This case study examined the effects of a physical therapy program focused on spinal stabilization exercises using a stability ball and pre-gait training activities on improving independent ambulation for a patient with incomplete spinal cord injury. Over nine physical therapy sessions, the patient performed static and dynamic stabilization exercises on a stability ball as well as standing balance and gait training drills. Outcome measures assessing balance, walking endurance, gait speed, and functional mobility all significantly improved from initial to final assessments, indicating the interventions helped increase the patient's ability to ambulate independently.

1. Effects of spinal stabilization and pre-gait
training activities on independent ambulation in
patient with incomplete spinal cord injury: a case
report
Sarah J Cademartori
December 2015
Mount St. Joseph University
Doctorate of Physical Therapy Program
PT 882

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Table of Contents
 Introduction ………...….. 3
 Patient Profile ……......... 3-4
 Objectives ……………. 4
 Interventions ……….… 4-8
 Outcome Measure Comparisons ………….… 9
 Outcome Findings ……...… 9-10
 Summary …….……. 10
 References …………... 11

3. 3
Sarah Cademartori
PT 882 Case Study
Effects of spinal stabilization and pre-gait training activities on independent ambulation in
patient with incomplete spinal cord injury: a case report
Introduction
Spinal cord injuries result in devastating life changes for an individual and require new
adaptations along their road to recovery. Continuous efforts within the rehabilitation field are
made in order to find effective treatments for spinal cord injuries (SCI) in addition to potential
interventions for functional recovery with various combinations of pharmacological and surgical
approaches1. Functional independence including self-care, ambulation, transfers, and activities
of daily living play a huge role in an individual’s recovery process. Within inpatient and
outpatient physical therapy clinics, restoration of functional ambulation is a high priority after
spinal cord injuries and continues to be a vital integration of the therapy process. Physical
therapists are determined to seek out the most effective and beneficial interventions for
individuals with spinal cord injuries in order to regain maximum functional potential.
Patients with SCI often lack the strength and stabilization to ambulate without use of an
assistive device2. Much research has been performed looking at rehabilitation methods to regain
independent ambulation using various ambulating training techniques such as robot-assisted gait
training2. However, minimal research has been performed isolating strength training or pre-gait
training activities as the main ingredients of the physical therapy program2. More specifically,
research is limited regarding interventions based on spinal stabilization training with the use of a
stability ball in order to improve ambulation in those patients with incomplete SCI. Poor trunk
control and lack of dynamic stabilization during ambulation limits a patient’s ability to reach
their full potential. With an individualized therapy program based on static and dynamic spinal
stabilization and pre-gait training activities, functional ambulation may be successfully
improved. Therefore, the primary aim of this case study was to investigate a physical therapy
plan of care consisting of spinal stabilization activities and pre-gait training in a patient with
chronic incomplete spinal cord injury and its effects on independent ambulation as assessed by
functional outcome measures.
Patient Profile
Patient is a 24-year old male who sustained a C5-C6 traumatic SCI on July 30th, 2010
while diving into a pool. Patient has been attending physical therapy at the clinic since August
14, 2012 where he initially presented in a power wheelchair with impaired independence and
functional mobility. Patient has a past medical history of bowel and bladder difficulties,
extension spasticity of bilateral lower extremities, heterotopic ossification of left hip, and a left
PCL injury from 2007 which requires a knee immobilizer when ambulating. Patient has been
attending physical therapy two times per week regularly since the beginning of his plan of care.
Prior to the initiation of case study on November 10, 2015, patient was able to ambulate without
an assistive device with moderate contact guard assistance on patient’s trunk anteriorly.
Additionally, patient performed sit <-> stand transfers independently with minimal use of hands,
performed stand pivot transfer from low to high surface with stand by assistance and use of
hands, and propelled a manual wheelchair with bilateral upper extremities over flat terrain

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without assistance. Patient exhibited gait abnormalities of decreased right step length with
intermittent circumduction, increased posterior trunk lean, excessive reciprocal arm swing, and
overall reduced trunk stabilization throughout ambulation. Patient has reduced endurance with
ambulation and tends to increase all gait abnormalities putting patient at risk for falls. Patient’s
long-term goals for therapy include ambulating with least restrictive device in the community in
addition to ambulating without any assistive device in the future. In order to improve
ambulation distance, speed, and symmetrical gait pattern, patient is an excellent candidate for
intensive training of static and dynamic spinal stabilization on a stability ball coupled with gait
training activities to progress ambulation and reduce the risk of falls.
Objectives
This case study consisted of two main intervention strategies: seated static and dynamic
spinal stabilization activities on an unstable surface of a stability ball and pre-gait training
exercises in the standing position. Exercises were chosen to focus on the patient’s main
impairments and limitations and initiated as light intensity activities. Rehabilitation
interventions were advanced throughout the case study by student physical therapist’s clinical
judgement and as tolerated by patient. Exercises were advanced by adding lower extremity or
upper extremity movements, including additional planes of movement, changing the surface,
varying intensity, or reducing therapist facilitation.
Four outcome measures were selected to track progress over the timeline of this clinical case
study. The Berg Balance Scale was chosen to measure various activities of balance in seated and
standing positions. The 6-Minute Walk Test (6MWT) was chosen to measure patient’s
endurance with ambulation from the initial to final assessment. The Timed 25-foot Walk test
was used to measure changes in gait speed over the course of the study. Lastly, the Timed Up-
And-Go (TUG) test was used to assess balance control while changing positions. The TUG was
utilized in this study as it provides strong validity and discriminative value when assessing
individuals with SCI who did not require an assistive device, for functional ambulation changes
over time3. Additionally, the 6MWT provides evidence of strong test-retest and inter-observer
reliability along with the ability to detect the minimum difference required for true change1. All
four tools were easily accessible and administered appropriately within the clinic.
Interventions
Day 1: 11/10/2015
 Outcome measures of Berg, 6MWT, Timed 25-foot Walk, and the TUG were assessed at
the beginning of today’s treatment session. Patient was given rest breaks in between tests
as needed.
Initial Outcome Measures
 Berg Balance Scale
o Score: 25/56 (medium fall risk)
 6-Minute Walk Test (6MWT)
o 109 feet with CGA from Student Physical Therapist (SPT) anteriorly at UEs
 Timed 25-foot Walk
o Trial 1: 42 seconds

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o Trial 2: 50 seconds
o Average: 46 seconds
o Both with CGA from SPT anteriorly at UEs
 Timed Up And Go (TUG)
o 61 seconds with minimal use of UEs for sit <-> stand & CGA for ambulation
 Standing exercises performed in parallel bars:
o Forwards & backwards weight shifts in tandem stance without UE support:
 Right foot forward: x 10
 Left foot forward: x 10
o R LE hip protraction & retraction in tandem stance with left foot forward without
UE support and manual resistance from SPT: x10 ea
 Sit <-> stands from powered wheelchair with minimal use of bilateral UEs: x5
Day 2: 11/13/2015
 Sit <-> stands from powered wheelchair with minimal use of bilateral UEs: x5
 Sit <-> stands onto stability ball with minimal use of bilateral UEs: x5
 Seated on stability ball without UE support & bilateral LE on flat ground:
o Stabilization holds: 3 x 20 seconds; 3 x 30 seconds; 2 x 1 minute
o Weight shifts medial to lateral: 2 x 10
o Weight shifts anterior to posterior: 3 x 10
o Clockwise/Counterclockwise: 2 x 10 each
 Seated trunk rotations with elbows flexed: 2 x 10 each direction
 Standing gait training activities in parallel bars:
o Tandem stance weight shifts:
 Left LE forward with UE support: 2 x 10
 Right LE forward with UE support: 2 x 10
 Patient required rest breaks in between exercises and had loss of balance at beginning of
new exercises that required use of UE to regain stable seated balance.
Day 3: 11/17/2015
 Physical therapy appointment cancelled today.
Day 4: 11/24/2015
 Sit <-> stands from powered wheelchair with minimal use of bilateral UEs: x5
 Sit <-> stands onto stability ball with minimal use of bilateral UEs: x5
 All seated stabilization activities performed with stability ball on large cushioned mat
with feet on ground to provide comfortable hip positioning at 90 degrees hip flexion.
Patient had left hip pain relief upon repositioning.
 Seated on stability ball without UE support & bilateral LE on flat ground:
o Stabilization holds: 5 x 30 seconds; 4 x 1 minute
o Weight shifts medial to lateral: 3 x 10
o Weight shifts anterior to posterior: 3 x 10
 Seated on stability ball with UE movements:
o Alternating UE punches at 90 degrees flexion: 3 x 20
o Reciprocal UE arm swings with minimal trunk rotations: 3 x 10

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o Bilateral UE chest press with hands together: 3 x 10
 Standing rhythmic gait training activities within parallel bars
o Tandem stance weight shifts:
 Left LE forward with UE support: 2 x 10
 With added reciprocal arm swings: 2 x 10
 With posterior LE step through: x5
 Right LE forward with UE support: 2 x 10
 With added reciprocal arm swings: 2 x 10
 With posterior LE step through: x5
 Patient attempted LE movements today on ball, but was unable to do so without
immediate loss of balance.
Day 5: 12/1/2015
 Sit <-> stands from powered wheelchair with minimal use of bilateral UEs: x5
 Standing gait training activities in parallel bars:
o R LE slides with foot on pillow case with emphasis on step length: 2 x 10
o R LE hip flexion with theraband resistance with emphasis on hip flexion: 2 x 10
o Tandem stance weight shifts:
 Left LE forward with UE support: 2 x 10
 With added reciprocal arm swings: 2 x 10
 Right LE forward with UE support: 2 x 10
 With added reciprocal arm swings: 2 x 10
 Patient presented to the clinic today with moderate muscle cramping and spasms
throughout R oblique musculature and lower back that he had been experiencing for the
past four days. Patient’s pain was increased with quick trunk movements and right trunk.
Patient declined therapy seated on stability ball today due to concern of increasing pain
and caution to prevent further muscle spasms.
Day 6: 12/4/2015
 Sit <-> stands from powered wheelchair with minimal use of bilateral UEs: x5
 Sit <-> stands onto stability ball with minimal use of bilateral UEs: x5
 All seated stabilization activities performed with stability ball on large cushioned mat
with feet on ground to provide hip flexion at 90 degrees:
 Seated on stability ball without UE support & bilateral LE on flat ground:
o Stabilization holds: 7 x 30 seconds; 5 x 1 minute
o Medial to lateral weight shifts: 2 x 10
 Seated on stability ball with UE movements:
o Reciprocal UE arm swings with added trunk rotations:
 With elbows flexed: 2 x 10
 With elbows extended: 2 x 10
o Bilateral UE chest press holding onto light ball: 2 x 10
o Bilateral chops holding onto light ball: 2 x 10 each direction
o Scapular rows with light resistance theraband: 2 x 10
 Seated on stability ball unilateral heel raises with minimal assistance: 2 x 10
 Standing gait training activities within parallel bars

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o Tandem stance weight shifts:
 Left LE forward without UE support: 2 x 10
 Right LE forward without UE support: 2 x 10
 Ambulation with therapist HHA: 4 x 40 feet (with one rest break)
o Patient required assistance for stabilization from hand hold assistance with swing
through phase R > L LE.
Day 7: 12/8/2015
 Sit <-> stands from powered wheelchair with minimal use of bilateral UEs: x5
 Sit <-> stands onto stability ball with minimal use of bilateral UEs: x5
 All seated stabilization activities performed with stability ball on large cushioned mat
with feet on ground to provide hip flexion at 90 degrees:
 Seated on stability ball without UE support & bilateral LE on flat ground
o Stabilization holds: 10 x 30 seconds; 4 x 1 minute
o Medial to lateral weight shifts: 2 x 10
 Seated on stability ball with UE movements:
o Reciprocal arm swings with maximal trunk rotations & elbows extended: 2 x 10
o Bilateral UE chest press holding onto light ball: 2 x 10
o Bilateral chops holding onto light ball: 2 x 10 each direction
o Bilateral D2 patterns: 2 x 10
 Seated on stability ball with LE movements:
o Unilateral Heel raises with minimal assistance: 2 x 10
o Long arc quads with moderate assistance from SPT for knee extension: x 10 each
 Ambulation with therapist HHA: 4 x 40 feet
o Patient required assistance for stabilization from hand hold assistance with swing
through phase R > L LE.
Day 8: 12/11/2015
 Sit <-> stands from powered wheelchair with minimal use of bilateral UEs: x5
 Sit <-> stands onto stability ball with minimal use of bilateral UEs: x5
 All seated stabilization activities performed with stability ball on large cushioned mat
with feet on ground to provide hip flexion at 90 degrees:
 Seated on stability ball without UE support & bilateral LE on flat ground:
o Stabilization holds: 10 x 30 seconds; 5 x 1 minute
o Medial to lateral weight shifts: 2 x 10
 Seated on stability ball with UE movements:
o Reciprocal arm swings with maximal trunk rotations & elbows extended: 3 x 10
o Bilateral chops holding onto light ball: 3 x 10 each direction
o Unilateral D2 patterns with light theraband resistance: 2 x 10
o Bilateral UE flexion: 2 x 10
o Bilateral chest press with light theraband resistance:
 Resistance directly lateral to RIGHT side of patient: x 15
 Resistance directly lateral to LEFT side of patient: x15
 Seated on stability ball with LE movements
o Unilateral Heel raises without any assistance: 2 x 10

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o Long arc quads without assistance for left LE and minimal assistance from SPT
for right LE for knee extension: 2 x 10 each
 Ambulation with therapist HHA: 2 x 40 feet
o Patient required assistance for stabilization from hand hold assistance with swing
through phase R > L LE.
 Today patient marked significant improvements with ability to perform some lower
extremity activity on stability ball without assistance compared to previous sessions.
Day 9: 12/15/2015
 Final treatment session consisted of assessment of outcome measures of the Berg Balance
Scale, 6MWT, Timed 25-foot Walk, and the TUG. Patient was given rest breaks in
between tests as needed. Patient demonstrated marked improvement with endurance with
less visible fatigue at the end of today’s assessment session.
Final Outcome Measures
 Berg Balance Scale
o Score: 33/56 (medium fall risk)
 6-Minute Walk Test (6MWT)
o 158 feet with CGA from Student Physical Therapist (SPT) anteriorly at UEs
 Timed 25-foot Walk
o Trial 1: 32.1 seconds
o Trial 2: 32.7 seconds
o Average: 32.4 seconds
o Both with CGA from SPT anteriorly at UEs
 Timed Up And Go (TUG)
o 46 seconds with minimal use of UEs for sit <-> stand & CGA for ambulation
Final Improvements:
 Berg: 25/56  33/56
 6MWT: 109 feet  158 feet
 25-foot walk: 46 seconds  32.4 seconds
 TUG: 61 seconds  46 seconds

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Outcome Measure Comparisons
Outcome Findings
Results revealed significant improvements in all four of the functional ambulation
outcome measures over the course of this case study. The Berg Balance Scale improved from an
initial score of 25/56 to a 33/56 at the final assessment with an increase of 8 points. Notable
improvements occurred with the task of reaching forward with an outstretched arm, standing
unsupported with feet together, and controlling the descent during a standing to sitting position
change. While the patient still remained in the “medium fall risk category”, the change of eight
points in scores demonstrated a genuine change in function between baseline and final
assessment.
The 6-Minute walk test improved from an initial distance of 109 feet to 158 feet at the
final assessment. While a difference of 49 feet between the two assessments does not meet the
smallest real difference1 (SRD) for the 6MWT, the patient was visibly less fatigued at the end of
the six minute duration demonstrating improved overall endurance. Additionally, the patient was
able to ambulate with reduced compensatory gait mechanics with improved trunk stabilization
and reduced right foot drag during swing phase. Tactile assistance from the SPT did not change
from the initial to final assessment of this ambulation outcome measure.
0
5
10
15
20
25
30
35
Berg Balance Scale
Initial
Final
0
50
100
150
200
6MWT
Initial
Final
0
10
20
30
40
50
Timed 25-foot Walk
Initial
Final
0
10
20
30
40
50
60
70
TUG
Initial
Final

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In the timed 25-foot walk test, the patient improved from an initial time of 46.0 seconds
to a final time of 32.4 seconds. Both, the initial and final assessments were completed using two
trials and taking an average for the final reporting score. Similar to the 6MWT, patient was able
to ambulate with improved gait mechanics including longer step lengths during this ambulation
test for speed.
Lastly, the Timed Up and Go was completed at a time of 61 seconds initially and a final
assessment time of 46 seconds. The smallest real difference was met with this TUG score
improvement of 15 seconds which surpasses the minimal difference of 10.8 seconds1. Real
change was demonstrated with this advancement of score exhibiting improvements in dynamic
balance when changing positions along with improvements in gait speed.
Overall, the patient demonstrated excellent progress in improved gait speed, ambulation
endurance, and static and dynamic balance which are all seen clearly from the positive results in
the functional ambulation outcome measures. In addition to the objective results, the patient
exhibited overall improved confidence and improved gait mechanics that have allowed the
patient to continue to progress towards accomplishing his long-term goal of community
ambulation with the least restrictive assistive device.
Discussion
In conclusion, this case study clearly demonstrated that physical therapy spinal
stabilization activities on a stability ball coupled with pre-gait training can effectively improve
independent ambulation in an individual with an incomplete spinal cord injury as assessed by
ambulation outcome measures. However, individual improvements from this study cannot be
generalized towards a population until further research for high-level evidence is performed.
Future treatment considerations for the most beneficial therapy program recommend that
an individual should initiate their rehabilitation process as soon as possible once the patient is
medically stabilized post-injury4. Individuals with chronic injuries are still able to improve their
ambulation outcomes, although it may require a longer time to see results. Training should be
intensive and frequent on a consistent weekly basis. Therapy should integrate aspects of spinal
stabilization exercises and pre-gait activities in addition to functional ambulation in order to
provide successful individualized outcomes.
This individual case study was limited to short-term results of a four week period due to
completion of SPT’s clinical rotation. Further research should include interventions that range
from 6 to 12 weeks or even longer to determine if additional intervention would provide more
significant outcome results. Additionally, limited research on spinal stabilization training
utilizing a stability ball did not provide this study with supporting evidence. Future research
should be expanded to include a larger sample size that provides further evidence into spinal
stabilization activities and pre-gait training interventions. Continued research is required to
provide clinicians with significant and quantified evidence of interventions that can maximize an
individual’s independent ambulation and quality of life during the subacute and chronic phases
of recovery in individuals with incomplete spinal cord injuries.

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References
1. Lam T, Noonan VK, Eng J. A systematic review of functional ambulation outcome
measures in spinal cord injury. Spinal Cord. 2008;46(4):246-254.
2. Labruyere R, van Hedel H. Strength training versus robot-assisted gait training after
incomplete spinal cord injury: a randomized pilot study in patients depending on walking
assistance. J Neuroengineering Rehabil. 2014;11(1):1-12.
3. Saensook W, Poncumhak P, Saengsuwan J, et al. Discriminative ability of the three
functional tests in independent ambulatory patients with spinal cord injury who walked
with and without ambulatory assistive devise. J Spinal Cord Med. 2014;37(2):212-217.
4. Yang JF, Musselman KE. Training to achieve over ground walking after spinal cord
injury: a review of who, what, when, and how. J Sinal Cord Med. 2012;35(5):293-304.