Can someone with an ASIA grade spinal cord injury walk?

Walking Ability in Patients with ASIA Grade Spinal Cord Injury

The ability to walk depends significantly on the ASIA Impairment Scale grade, with ASIA C and D patients having much better chances of walking than ASIA A or B patients.

Understanding ASIA Classification and Walking Potential

The American Spinal Injury Association (ASIA) Impairment Scale is the standard neurological classification system for spinal cord injury (SCI) patients. It categorizes patients based on motor and sensory function preservation:

• ASIA A (Complete): No motor or sensory function preserved in sacral segments S4-S5
• ASIA B (Incomplete): Sensory but no motor function preserved below the neurological level including S4-S5
• ASIA C (Incomplete): Motor function preserved below the neurological level with more than half of key muscles below the level having muscle grade less than 3/5
• ASIA D (Incomplete): Motor function preserved below the neurological level with at least half of key muscles below the level having muscle grade 3/5 or greater
• ASIA E (Normal): Normal motor and sensory function

Walking Outcomes by ASIA Grade

Research clearly demonstrates significant differences in walking ability based on ASIA grade:

• ASIA A & B: Only 0.9% of patients with ASIA A or B injuries were able to walk at discharge from rehabilitation 1
• ASIA C: Approximately 28.3% of patients with ASIA C injuries were able to walk at discharge 1
• ASIA D: About 67.2% of patients with ASIA D injuries were able to walk at discharge 1

Factors Affecting Walking Recovery

1. ASIA Grade: The most significant predictor of walking ability
2. Level of Injury: Interestingly, level of injury does not significantly affect walking outcomes for ASIA C and D patients 1
3. Age: Being 50 years or older negatively affects walking outcomes in ASIA D patients but not in ASIA C patients 1
4. Time Since Injury: Recovery potential is greatest in the first year post-injury, though improvements can continue with appropriate therapy

Assessment Tools for Walking Ability

Several validated assessment tools are used to measure walking ability in SCI patients:

• Walking Index for Spinal Cord Injury (WISCI): A 21-level hierarchical scale that incorporates gradations of physical assistance and devices required for walking 2, 3
• 10-meter walk test: Measures walking speed
• 6-minute walk test: Measures walking endurance
• Functional Independence Measure (FIM): Assesses general level of independence
• Spinal Cord Independence Measure (SCIM): More specific for SCI patients than FIM

The WISCI has been validated across multiple countries and shows strong correlation with lower extremity motor scores (LEMS) 2. It is more detailed and appears more sensitive to walking recovery than other scales 3.

Therapeutic Approaches to Improve Walking

Activity-based therapy (ABT) has shown promise in improving walking ability even in chronic SCI:

• A randomized controlled trial demonstrated that 9 hours/week of ABT for 24 weeks resulted in significant improvements in walking speed and distance compared to controls 4
• ABT includes developmental sequencing, resistance training, repetitive patterned motor activity, and task-specific locomotor training

Clinical Implications

When counseling patients about walking potential:

1. Perform thorough ASIA classification to accurately determine grade
2. Recognize that ASIA C patients should not be considered functionally complete when predicting walking ability 1
3. Understand that level of injury is less important than ASIA grade for predicting walking outcomes in ASIA C and D patients
4. Consider age as a factor, particularly for ASIA D patients
5. Utilize validated assessment tools like the WISCI to track progress

Common Pitfalls to Avoid

• Overgeneralization: Avoid making blanket statements about walking potential without considering ASIA grade
• Underestimating ASIA C patients: While less likely to walk than ASIA D patients, many ASIA C patients can achieve functional ambulation
• Neglecting other functional outcomes: Remember that patients often prioritize bowel, bladder, and sexual function equally or more than walking 5
• Focusing solely on walking: A comprehensive approach should address all aspects of function and quality of life

Walking recovery is an important but not the only goal in SCI rehabilitation. Functional independence and quality of life should remain the primary focus of treatment planning.