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C - Walking

Current Practice: Assessing Walking Ability The recovery of walking ability has been measured using many different approaches and constructs: kinetics and kinematics in research laboratories, metrics such as speed, cadence and distance in the clinical setting, and categorical measures such as the use of assistive devices, level of independence, walking ability scales and patient preference/satisfaction. Lam et al.2 have conducted a seminal review regarding the psychometric properties of the measures. However, depending on the clinical site, only some have been incorporated into clinical practice. Despite a plethora of literature on walking, there are no current guidelines regarding best practices in walking assessment. What is less well documented is the meaningfulness of functional walking, at the patient level. The most recent assessment approach, the SCI Functional Ambulation Profile (SCI-FAP), which captures functional walking (carrying objects, maneuvering around obstacles, etc.), has been developed by Musselman et al.3 However the psychometric properties of the test - the sensitivity of the measure to detect change and the minimal clinically important difference - still need to be determined. In general, only about 50% of patients being admitted to active rehabilitative centres have the ability to walk at the time of discharge, though they continue to gain improved walking performance over the course of the first year to 18 months post-injury, particularly if they are enrolled in outpatient rehabilitation programs. How much the healthcare system in Canada is willing to fund outpatient walking rehabilitation programs requires immediate attention from a policy perspective. Therapeutic interventions for facilitating functional walking using standard equipment (parallel bars, walkers, forearm crutches, canes, walkers and lower limb bracing) are in place in all 12 clinical spinal cord programs, as is therapist-assisted treadmill walking. Standard therapeutic approaches such as strengthening and balance training are being practiced in clinical sites (Figure 1.0 ). Other traditional therapies, like neurodevelopment approaches, appear to be less popular (approximately 60% of the centres are using these approaches). The clinical use of a robotic system is present in only one inpatient site (Glenrose), and in one private outpatient facility in Ontario. There were no reported standard guidelines or protocols for walking or related physical therapy in any Canadian site. the SCI Functional Ambulation Profile (SCI-FAP), captures functional walking ; carying objects, maneuvering around obstacles . Figure 1.0 Therapeutic Approaches for Posture and Gait Training 0 2 4 6 8 10 12 Core Strengthening Limb Strengthening Normalize Hip, Knee, Ankle ROM Passive Standing Balance Training (e.g., Posture) Sensory Motor Training Bobath Training Neurodevelopmental Training Lower Limb Cycling Therapist-Assisted Treadmill Walking Independent Treadmill Walking Therapist-Assisted Overground Walking Independent Overground Walking Body-Weight-Supported Treadmill/Overground Training Robotic Assisted Lokomat Walking Number of Sites Specialized equipment for body-weight-supported treadmill training (BWSTT) has been adopted in only nine of the 12 sites, but treadmill training itself is now commonplace in 10 of the 12 centres (Figure 2.0). More sophisticated postural approaches like the use of the Balance Master are only available in less than 50% of the sites, and Functional Electrical Stimulation (FES) systems for biking and walking are available in only 25% of the facilities. Figure 2.0 Specialized equipment for posture and gait asesment and training FIGURE 2.0. SPECIALIZED EQUIPMENT FOR POSTURE AND GAIT ASSESSMENT AND TRAINING 0 2 4 6 8 10 12 Number of Sites Body Weight Support Harness Body Weight Support Treadmill Body Weight Support Overground Treadmill Treadmill - Variable Speed Force Plate - Balance Master GAITRite Gait Lab (Kinematics/Kinetics) Force Plate - Gait Force Plate - Posture Force Plate - Sitting Force Plate - Other FES - Biking System FES - Walking System 48 CAPTURING CAPACITY IN CANADIAN SCI REHABILITATION


C - Walking
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