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Gutter Crutches: An Unconventional Walking Aid for Incomplete Tetraplegics - A Case Report, Schemes and Mind Maps of Medicine

A case report of a 53-year-old man with chronic, incomplete tetraplegia who achieved enhanced walking ability using gutter crutches. The challenges faced by the patient due to poor hand grip and muscle weakness, and how gutter crutches were found to be a suitable alternative to conventional walking aids. The document also includes a discussion on the goals of rehabilitation and the importance of selecting an ambulatory aid that maximizes walking ability, maneuverability, and independence while maintaining safety and stability.

What you will learn

  • What are the challenges faced by a person with chronic incomplete tetraplegia when it comes to selecting a walking aid?
  • What are the goals of rehabilitation for persons with spinal cord injury when it comes to selecting an ambulatory aid?
  • How did gutter crutches help the patient in this case report achieve enhanced walking ability?

Typology: Schemes and Mind Maps

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76
September Issue-2012 (3rd Proof)
Abstract
The goal of the therapists and patient while selecting an ambulatory aid is to maximise walking ability, manoeuverability
and independence, while maintaining safety and stability. Unlike elbow crutches or walker, gutter crutches are not a
familiar and well established walking aid in the rehabilitation of persons with incomplete spinal cord injury. In this case
report we highlight enhanced ambulation achieved by a 53-year-old man with chronic, incomplete tetraplegia with the
use of gutter crutches.
Introduction:
The walking outcome of a person with chronic
incomplete tetraplegia could be impacted by factors
such as potentially poor hand grip, trunk weakness, lower
extremity weakness and the consequential effects on
balance, to name a few. Inappropriate walking aid
prescription and inadequate user training could
exacerbate the problem1-4. For persons with chronic
incomplete tetraplegia, it is hence important to have an
aid that fits into the available hand function and ensure
weight transmission through the forearm, as hand
deformity will be an issue. Selection of an appropriate
walking aid can help enhance confidence, feeling of
safety and lead to a more meaningful walking outcome,
which in turn, can help raise the level of activity and
degree of independence.
Case Report
Key words: Gutter crutch, tetraplegia, walking aid, ambulation.
Gutter crutches were basically designed for patients with
rheumatoid arthritis for whom poor hand grip and
difficulty in weight bearing through inflammed joints is
a common constraint5,6. As persons with incomplete
tetraplegia may also have poor hand grip similar to those
with rheumatoid arthritis, it was thought that this group
of patients may also be benefited from using gutter
crutches. In this case study, we report enhanced walking
achieved by a patient with chronic incomplete tetraplegia
with the use of gutter crutches.
Case Report:
A 53-year-old man, who was employed in a public
transport corporation developed C5 incomplete
tetraplegia in the C category according to the American
Spinal Injury Association (ASIA) impairment scale
following an alleged history of fall. Magnetic resonance
imaging showed C4-C5 cord changes and central disc
herniation which was managed by laminectomy.
He was initially treated elsewhere and was then
transferred to our institution for rehabilitation. He was
started on conventional programme which included
flexibility and strengthening exercises for the key
muscles of upper and lower limbs, balance, ADL and
functional training. He was tilted and progressed to
standing and walking in the parallel bars. His
improvement in the self care activities is displayed in
Table 1.
Progression in gait training was slow due to difficulty in
gripping the walking aid due to poor hand function. At
76
Gutter Crutches: An Unconventional Walking Aid for
Incomplete Tetraplegics – A Case Report
Senthilvelkumar T1, Raji Thomas2
Author’s affiliations:
1 Lecturer- Physiotherapy
2 MD (PMR), Professor
Department of Physical Medicine & Rehabilitation, Christian Medical
College, Vellore-632002, Tamil Nadu, India
Cite as:
Senthilvelkumar T, Raji Thomas. Gutter Crutches: An unconventional
walking aid for incomplete tetraplegics - a case report. IJPMR
September 2013; Vol 24(3): 76-9.
Correspondence:
Dr. Raji Thomas MD (PMR), Professor
Department of Physical Medicine & Rehabilitation, Christian Medical
College, Vellore-632002, Tamil Nadu, India
Phone +91 416 2282158
Email: rajithomas@cmcvellore.ac.in
Received on 01/08/2012, Revised on 27/09/2013
Accepted on 28/11/2013
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Abstract

The goal of the therapists and patient while selecting an ambulatory aid is to maximise walking ability, manoeuverability and independence, while maintaining safety and stability. Unlike elbow crutches or walker, gutter crutches are not a familiar and well established walking aid in the rehabilitation of persons with incomplete spinal cord injury. In this case report we highlight enhanced ambulation achieved by a 53-year-old man with chronic, incomplete tetraplegia with the use of gutter crutches.

Introduction:

T

he walking outcome of a person with chronic incomplete tetraplegia could be impacted by factors such as potentially poor hand grip, trunk weakness, lower extremity weakness and the consequential effects on balance, to name a few. Inappropriate walking aid prescription and inadequate user training could exacerbate the problem1-4^. For persons with chronic incomplete tetraplegia, it is hence important to have an aid that fits into the available hand function and ensure weight transmission through the forearm, as hand deformity will be an issue. Selection of an appropriate walking aid can help enhance confidence, feeling of safety and lead to a more meaningful walking outcome, which in turn, can help raise the level of activity and degree of independence.

Case Report

Key words: Gutter crutch, tetraplegia, walking aid, ambulation.

Gutter crutches were basically designed for patients with rheumatoid arthritis for whom poor hand grip and difficulty in weight bearing through inflammed joints is a common constraint 5,6. As persons with incomplete tetraplegia may also have poor hand grip similar to those with rheumatoid arthritis, it was thought that this group of patients may also be benefited from using gutter crutches. In this case study, we report enhanced walking achieved by a patient with chronic incomplete tetraplegia with the use of gutter crutches.

Case Report: A 53-year-old man, who was employed in a public transport corporation developed C5 incomplete tetraplegia in the C category according to the American Spinal Injury Association (ASIA) impairment scale following an alleged history of fall. Magnetic resonance imaging showed C4-C5 cord changes and central disc herniation which was managed by laminectomy. He was initially treated elsewhere and was then transferred to our institution for rehabilitation. He was started on conventional programme which included flexibility and strengthening exercises for the key muscles of upper and lower limbs, balance, ADL and functional training. He was tilted and progressed to standing and walking in the parallel bars. His improvement in the self care activities is displayed in Table 1. Progression in gait training was slow due to difficulty in gripping the walking aid due to poor hand function. At

76

Gutter Crutches: An Unconventional Walking Aid for

Incomplete Tetraplegics – A Case Report

Senthilvelkumar T 1 , Raji Thomas^2

Author’s affiliations: 1 Lecturer- Physiotherapy 2 MD (PMR), Professor Department of Physical Medicine & Rehabilitation, Christian Medical College, Vellore-632002, Tamil Nadu, India Cite as: Senthilvelkumar T, Raji Thomas. Gutter Crutches: An unconventional walking aid for incomplete tetraplegics - a case report. IJPMR September 2013 ; Vol 24(3): 76-9. Correspondence: Dr. Raji Thomas MD (PMR), Professor Department of Physical Medicine & Rehabilitation, Christian Medical College, Vellore-632002, Tamil Nadu, India Phone +91 416 2282158 Email: rajithomas@cmcvellore.ac.in Received on 01/08/2012, Revised on 27/09/ Accepted on 28/11/

77

discharge, he was able to walk 50 metres in 25 minutes with a right knee brace and a walker; he used the hook grasp to progress the walker. This walking aid was chosen as he was incapable of using other conventional options. He was on level 9 in Walking Index for Spinal Cord Injury scale (WISCI II).

During the 19 months at home after the rehabilitation, there was no significant improvement in the ambulatory status. Ambulation was confined to home, as he found it difficult to attain functional mobility outdoors in rough terrains with the walker. Moreover, the walker needs more space for manoeuvering, which is usually not available in the community in rural India and is unsuitable for negotiation of ramps, stairs and obstacles.

He was readmitted with the aim of improving his outdoor mobility. His upper extremity muscle score was 28.50/ 50 and his lower extremity muscle score was 25.75/ as measured by manual muscle testing. He had grade 1 spasticity in all four limbs as measured by modified Ashworth scale. He had mass grasp and hook grip in the hands bilaterally. He was independent in bed mobility and was able to come to a sitting position by himself. Without any appliances he was able to walk for 80 metres with the help of a walker.

Due to poor hand grip, wrist flexion contracture and weakness of crutch muscles, he was not able to use elbow crutches, canes or axillary crutches. We considered various options to choose a different walking aid that could overcome the limitations caused by muscle weakness and deformities. This is how gutter crutches came into the radar as a possible option. Gutter crutches could fit his hand function and also allow weight transmission through the forearm (Fig 1).

Initially he found it difficult to adjust to the new walking aid and felt unsafe using it. With proper instruction (Table

  1. and reassurance, he started gripping the crutches well enough to lift and place them forward safely. After the end of first week, he was made to walk outside the parallel bars using two gutter crutches with the help of one person, whose principle role was to help maintain balance. His walking endurance was worked on in a gradual manner. At the end of third week he achieved 100 metres with gutter crutches. Advanced walking skills such as negotiating ramps, rough terrain and stairs was introduced into his daily regimen in the later stages. At the end of the training, he was able to walk 150 metres in half an hour under supervision.

A follow-up visit was done after three months to review

Fig 1- Illustration Shows the Gutter Crutches Used in the Study

his ambulatory status in his given environment. He was able to move around better at home as well as in the community than before. He did not report any fall in the first three months of experience at home and in the community.

Discussion: The goal of rehabilitation (Table 3) for persons with spinal cord injury is to help them adjust to life by equipping them and their families with the skills and resources required for living in the community^7. In the selection of an ambulatory aid, the goal of the therapists and patient is to maximise walking ability, manoeuverability and independence, while maintaining safety and stability. Unlike elbow crutches or walker, gutter crutches are not a familiar and well established walking aid in the rehabilitation of patients with spinal cord injury, especially those with chronic tetraplegia. Even the WISCI II scale does not have a level describing the use of gutter crutches. The absence of literature exploring the potential use of gutter crutches for persons with

Gutter crutches: an unconventional walking aid – Sentholvekumar T et al

79

day life. The outcome in the initial stages was encouraging enough for the patient and us to go the distance with gutter crutches.

In rural communities in developing countries such as India, the physical environment is a major barrier for people with physical challenges. In this context, any form of walking is a superior option to wheelchair-based mobility and this aspect is emphasised in our rehabilitation process. Our evaluation and interaction with the patient clearly pointed to the need for enhanced ambulation, an opportunity to re-integrate in his community, and, most importantly, a way to resume his occupation to ensure a sustainable livelihood. These aspects forced us to look hard at possible options to explore the maximum potential of this individual with incomplete tetraplegia.

Conclusion:

Gutter crutches must be considered as a possible option for persons with incomplete tetraplegia whose hand function usually does not allow the use of conventional walking aids.

Acknowledgement:

We thank Dr. George Tharion- Head, Department of Physical Medicine & Rehabilitation, Christian Medical

College for oversight and the rehabilitation team for support extended to this project. Learning from the article

  • Incomplete tetraplegics may be less capable of using the usual assistive devices that rely largely on upper extremity integrity.
  • Gutter crutches fit their hand functions, and hence must be considered as an option for persons with almost similar profiles.

References:

  1. Schemm RL, Gitlin LN. How occupational therapists teach older patients to use bathing and dressing devices in rehabilitation. Am J Occup Ther 1998; 52: 276-82.
  2. Gitlin LN, Burgh D. Issuing assistive devices to older patients in rehabilitation: an exploratory study. Am J Occup Ther 1995; 49: 994-1000.
  3. Brooks LL, Wertsch JJ, Duthi HE. Use of devices for mobility by elderly. Wis Med J 1994; 93: 16-20.
  4. Mann WC, Hurren D, Tomita M. Comparison of assistive device use and needs of home-based older persons with different impairments. Am J Occup Ther 1993; 47: 980-7.
  5. Clarke AK. Community care in the management of rheumatoid arthritis. Disabil Rehabil 1982; 4: 144-7.
  6. Goodwill J, Chamberlain MA. Rehabilitation of the Physically Disabled Adult. 2 nd^ ed. Oxford: Oxford University Press, 1988.
  7. Jang Y, Wang, YH, Wang JD. Return to work after spinal cord injury in Taiwan: the contribution of functional independence. Arch Phys Med Rehabil 2005; 86: 681-7.

Gutter crutches: an unconventional walking aid – Sentholvekumar T et al

Table 3: Strength and Mobility Variables at Different Stages of Rehabilitation Process At the end of initial At the time of admission At the time of discharge rehabilitation for second round UEMS 27.75/50 28.50/50 28.50/ LEMS 25.25/50 25.75/50 25.75/ Ambulatory status Limited household Limited household Limited community Aid Walker Walker Gutter crutches Appliance Right knee brace Nil Nil

UEMS - Upper extremity muscle score; LEMS - Lower extremity muscle score