SELECTION OF PATIENTS

Spinal cord damaged persons.

Our current criteria for selecting chronic SCI spastic paretic patients to enter LB therapy are: presence of some voluntary muscle activity in the lower limbs, particularly the quadriceps femoris; mobility of joints; no severe muscle shortenings, and no skin ulceration or other severe diseases. Missing voluntary hip flexion can be tolerated initially, especially when it can be elicited by facilitating measures in the initial testing on the treadmill (see above). With all patients we thoroughly discuss the possible therapeutic goals based on the results presented and referred to in this report. Thus for patients with low amounts of voluntary activity in their legs and with additional arm and/or rump paralyses hindering the use of crutches or rollators, gain of independent walking is an unlikely outcome, while walking with help is still a realistic outcome . In severely paralyzed paraplegics, even with the use of arms, the possible entraining of stepping may allow limited walking over short distances only. However, aided walking with the help of another person, including or not including stair case climbing, or independent walking for even a few steps only, would be of advantage in daily life, and are thus acceptable therapeutic goals. The leading principle may thus be to enable each patient to reach his/her highest level of individual walking capability by intensive and aided training of upright walking. In general it is important to stress that LB therapy is always combined with training of independent standing up from the wheel chair as well as sitting down and the manoevers connected to this, like curving with the rollator on narrow space, walking backwards for a few steps and so on.

Criteria for selecting acute patients are basically similar as described for chronic patients. Taking into account spontaneous recovery continuing for several weeks after spinal cord damage, LB therapy is started as soon as some voluntary movements in lower limbs appears rather than waiting for spontaneous recovery of motor functions to plateau. In acute patients who have suffered trauma of the spinal column, the safety of the procedure has to be assured by the orthopedic surgeon. With surgical stabilization of the vertebral column (Harms, 1992), the start of walking exercise was usually allowed within a few weeks after trauma (for details see Wernig et al., 1995). Also with acutely spinal cord lesioned patients, LB therapy was usually performed for 5 days a week from the very beginning, which was well tolerated.

The cause of spinal cord injury is not an important criterium but the degree of flaccid paralysis due to cell loss in myelitis or vascular disorders can be a limiting factor. In our collection of patients trauma was most frequent, followed by non-progressive myelitis, tumors, vascular disorders and other causes.