Stephanie Myers, PT, DPT.

Improved bilateral lower extremity strength, gait and balance following non-traumatic spinal cord injury.


History
23 year old male admitted to the hospital on August 16, 2010 for hemoptysis.  On August 16, 2010 he had a thoracotomy and left lower lobe wedge resection. He had removal of previous thoracic spine hardware with an aortic interposition graft placement. He had inpatient rehabilitation from August 30 to September 16, 2010. He then began outpatient PT at Avera McKennan on September 17, 2010.  His primary goals were to improve gait so he did not have to rely on his manual wheelchair, improve his balance and his leg strength.

Initial evaluation
On September 17, 2010, this pt presented in a manual wheelchair.

Gait: He was able to ambulate 90 feet with the use of a FWW and B AFO’s with MOD A. Pt. demonstrated decreased foot clearance with swing through phase of gait bilaterally and utilized his upper extremities significantly with gait. Pt. also demonstrated hyperextension of bilateral knees with stance phase of gait.

Balance: Sitting balance was good with upper extremity support at the edge of mat table; static standing with FWW and B AFO’s MIN A, dynamic balance MOD-MAX A in standing.

Transfers: Pt. performed sit pivot and stand pivot transfers with FWW and MIN A. Sit to stand from wheelchair MIN A, stand to sit to wheelchair MIN A due to leg weakness and pt. plopping into chair.

Strength: measured with microfet 2: measures #’s of muscle force: ave of 3 trials in sitting (high setting): R hip flex: 7, L hip flex: 6.7 (3/5 B); all others unable to use microfet secondary to 0 readings; R knee ext 2-/5, L knee ext 2-/5; R and L knee flex 1+/5; R and L hip abd/add 2-/5, R ankle eve: 2/5, L ankle eve: 2-/5, R ankle Inv: 0/5, L ankle Inv: 1/5, R/L ankle DF: 0/5.

Treatment Progression

Patient received outpatient PT 4x/wk and aquatic PT 3x/wk from November to March 2010 and then 2x/wk aquatic and 3x/wk land from March to May 2011 and from May to discharge in June 2011, 2x/wk land PT.

In PT initially treatment consisted of gait training, standing balance, supine and sidelying exercises and RT300 FES leg system.  This patient was very involved in his case. He was seen initially on the RT300 lower extremity system with the therapist for instruction in and education on the FES cycle and its set up and take down. The patient utilized the FES cycle in addition to his PT sessions independently for 20-35 minutes beginning 2-3 times a week and then he wanted to perform daily and sometimes two times a day for 20-30 minutes each session if the RT300 was not being used by other clients. One of those sessions he placed the electrodes on bilateral quadriceps/hamstrings and gluteals and the other session he alternated between quads and hamstrings with tibialis anterior and gastrocnemius. 

This patient ended up getting a home FES cycle from his insurance company.

Final Presentation
Gait: Pt. was able to ambulate with MI using SBQC and B AFO’s x 200 feet with improved step length. He was able to ambulate with FWW, community distances with MI. He was able to reach into cupboards to get out plates, carry plate to the table, carry syrup bottle to table and carry water jug full to and from the table with SBA and no loss of balance using SBQC.

Balance: Pt. scored 21/28 with SBQC on Tinetti gait and balance test using B AFO’s.

Transfers:  Pt. was able to perform sit<>stand and SPT with SBQC and MI.

Strength: re-tested with Microfet 2 (measures #’s of muscle force: ave. of 3 trials on high setting) R hip flex: 23 (4/5), L hip flex: 20.3 (4/5 ); R knee ext: 10 (3/5), L knee ext: 6 (3/5) ; ( he was unable to get >0 in previous months), R hip abd: 13.7, L hip abd: 17, R hip add: 13.7, L hip add: 9.3; In sidelying: R hip abd: 26.3; L hip abd: 18.7 (4/5 B); R knee flex with roll between knee and support at knee to avoid substitution: 4.3, L knee flex: 5; R and L ankle DF 1/5, R and L ankle Inv 2/5, R ankle L ankle Eve: 3/5. 

Treatment consisted of neuromuscular re-education, therapeutic exercise, therapeutic activity, gait training, aquatic ther ex and FES bike program. The addition of FES LE cycling was very important with this patient’s recovery. He was very involved in his care and through the use of electrical stimulation; he was able to progress with his overall strength, balance, gait and independence with functional mobility. He stopped by the clinic approximately 2 months after discharge and he reached his goal of being able to use a STC in the community and was able to live independently in his own home. The LE FES cycle was vital in the success and progression of this patient. It has been highly utilized in our clinic and will continue to be an important tool in recovery for our neurological population.