Incomplete Spinal Cord Injury

Non-Traumatic SCI causes

spinal stenosis (most common) tumor (second most common) -malignant or benign infection/spinal abscess myelitis spinal stroke/spinal infection

Percentage of AIS C's that stay AIS C from 72 hours post injury to discharge

39.6%

Percentage of AIS B's that stay AIS B from 72 hours post injury to discharge

48.1%

The greatest variability exists in the Middendorp's prediction rule chart between which scores?

5-25 on X axis

Percentage of AIS A's that stay AIS A from 72 hours post injury to discharge

84.9%

Percentage of AIS D's that stay AIS D from 72 hours post injury to discharge

93.2%

with whom can you expect recovery based on AIS grade?

AIS A and AIS D generally stay the same About half of AIS B stay the same *(half get better!)* *Most AIS C get better* (less than half stay the same)

What are significant factors in determining outcomes across incomplete SCI patients?

Age prognosis can be greatly impacted by the presence of a malignant tumor (pt has to fight cancer as well)

Middendorp et al 2011: Prediction tool for independent ambulators (for traumatic SCI, focus on AIS B and C)

Age greater than or equal to 65 years motor score in myotome L3 motor score in myotome S1 light touch score in dermatome L3 light touch score in dermatome S1

Recovery of walking: *intervention KEYS: Balance*

Balance (upright dynamic balance/postural control is key) -dynamic balance interventions that are closely linked to walking will likely help walking -utilize evaluation findings, especially FGA, mini BESTest, etc to inform your dynamic balance treatment decisions -consider pro-active and re-active balance training, sensory reintegration sitting balance training ONLY makes sense if standing is not possible, if walking is intervention goal consider your patients balance confidence, and integrate activities that challenge patients confidence

THM with Research Strength Training Post-SCI

CALCULATE 1 RM!!! we are not sure if straight up strength training helps gait but it does improve strength (when done intensely) and this may be part of the goal

Recovery of walking: *intervention KEYS: strength*

INTENSITY IS KEY strength training improves strength, and may also improve walking/function intensity: utilize 70-100% 1 rep max for muscles you are interested in strengthening ACSM guidelines

Research Strength Training Post-SCI SUMMARY

Labruyere & van Hedel found significant strength improvements after intense strengthening intense strengthening = *70% maximal voluntary contraction, 10-12 reps* Jayaraman et al significant strength, balance, and gait improvements in AIS C and D biodex isokinetic dynamometer used to *determine 1 rep max* training was at *60-65% max, then progressively increased* strength, balance, and gait improvements were all statistically significant when compared to conventional strength training

AIS D

Motor function is preserved below the neurological level and at least half of the key muscles have a muscle grade of 3 or more

Based on the research, should you do sitting balance with the goal of improving walking?

NO no rationale weakly correlated and not supported by research however, there are other reasons to work on this activity

Research: Walking correlations Post-SCI SUMMARY

Saraf: walking was correlated: -balance measures: Berg balance scale -LE strength measures (LE AIS motor score, max isometric knee ext & hip flex) -metabolic measures (VO2 peak, O2 cost) -balance confidence measure (ABC) *balance score was most strongly correlated impairment with walking ability across entire sample* Forrest: *speed of walking, endurance walking, and standing balance were related to each other* standing and sitting balance are not highly correlated sitting balance was weakly correlated to walking

Research: walking training post-SCI SUMMARY

Yang Massed practice vs precision practice (cortex engaged): everyone got better in self-selected walking speed, fastest walking speed, WISCI, and ABC -6MWT improved significantly more in massed practice group -walking SKILL improved in massed practice group just as much as in precision group =ANOTHER argument for massed practice Leech more intense walking -> muscle activity and gait kinematics that more closely match those of healthy control subjects at similar speeds =higher the intensity the better their walking looked in terms of kinematics Brazg -high-intensity training yielded greater improvements in peak treadmill speed, fast over-ground speed, VO2 peak as compared to low intensity -self-selected over-ground walking speed and 6MWT improvements approached stat significance

increased intensity promotes:

a more normal gait pattern better improvements in walking speed better improvements in cardiovascular measures an increase in BDNF circulation

Take home points for gait treatment from stroke unit: REVIEW

apply the 5 principles of gait there is an argument for stretching of key trunk and LE groups prior to walking in order to control spasticity & contracture whole-task practice minimize the use of AD's and braces early on use technology to get a large number of decent quality steps in during your sessions include activities that challenge balance include activities that promote locomotor rhythm vary environmental and task demands use your hands to cue or to facilitate

tools to achieve maximal recovery

body-weight supported treadmill training lokomat-assisted walking training robotic exoskeletons research is quite inconclusive with respect to these devices -locomotor training CPG was based on chronic injuries -sub-acute forming now -watch the research! may be space for these in more acute or subacute patients

Summary points of Middendorp et al 2011: With whom can you expect independent walking 1 year after traumatic SCI?

first thing they looked at was complete vs incomplete diagnosis at injury (PPV: 8.3% complete could walk 1 year post, 71.4% incomplete could walk 1 year post) Second thing they did was break down incomplete SCI's into specific AIS grades Found as you progress through AIS grades (B->C->D) there is a greater chance of walking 1 year post injury which is logical the interesting thing they found was a PPV of 39.4% of AIS B's, although it is very likely that AIS B stays AIS B some change AND some CAN WALK

How do you use Middendorp's prediction rule?

for each of the 5 variables give your patient a score ex. if patient greater than or equal to 65 years of age, score the patient 1, if they are not score them 0 THEN multiply the score by the weighted co-efficient in the next column of the chart to get a score MMT scoring is the 0-5 scale we are familiar with light touch scores 0= absent, 1= impaired, 2=normal) at the end add up all of the scores (after multiplying) and use the total on the X axis of the chart to find the predictive value

Are most spinal cord injuries complete or incomplete?

incomplete incomplete tetraplegia > incomplete paraplegia

Where do we fall compensation vs recovery when it comes to incomplete SCI? What impacts your decision?

more towards recovery than compensation, more often than note we are aiming for RECOVERY factors: does the patient meet the criteria to have a high likelihood of walking in a year? what is this patients AIS level?

AIS E

motor and sensory function are normal

AIS C

motor function is preserved below the neurological level and more than half of the key muscles have a muscle grade of less than 3

Traumatic SCI causes

motor vehicle accidents falls violence sports-related injuries, including diving accidents

AIS A

no motor or sensory preserved in sacral segments

AIS B

sensory, but no motor function is preserved in the sacral segment

Treatment when recovery is the goal

task-oriented approach based on the principles of neuroplasticity maximize strength through functional means whenever possible appropriately manage spasticity and ROM limitations prior to, and during functional interventions via stretching and weight bearing don't forget about the trunk: it must be stable, responsive, and adaptable don't forget about the UE's: subluxation, edema, muscle imbalance, are all possible here too

Recovery of walking: *intervention KEYS*

task-specific walking training (intensity is key) =precision of training *focused on practice of precise stepping patterns) is NOT superior to mass/endurance training but is NOT bad intensity: *calculate HRmax: (208-(0.7 x age))*; know what HR is defined as high intensity for your patient then aim for *60-80%* OR utilize the RPE scale at 15-17 AND MONITOR CONTINUOUSLY increased intensity promotes: a more normal gait pattern better improvements in walking speed better improvements in cardiovascular measures an increase in BDNF circulation

What is the physical therapist's goal with treatment of iSCI?

to maximize recovery of all aspects of normal movement (walking & every other way a pt will move) to utilize compensatory strategies when recovery has been met with a plateau

The vast majority of published information on incomplete SCI's is on which MOI?

traumatic be careful not to apply prediction rules to individuals with non traumatic diagnoses, do not expect the same outcomes especially with those with malignant tumors

What are the categories of what causes an incomplete SCI?

traumatic and non traumatic