Hi

Does he have any active knee flexion? What grade?

One comment I would make is that now that almost a year has elapsed further improvements in motor function are likely to be modest. And if he does improve a bit more will it be clinically meaningful ie will it help him be more independent or to walk more independently, or to participate in things that matter to him?

It may be better to think of what activity you your patient wants to achieve rather than trying to improve a specific impairment like knee flexion. For example: can he clear the ground in the swing phase of walking? If he isn’t managing to get enough knee flexion here, it is more likely to be a problem with getting the hip flexors to fire at the beginning of swing phase. The hip flexors fire early to create and inertial flexor moment at the knee. The hamstrings are relatively quiet during knee flexion in swing phase

Body Weight Support Treadmill Training

Do you have access to body weight support treadmill training? This may be useful for walking and getting the write joint motions going. However it costs money. You can get by with building one if your hospital engineers can help you – all you need is a treadmill that will operate at low speeds, someone to build you a frame to suspend a harness, a large spring balance for measuring the amount of weight suspended, the right configuration of ropes ratchets and pulleys and a comfortable body harness. This is a bit of a major project however. And you also do need some training in how to use it with patients.


If you really are intent on getting the knee flexors to work then:

Functional Electrical Stimulation

FES probably has some of the best evidence for strengthening the knee flexors. You need to use classical conditioning (pairing up the contraction delivered by the FES unit with a voluntary command to “bend your leg” FES units are now coming down in price so it could be a viable purchase for you if you don’t have a unit.

Biofeedback

EMG unit applied over the hamstrings. If you don’t have this you can rig up a simple visual feedback loop using a mirror. NB you can get combined FES/EMG biofeedback units where you use both – in this case you use the EMG to give them feedback of performance and when a set threshold of EMG is reached the patient is reinforced with a burst of stimulation from the FES part of the unit. This is basically using operant learning. – again some good evidence for this technique

Bilateral training

Is one leg better than the other. You could try seeing if you get a contraction on the weaker side be contracting both at the same time. Apply resistance to get the stronger side working maximally. Alternate leg is another method. The theory behind this is to use the Central Pattern Generator in the spinal cord. So get the patient to extend one leg while flexing the other . Don’t’ know of any evidence for these techniques but they are easy to do and if they don’t work then at least you have tried something.

Mental Practice

this works often even when there is very little active contraction. Patient imagines contracting the muscle and imagines seeing and feeling the leg move. However there is quite an art to this method. You have to really get the patient to devote their full attention to the imagined movement. So really get them to concentrate on the movement and "count to 10" while contracting the muscle. It won't work if the technique is performed vaguely or with little attention. The technique has some evidence for being effective both in normal and neurologically impaired populations.

Progressive resistance training

He needs at least a good grade 2 (MRC scale) to do this. Options are, slings or a polished board in side lying if really weak, theraband, springs or weights if a bit stronger and can work against gravity in standing or prone lying.

An excellent up-to-date book on physiotherapy for spinal cord injuries is:

Harvey, L. (2008). Management of spinal cord injuries : a guide for physiotherapists. Edinburgh ; New York: Butterworth-Heinemann Elsevier.


Amazon.com: Management of Spinal Cord Injuries: A Guide for Physiotherapists (9780443068584): Lisa Harvey BAppSc GradDipAppSc(ExSpSc) MAppSc PhD: Books