Assessments 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.

SCI.
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
chair.

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 muscle).

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.
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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 months:
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.

7.2 Hemiplegia
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, 12 months.
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 2 weeks
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)