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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6022_Библиотеки_им_академика_М_И_Перельмана

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and no individuals with complete tetraplegia (12) will become community ambulators 1 year after injury. In the studies mentioned earlier, community ambulation was defined as the ability to walk more than 250 meters. Persons withparaplegia lacksufficienthip flexionbecause reciprocal gaitpatternmust utilize an energy-intensive swing-through, crutch-assisted method (11). This techniquerequiresarmandshouldergirdlestrengthsufficienttolifttheweight of the entire body and swing it forward—impractical for routine mobility becauseof the high rate ofenergyrequired, resultinginasubstantially slower walkingspeed(115).Thus,althoughanindividualmayutilizeaswing-through gait pattern to negotiate architectural barriers or to walk for exercise or psychologicalreasons, fewemploy thismannerof ambulationastheir primary modeofmobility.
Areciprocalgaitpatterncanbeutilizedwhenthereispelviccontrolwithat least3/5 strength inthehip flexors and inonequadriceps (116).This formof gait allows for knee stability without the use of a knee–ankle–foot orthosis (KAFO).Although a reciprocalgaitpattern requires less energythan a swing­throughpattern,therateofenergyexpenditureisstillhigherthanthatforable­bodied subjects. Those with incomplete injury are more likely to recover sufficient motor strength to permit reciprocal gait. Motor-complete, sensory­incompletelesionshavelesserprobabilityofrecoverythandomotor-incomplete lesions.Findingsofseveralstudies(37,40,41,43,46,47)examiningambulationas theprimaryoutcomemeasurearehighlightedinTable9.3.Althoughtheoverall ratesofcommunityambulationare76%forincompleteparaplegiaand46%for incomplete tetraplegia, results are greatly influenced by ASIA grade and the modalityofsensorysparing.
HusseyandStaufferdeterminedthatthereisadirectrelationshipbetweenLE strength and the ability to ambulate (116). They reported that “good pelvic control and active hip flexors and preferably one quadriceps muscle with functioninthefairorbetterrange”isrequiredforcommunityambulationwitha reciprocalgait pattern.Statedsimply,bilateralhip flexorsof at leasta 3/5and onekneeextensorofatleast3/5.Inanotherinvestigation,Crozierandcoworkers studied individuals with Frankel C (“motor useless”) injuries (117). They focusedontherecoveryofthequadricepsmuscleandreportedthatallpatients who had achieved quadriceps strength of at least 3/5 at 2 months following injuryprogressedto become functional ambulators, whereas only twoofeight patientswhohadnotattainedatleast3/5by2monthsachievedthisstatus.Itis believedthatstrengthgreaterthanorequalto3/5inthehipflexorsononeside
and greater than or equal to 3/5 quadriceps strength on the contralateral side allowssuccessfulcommunityambulation.Thisdegreeoffunctionwouldpermit useofone longlegbracewithafixedanklein dorsiflexionanda lockedknee and one short leg brace with a similarly dorsiflexed ankle. Proprioception, however,wouldalsoneedtobelargelyintact.
Waters and colleagues examined energy expenditure during walking with instrumented crutches that measured axial loading. Theyfound that the motor scoring system utilized by ASIA was a simple clinical measure that also correlatedstronglywithwalkingability(118).IndividualswithASIALEmotor scores(LEMS)of20orlesswereclassedaslimitedambulators.Thesepatients had slower average velocities, higher heart rates, subsequent greater energy expenditure, and greater axial loading exerted on assistive devices when compared to patients with LEMS of 30 or more who attained community ambulation status. Individuals with LEMS of 30 or more ambulated with physiologicparametersclosetothosedemonstratedbyable-bodiedsubjects.
Apart from residual strength, a patient’s balance, proprioception, and cognition are also important considerations in determining who will achieve communitymobilityasopposedtosimplysupervisedhouseholdambulation.
PredictionModelsBasedonLinearRegression A number of studies have looked at logistic regression analysis models for predictingneurological and functional outcomes(119–125).Wilsonet al. used both clinical and imaging data to predict functional outcome and found four factorsthatofferedprediction(119).Amongtheseareincludedbetterfunctional statuspredicted(1)bylesssevereinitialAISgradeanda(2)motorscoremore than50atadmission,and predictorsofworsefunctionaloutcome predictedby (3)olderageattimeofinjuryand(4)MRIsignalcharacteristicsconsistentwith spinal cord edema or hemorrhage. Kaminski et al. examined many different variables that could influence functional outcomes after traumatic SCI. The authorsfound thattheLTscore,followed bytheAIS classificationgrade,was the most powerful predictors. The next most influential factors included the Injury Severity Score (an anatomical scoring system that provides an overall score for patients with multiple injuries and hasbeen shownto correlate with disability) and the ASIA motor score (120). van Middendorp (121) (using clinical data) and Belliveau (122) (using clinical and demographic data) developed a model to predict ambulation at up to 1 year post-injury. van Middendorpreportedfivekeyprognosticvariablesforambulationthatincluded
age(cut-offat65years),motorscoresofthequadriceps(L3)andgastroc/soleus (S1)keymotorgroups,andlighttouchsensationatL3andS1dermatomes.This wasconfirmedbyothers(124).Inafurthervalidationofthesefactors,Hickset al. reported that further simplification of the prediction model would include threevariables (atadmission)including age(<65years), L3 motorscores, and LT scores at S1 at admission (123). For further details regarding predictive modelsofwhowillregaintheabilitytowalkafterSCI,pleaseseeChapter42.
CONCLUSION
The ability to predict outcome following spinal cord injury is extremely importantnotonlyforpersonswhosustainatraumaticinjuryandtheirfamilies, but also for the rehabilitation professionals charged with developing an appropriate plan of care and the researchers investigating the role of natural recovery in future therapeutic investigations. Factors involved in anticipating outcome have been reviewed in this chapter.In the past decades, the need to identify such early predictors has become increasingly critical, given the decreased length of both hospital andrehabilitationstays and the concomitant demandforprompt decision-making regarding discharge.Inaddition,research interventions,nowbeinginitiatedsoonafterinjury,underscorethesignificance of creating prediction models for the period immediately after injury. In the future,theemerging,interdisciplinaryfieldofgenomicswillmostlikelyplaya muchgreaterroleindeterminingprognosis.
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