Balance training for improving gait in patients with chronic incomplete spinal cord Injury

Posted on 5th March 2014 by Jennifer Ciucevich

Introduction

It was during an acute care clinical of mine that I first was able to work with patients who had just been diagnosed with a spinal cord injury (SCI) leaving him or her completely or partially paralysed. Before my clinical experience working with patients, I was fascinated with the way the body adapts and accommodates to traumatic experiences and changes in neural networking. I cannot say I know what it is like to lose sensation or the use of my extremities, and I will never pretend I do to a patient, but I do want to be able to treat my patients with such impairments so that they may be able to maximize their functional gains. I remember one patient in particular who was involved in a motor vehicle accident, a high school student and a football player.  The boy was eighteen and diagnosed as an incomplete SCI, feeling very little in his legs, but still able to partially control their movement. He was incredibly determined and driven, despite the acute nature of the accident and my clinical instructor and I were able to walk with him for his first steps since the accident. Being able to assist a person in these experiences is what inspired me to look into the research for what some of the best interventions are for patients with spinal cord injury. The following is my review on an article that incorporates balance into therapy sessions as a means to improve walking after SCI.

Walking related to spinal cord injury

It is approximated that half of the spinal cord injuries diagnosed are incomplete. This means that the person likely has some sensory or motor control below the level of the lesion and depending on the severity that patient may be able to walk again one day. Often, this is one of the biggest goals for patients.

About the study

The goal of this study was to determine the efficacy of visual biofeedback task specific standing balance (vBFB) training in improving balance performance and gait in subjects with chronic motor incomplete SCI compared with conventional over-ground rehabilitation. The study was performed as a pilot study in Rome, Italy by the IRCCS Santa Lucia Foundation and was an open case study with a retrospective, matched control. Participants were referred to the spinal cord unit as outpatients for the experimental group while the control group was gathered from the unit’s database that had matching epidemiology, clinical and neurological features.  Inclusion criteria consisted of  an ASIA Level D diagnosis (Motor Incomplete: Motor function is preserved below the neurological level**, and at least half or more of key muscle functions below the NLI have a muscle grade > 3.), patients needed to be of a chronic diagnosis (>12 months post-injury), and were required to have the ability to maintain a standing position unsupported for at least 1 minute. Participants also needed to walk at least 10 m (could use assistive device).  The study also used healthy subjects (without SCI diagnosis) as a means for comparing.

Outcome measures included the ASIA Impairment scale, Berg Balance Scale (BBS), Walking index for SCI (WISCI), 10m-walk test (10MWT), 6 min walk test (6MWT) and the Timed Up and Go (TUG) to assess changes with intervention. Experimental groups received 40 minutes of conventional over ground rehab with 20 minutes of specific vBFB training. The control group received 60 minutes over ground conventional rehabilitation including balance and walking training. All subjects were involved in five sessions per week for eight weeks. The over group training consisted of body weight support treadmill with physical therapist verbal and tactile cues,  an over ground assessment, and community integration.

Results of the study

After eight weeks of intervention both the experimental and control groups improved, but there were more statistically significant improvements in the experimental group. Patients who received the visual biofeedback balance training improved upon their walking times and showed a lower risk of falling (as per TUG measurements).

My thoughts

This study showed that balance training could be an important intervention towards improving gait in patients with spinal cord injuries. While the intervention did not bring the outcome measure scores to the same levels of performance as the healthy subjects, it did bring them closer.  Due to the fact that walking is an important goal for many patients with incomplete SCI, this can assist patients in accomplishing their goals.

Would I use this intervention?

While I would not use a balance intervention as a sole means of treating a patient with an incomplete SCI, there is supportive evidence to suggest that it can benefit patients. While in the clinic I would use balance in tandem with gait training among other task-specific exercises and activities to assist these patients.  I look forward to seeing more research in this area as to best assist patients with chronic and acute spinal cord injuries.

References

Tamburella, F., Scivoletto, G., Molinari, M. Balance training improves static stability and gait in chronic incomplete spinal cord injury subjects: a pilot study. European Journal of Physical and Rehabilitation. 2013; 49: 353-64

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