints “adaptive mode” allows for some kinematic variability during walking

FIGURE 4 Robotic-Assisted Gait Training and Restoration. Esquenazi, Alberto; Packel, Andrew; PT, NCS American FIGURE 4 Robotic-Assisted Gait Training and Restoration. Esquenazi, Alberto; Packel, Andrew; PT, NCS American Journal of Physical Medicine & Rehabilitation. 91(11) Supplement 3: S 217 -S 231, November 2012. DOI: 10. 1097/PHM. 0 b 013 e 31826 bce 18 FIGURE 4. Photo of G-EO in use by a patient with a stroke, courtesy of Moss. Rehab. © 2012 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc. 5

Locomotor Training Locomotor training trials Historically ▪ Largely nonrandomized ▪ No control group ▪ Locomotor Training Locomotor training trials Historically ▪ Largely nonrandomized ▪ No control group ▪ Various outcome measures ▪ Various training duration/intensity

Lokomat Wirz et al. 2005, multisite trial ▪ N = 20, chronic (>2 yr) Lokomat Wirz et al. 2005, multisite trial ▪ N = 20, chronic (>2 yr) motor ▪ ▪ incomplete 16 could ambulate overground (>10 m) @ baseline Up to 45 min, 3 -5 x/week, x 8 weeks Improved overground walking speed/endurance No change in walking aids, orthoses, physical assistance

Locomotor Training FIELD-FOTE ET AL. 2005 Walking outcomes for chronic, motor incomplete SCI (n Locomotor Training FIELD-FOTE ET AL. 2005 Walking outcomes for chronic, motor incomplete SCI (n = 27) BSWTT with manual assistance, BWSTT w/FES, BWS overground w/FES, Lokomat 0% became community ambulators Improvement in walking speed in each group, improved household ambulation No significant difference b/w groups FIELD-FOTE AND ROACH, 2011 Single-blind, randomized N= 74 (64 completed training), chronic motor incomplete SCI 5 x/week, 12 weeks Treadmill training with manual assistance, treadmill/FES, overground/FES, treadmill with robotic assist Walking speed improved with overground and treadmillbased training Walking distance improved more with overground training

Locomotor Training Cochrane Review (Mehroholz et al. 2008) Insufficient evidence that any one LT Locomotor Training Cochrane Review (Mehroholz et al. 2008) Insufficient evidence that any one LT strategy improves walking recovery more than any other Tefertiller et al. 2011 Review of locomotor training after SCI, CVA, MS, TBI, Parkinson Supported LT with robotic assistance for improving walking function after SCI and CVA Gait speed/endurance not significantly different b/w LT approaches in motor incomplete SCI

Locomotor training Additional potential benefits Metabolism Body composition Attenuating bone loss Cardiovascular Bowel Care/reduced Locomotor training Additional potential benefits Metabolism Body composition Attenuating bone loss Cardiovascular Bowel Care/reduced time Pressure ulcer ▪ Increased muscle mass, increased peripheral blood flow, less seating pressure (Kirshblum 2011)

Weight Bearing Full body unloading during robotic assisted walking does not lead to significant Weight Bearing Full body unloading during robotic assisted walking does not lead to significant leg muscle activation Ground contact is key Hubli and Dietz, 2013

Exoskeleton Exoskeleton

FIGURE 5 Robotic-Assisted Gait Training and Restoration. Esquenazi, Alberto; Packel, Andrew; PT, NCS American FIGURE 5 Robotic-Assisted Gait Training and Restoration. Esquenazi, Alberto; Packel, Andrew; PT, NCS American Journal of Physical Medicine & Rehabilitation. 91(11) Supplement 3: S 217 -S 231, November 2012. DOI: 10. 1097/PHM. 0 b 013 e 31826 bce 18 FIGURE 5. Photo of Re. Walk in use by a patient with complete spinal cord injury, courtesy of Moss. Rehab. © 2012 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc. 6

Re. Walking robot, Patient controlled Intended for patients with motor complete paraplegia Zeilig et Re. Walking robot, Patient controlled Intended for patients with motor complete paraplegia Zeilig et al. 2012, pilot study for safety N = 6 Avg 13 -14 training sessions no adverse safety events Esquenazi et al. 2012 Study of safety and performance Motor complete SCI After training 100% (n = 11) , could transfer and walk atleast 50 -100 m continuously over 5 -10 min Self reported improvement in bowel function (n = 5/11), and spasticity (n = 3/11)

Re. Walk Fineburg et al. 2013 Chronic motor complete (n=6) 1. 5 -14 yr Re. Walk Fineburg et al. 2013 Chronic motor complete (n=6) 1. 5 -14 yr post injury (5 AIS A, 1 AIS B) ▪ Able bodied controls (n=3) with their normal gait no exoskeleton Outcomes ▪ F-scan in shoe pressure monitoring system to measure ground reactive force Results ▪ those in Re. Walk who could ambulate w/out assistance had v. GRF that were similar to able bodied controls (no exoskeleton) ▪ If needed min A to ambulate, ~50% compared to able bodied

Ekso Ekso

Indego (Vanderbilt/Shephard Center) Parker-Hannifin design concept for the commercial version of the exoskeleton. (Courtesy Indego (Vanderbilt/Shephard Center) Parker-Hannifin design concept for the commercial version of the exoskeleton. (Courtesy of Parker-Hannifin)

Overall Esquenazi A, Packel A. Robotic-assisted gait training and restoration. Am J Phys Med Overall Esquenazi A, Packel A. Robotic-assisted gait training and restoration. Am J Phys Med Rehabil. 2012 Nov; 91(11 Suppl 3): S 217 -31. Good Review “seek to provide intensive, task-specific training with high numbers of repititions. ” Identify and address underlying components that are interfering with walking Overground walking would be most “task-specific” activity for household/community ambulation ▪ Consider robotic assisted gait training if cannot achieve the desired intensity/volume overground

Conclusions Still unanswered questions regarding locomotor training in SCI: How early to start therapy? Conclusions Still unanswered questions regarding locomotor training in SCI: How early to start therapy? How intense should it be? Duration of training? In general, locomotor training should be challenging with only minimal support by therapists/robot

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