After reading this chapter, the reader will be able to:
Describe the impact that level and completeness of spinal cord injury (SCI) has on walking potential
Explain the influence of sensory and motor impairments on walking function after SCI
List the critical events of the gait cycle and common gait deviations after SCI
Describe how lower extremity orthoses can improve walking function and stabilize and assist with residual impairments after SCI
List the advantages and disadvantages of each of the designs of lower extremity orthoses
Discuss the decision-making process for selection of the most appropriate lower extremity orthosis for maximizing walking function based on the individual's level of injury, motor and sensory impairments, secondary deformities, and personal preferences
The goal to walk is shared by most individuals following spinal cord injury (SCI). Walking is feasible at discharge from rehabilitation for approximately one-third1 and is maintained at 1 year in less than one-third of the overall SCI population.2,3 To achieve ambulation goals, assessing the appropriateness of walking, degree of impairment, and the advantages and disadvantages of the various lower extremity orthoses to maximize functional mobility is important. Clinicians are faced with making daily decisions and recommendations for orthotic prescription. The evidence supports use of orthoses such as ankle-foot orthoses (AFOs) and/or knee-ankle-foot orthoses (KAFOs) to improve walking ability after SCI.4,5,6,7,8 Some clinicians, however, question the use of bracing to assist ambulation, believing that braces inhibit and limit muscle function. How does one determine when "to brace" or "not to brace"? Once a brace is deemed appropriate, how does one select the optimal settings for the brace? This chapter will address some of these questions as they relate to individuals with SCI. An algorithm to guide clinical decision making for AFO and KAFO prescription will be presented. Key determinants in appropriate orthosis selection for persons with motor incomplete SCI will be presented, as well. Case studies will be used to enhance concepts and demonstrate the principles introduced.
Complete Spinal Cord Injuries
Following SCI, the potential for walking function depends primarily on the level and completeness of injury.9,10 Age, level of motivation, medical history, and body type also impact the feasibility of walking.11 Persons diagnosed with complete motor and sensory tetraplegia (AIS A) as defined by the American Spinal Cord Injury Association (ASIA) Impairment Scale (AIS)12 generally do not become functional ambulators.13 For those diagnosed with complete motor and sensory paraplegia (AIS A), the potential for ambulation increases as level of injury descends caudally.10,14
Individuals with complete thoracic SCIs (T2–T12) have no volitional control of the lower extremities and limited trunk control, determined by the level of preserved innervation in the thoracic spine. At this level of ...