Development of Walking indicators to advance the quality of spinal cord injury rehabilitation: SCI-High Project

Figures & data

Figure 1 Walking Domain Driver diagram. UEMS: Upper-Extremity Motor Score; LEMS: Lower-Extremity Motor Score; NLI: Neurological Level of Injury; AIS: ASIA Impairment Scale; HR: Heart Rate; BP: Blood Pressure; 4-AP: 4-Aminopyridine; FES: Functional Electrical Stimulation; FET: Functional Electrical Training; PSW: Personal Support Worker.

Table 1 Canadian SCI Standing and Walking Assessment Toolkit (SWAT) Stages of Walking Recovery ©RHSCIR Canadian SCI Standing and Walking Module Group on behalf of Rick Hansen Institute, 2014.

Stage	Classification	Definition
0.0	No independent sitting capacity	Patient is unable to sit independently of a seating system on a firm surface with hips and knees at 90 degrees and feet on the floor for 60 s without using arms to stabilize.
0.5	Independent sitting capacity	Patient is able to sit independently of a seating system on a solid surface with hips and knees at 90 degrees and feet on the floor for 60 s without using arms to stabilize.
1	No walking capacity	Patient cannot ambulate but may be able to stand with total assistance
1A	No lower extremity movement	Unable to stand without total assistance of gait aid and/or orthoses and/or therapist(s). No voluntary LE functional movement (L/E MMTs Gr 1 or less in: Tib. Ant and soleus, Quads, and Gluteus.)
1B	Voluntary non-functional lower extremity movement	Unable to stand independently/Needs partial assistance of gait aid and/or orthoses (except bilateral KAFOs) and/or therapist(s) to stand. The use of Bilateral KAFOs is not allowed. Voluntary L/E Movement (L/E MMTs of Gr 1+/2- to Gr3- in anti-gravity muscles*).
1C	Voluntary functional lower extremity movement	Able to stand independently with minimal assistance of gait aid for limited amount of time (less than 30 secs). Orthoses are allowed except for Bilateral KAFOs. Voluntary L/E Movement. (L/E MMTs of Gr 3 or higher in most anti-gravity muscles* except Gr 1 Tib. Ant with an orthoses would fit this group.)
2	Therapeutic walking capacity (Indoors)	Patient is starting to ambulate with Therapist Assistance and Gait Aids/Orthoses and progresses toward Minimal Assistance.
2A	Maximum assistant	Ability to stand and initiate reciprocal steps through voluntary L/E movement but requires maximal physical assistance (>50% of total effort) of at least one person and may include use of assistive devices and/or orthoses with the exception of bilateral KAFOs.
2B	Moderate assistant	Ability to stand and initiate reciprocal steps through voluntary L/E movement but requires moderate physical assistance (25–50% of total effort) of one person and may include use of assistive devices and/or orthoses with the exception of the bilateral KAFOs
2C	Minimum assistant	Ability to stand and initiate reciprocal steps through voluntary L/E movement but requires minimal physical assistance (<25% of total effort) of one person and may include use of assistive devices and/or orthoses with the exception of the bilateral KAFOs.
3	Functional walking capacity (outdoors)	Patient is starting to ambulate without Therapist Assistance but still requires Gait Aids/Orthoses. Patient progresses to ambulating in the Community.
3A	Supervised household ambulator	Ability to ambulate daily using reciprocal steps over ground for short distances (10–100 m) with supervision. Person may use assistive devices and /or orthoses with the exception of bilateral KAFOs.
3B	Independent household ambulator	Ability to ambulate daily using reciprocal steps over ground for short distances (10–100 m) independently. Person may use assistive devices and/or orthoses with the exception of the bilateral KAFOs.
3C	Community ambulator	Ability to ambulate daily using reciprocal steps over ground for long distances (>100 m) independently. Person may use assistive devices and/or orthoses with the exception of the bilateral KAFOs.
4	Full walking capacity	Patient ambulates independently without Therapist Assistance or Gait Aids/Orthoses. Independent Ambulator – ability to ambulate full time daily at home and in the community without assistive devices, orthoses, or physical assistance.

Table 2 List of walking outcome measures.

Acronym	Measurement tool
10MWT	10-Meter Walk Test^Citation32
6MWT	6-Minute Walk Test^Citation32
SCIM III	Spinal Cord Independence Measure III (Mobility Subscale)^Citation33
mTUG	Modified Timed Up & Go Test^Citation34
WISCI II	Walking Index for Spinal Cord Injury II^Citation35
SCI-FAP	Spinal Cord Injury Functional Ambulation Profile^Citation34

Table 3 Taxonomy of walking interventions for process indicator tracking.

Walking interventions*
Transfers	Between sitting and standing
Pre-gait activities	Part-practice of gait events & Standing activities
Gait	Whole practice of gait
Balance	Challenged during whole-gait
Endurance	Challenged during whole-gait
Stairs	Part or whole practice of ascending or descending stairs

*Interventions may include use of orthoses, electrical stimulation, gait aids, body weight support, physical assistance and the aquatic environment.

Table 4 Selected structure, process and outcome indicators for the Walking Domain, and the related denominator for calculating the indicator and the time of collection.

Indicator	Denominator	Indicator type	Time of measurement
Number of therapists who demonstrate regular use* of evidence-based walking interventions	Total number of therapists participating in walking intervention service provision at each site per FY	Structure	Annual
Total hours of received interventional therapies contributing to walking	Number of ambulatory individuals with SCI/D (SWAT Levels 2A or higher)	Process	Rehabilitation discharge
Proportion of ambulatory individuals with SCI/D* that completed a mTUG or 10MWT	Number of ambulatory individuals with SCI/D (SWAT Levels 2A or higher)	Outcome – Intermediary	Within 5 days prior to rehabilitation discharge
SCIM III Self-Report, Mobility subscale	Number of ambulatory patients with SCI/D (SWAT Levels 2A or higher)	Outcome – Final	18 months post rehabilitation admission

*Regular use implies use of evidence-based walking interventions with all patients with SCI/D who are ambulatory.

FY = Fiscal Year; SWAT = Standing and Walking Assessment Tool; mTUG = modified Timed Up and Go Test; 10MWT = 10 Meter Walk Test; SCIM III = Spinal Cord Independence Measure, Version III.

Figure 2 SCI-High Walking and Wheeled Mobility Domain indicator decision tree. Appropriate indicator data collection in based on the patient's stage of standing and walking recovery ascertained using the Canadian SCI Standing and Walking Assessment Tool.¹⁷ The Figure is intended to help clinicians decide when it is appropriate or not to collect Walking or Wheeled Mobility indicators, or both, based on the individual's stage of standing and walking recovery.

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