of motor capability in SCI and stroke patients
In order to be sure of progress in motor rehabilitation,
video documentation and regular measurements are helpful and they
are a must for any scientific work to be done. In the latter case
it is also important to have comparable assessments.
In spinal cord injury the ASIA scores have been in use internationally.
However, for measuring progress in motor rehabilitation in a realistic
way ASIA scores are impractical. Their classification is A=motor
and sensory complete, B=motor complete, sensory maintained, C=sensory
and motor incomplete with less than half of the segmental key muscles
with values of 3 and above and D= more than half of the segmental
key muscles with values of 3 or more. In terms of walking we have
a very unlucky mixture of the function of key muscles important
for defining a segment but not necessarily important for walking;
thus in C and D there can be patients capable of walking as well
as not capable of walking. The same is true to an even higher degree
for the ASIA muscle score: segmental key muscles rather than muscles
relevant for walking are being evaluated.
FRANKEL scale is very practical since it gives a quick
and simple functional assessment, but is not sensitive enough to
measure progress in walking either,
FIM does not even distinguish between locomotion with
and without wheel
For these reasons and to adopt to the progress in
walking we may achieve with LB therapy we have suggested 2 new assessments.
Functional Classes (0 to 5; Wernig-scale see Hicks et al 2005) which
cover the whole range of locomotion (not capable of walking even
with help of 2 therapists to free walking without devices) and dissociates
between patients who are independent or dependent on other persons
for walking. Validity of the test is obvious (test walking by walking
performance), reliability is high (0.84, Maegele et al. 2002)
For muscle function we propose a Cumulated Muscle Index (CMI EU
Functional Classes (0 - 5 ) for locomotion: Minimum
distance: 5 m
Dependent: 0: not capable of walking even with
help from two therapists; 1: capable of walking with moderate help
from 2 therapists; 2: walking at the railing with one therapist.
Independent: 3: rollator or reciprocal frame; 4: Regular crutches;
5: without devices. The classes graphically:
Functional Classes SCI:
The amount of voluntary muscle activity may be evaluated
from the force and range of single joint movements evokable upon
verbal command in defined resting positions (horizontal and sitting),
avoiding readily evokable spastic extension or flexion patterns
(Kendall et al.,1971). Under these rating conditions, values were
defined as follows: 0=no muscle contraction visible or palpable;
1=muscle contraction visible and/or palpable, no movement of limbs;
2=some joint angle movement with passive support by the therapist
balancing gravity; 3=full range of joint angle movement against
gravity; 4=full movement plus maintenance of position against moderate
applied resistance; 5=like 4, against maximal applied resistance.
Values in between were allowed and valued as 1/2 points. Cumulated
Muscle Index: Glutaeus maximus, Glut.med. and min., Iliopsoas, Sartorius,
Quadriceps fem., Ischiocrurales, Tibials ant., Triceps surae.
7.1.3 Assessments for clinical scientific trials
For a study with different interventions to improve locomotion in
SCI persons to compare, the following schedule might be practical.
ASSESSMENTS for SCI persons
Every 2 weeks till end of therapy and at 6, 12 months:
1.Walking capability: FIM-walking (not locomotion
or stairs), EU-
walking (Functional Classes, Wernig et al. 1995)
2. Muscle activity scores for lower limbs: EU-muscle (8 functionally
important lower limb muscles per side) . ASIA -muscle (key muscles
of lower limbs only; as long as the score is in use and EU-muscle
is not yet in general use, both should be done)
3. Ashworth Spasticity Scale, Antispastic medication
At the beginning and end of therapy and at 6 and 12
4. Endurance: Distance walked in 6 min
5. Time to walk 10 m
PLEASE NOTE: Definition of the treatment given to
the control group is obviously important. It appears that more and
more researchers (e.g. Nilsson et al 2001; Kosak et al 2000) choose
to give the control group a very intensive locomotor training, which
was not done a few years ago, when non-ambulating patients were
rather discouraged to consider walking as a primary goal rather
than to try the borders. We realise that this shift in attitude
very much comforts our new dogma: If one wants to walk again one
needs to exercise upright walking (Wernig et al 1991, 1992). If
our previous work has contributed to this dramatic shift in therapeutic
approach, much has already been achieved. However, it blurs the
definitions of such trials. Now not any longer intensive upright
walking (on the treadmill) is compared to "conventional"
physiotherapy (with limited stress on training of walking for non-ambulating
patients), but different ways to train upright walking. This shift
then necessarily causes a shift in the scientific questions to ask
from a trial. Rather than asking whether LB therapy is superior
to conventional physiotherapy, the question now is for the efficacy
of the therapeutic approach: This includes therapy time, amount
of effort therapists need to put into walking the patient (walking
on the treadmill with the patient secured by a harness and body
weight supported versus walking over ground also with non-ambulating
patients), number of therapists necessary to support the training,
time to reach independent ambulating and so on.
For hemiplegia the Functional Ambulation Category (FAC) has been
convincing for classification of locomotion, the Motricity Index
may be used to assess muscle function
7.2.1 Functional Ambulation Category (FAC):
Holden et al 1984, Phys Ther 64, 35-40.
0: Patient cannot walk, or needs help from 2 or more persons
1: Patients needs firm continuous support from 1 person who helps
carrying weight and with balance
2: Patient needs continuous or intermittent support of one person
to help with balance and coordination.
3: Patient requires verbal supervision or stand-by help from one
person without physical contact
4: Patient can walk independently on level ground, but requires
help on stairs, slopes or uneven surfaces
5: Patient can walk independently anywhere
7.2.2 Motricity Index to test motor strength
(both sides)(Demeurisse et al 1980, Eur Neurol 19, 382-389.): Pinch
grip, elbow flexion, shoulder abductíon, ankle dorsiflexion,
knee extension, hip flexion.
7.2.3 Scientific trial
In preparing a European multicenter trial to study the effect of
LB therapy, the following general assessments have been suggested
for hemiparetic persons.
Assessments (including Video):
1. FAC every week during period of therapy; 6, 12 months.
2. Rivermead Motor Score Assessment (Gross function, Leg and Trunk)
at the end of therapy; 6, 12 months.
3. Walking speed tested over 10 m, at the end of intervention; 6,
4. Endurance test: Measure distance walked within 6 min. At the
end of intervention; 6, 12 months.
For later stratification:
1. Scand. Stroke Scale: at the time of randomization.
2. CT topographic assessment
3. CT-small vessel disease (Lacunar Infarct) /CT-large vessel disease
(Territorial Infarct)/CT normal
4. Motricity Index to test motor strength (both sides)(Demeurisse
et al 1980, Eur Neurol 19, 382-389.): Pinch grip, elbow flexion,
shoulder abductíon, ankle dorsiflexion, knee extension, hip
flexion. At the beginning and end of therapy period.
5. Reduction in proprioception (tested manually at digit 1) every
6. Balance Scale (Bohannon). Every week
7. Ability to maintain a vertical position while sitting unsupported
(inclination of trunk measured in sagittal and lateral directions).
Every 2 weeks during therapy.
8. Zung Self-rating Depression Scale (Zung, Arch Gen Psych 1965,
12, 63-70). Every 2 weeks
9. Total Comorbidity (respiratory, heart and circulation problems)