NCS Exam- Week 2- SCI
Prognosis in SCI
-incomplete = greater recovery change than complete -preservation of pinprick at 4mo at LE or sacral= increased potential for motor recovery -plateau between 12-18months **box 20 in O'Sullivan Text: -motor level, PLOF, prior health leel, secondary complications, body type, pschosocial support system
Causes of Non-Traumatic SCI
disc prolapse vascular insult (AVM or AAA) infection (transverse myelitis or meningitis)
Research on FES in shoulder subluxation in SCI patients -best mm stimulation to minimize pain and subluxation
**deltoid= best spot- improved pain by 46% *supraspinatus= 24% decrease in pain * improvement in 3cm of subluxation for both -control group- increase by 3% in pain!
2012 study: exercise and sport in SCI population
*Physical Capacity - cardiac hypertrophy, max work rate, max oxygen consumption, max lactate level, pulmonary function *Muscular Strength - improved upper body strength *Body Composition - higher lean mass and lower fat mass *Functional Performance - 25% of paraplegias have fitness level to be indep. Improved motor FIMs with exercise. *Psycho-social Well Being - significant association with physical well being and PSWB
Most Common Pain complaint in SCI?
*shoulder pain
How to improve CV RIsk factors?
*to improve HDL and triglycerides= 8wks of mod intensity exercise, 30min/day, 5days/week -vascular inflammation will take >12mo to return to baseline of typical functioning person *recommend resistance + cardio rather than just cardio alone
Whole Body Vibration Rats Study SCI rats + vibration plate at 7 days vs 14days vs control
+ vibration plate 14 days= improvement in body weight support and stepping mechanics (improved bladder function as well) -better at 14 days than 7 than sham/control
Factors Influencing Spacticity
- any noxious stimulus -UTI, ingrown toenail, seating system -constipation, pressure ulcer -skin infection, DVT, pressure from orthosis
Research on a Tricycle with FES
-23 subjects -low intensity stim to hams, quads and glut max -30 RPM vs 60RMP vs spasticity resistance -5min warmup/15min cycle with stim 30RPM= power increased by 4.4 W 60RPM= power increased by 18.2 W 12.2W reduction in spasticity resistance (resistance of spasms working against the body)- at 60RPM -improved activation of LE mm with reduction in spasticity
Appropriate WC Set-up to minimize shoulder pain
-AC joint in shoulder neutral should be right over axis of the wheels/arm straigt down= hand hits axis if too far forward from axis= too much reaching back fpr manual propulsion= increased anterior shoulder stress and anterior capsule injury
Medication Management of Spasticity 2. Tizanidine
-Alpha-2 Receptor agonist that inhibits excitatory spinal interneurons and tracts -more of a CNS effect side effects: hepatotoxicity, drowsiness, dry mouth, GI disturbance, hypotension
When should bwe expect most improvement following SCI?
-SCI pts: research demonstrates most recovery in first 6mo -physicians give a 12mo window
Research on TENs effect on Spasticity
-TENs unit on low back for 60min vs control group/sham -TENs did decrease overall spasticity composite score by 29% -DF 31% less limited, clonus decreased by 29% -may be a backup option to help if trying to avoid medications
Central Cord Syndrome -how does it present -what causes this
-UE affected> LE -loss of more centrally located cervical tracts (arm function), with preservation of peripherally located lumbar/sacral tracts (leg function) Cause: hyperextension injuries, post-op neck surgeries due to excessive swelling
Exercise Modifications for SCI Patients
-WC bound, no standing -don't move as easily -difficulty holding equipment- ways to tie, make grips larger, etc -basic machines aren't always practical due to transfer challenges website: physiotherapyexercises.com- amputee, stroke, TBI and can sort by C5 vs T12 or example! *free site
Medication Management of Spasticity 4. Gabapentin
-acts both on pain and spasticity 11% reduction in spasticity in SCI specifically
Physical Activity Guidelines in SCI- a systematic review of 69 studies...
-aerbobic training AT LEAST: 20minute,x2/weak of mod-vig exercise -anaerobic training at least: x2/week on major mm groups *unfortunately this is reality *high training times= decreased participation *suggest less pushing.... :( -consider ACSM guidelines!!! they need more exercise than this to improve function and strength
ACSM Guidelines for SCI patients- Guidelines -aerobic training? -fatigue? -other things
-aerobic training in highly recommended -exercise the SAME manner as the general population -peripheral fatigue before central fatigue bc of decreased mm activation -decreased CV and physical capacity for exercise
Postural Assessment in SCI
-biggest difference in SCI patients is sporatic mm activation and varied trunk control -dependent on level -high level with decreased trunk control may "hang" on their vertebrae with excessive rounded shoulders and kyphotic, forward head
Precautions in SCI with exercise?
-blunted tachycardia -lack of a pressor response -low BP (100-110/60 normal) -monitor for decreased sensation -> increased tolerance (easy to over do) -higher core temperatures - ensure not to overheat with exercise -monitor for autonomic dysreflexia
UTI
-can come from spastic bladder (UMN injury) or flaccid bladder (LMN injury) -50% of all SCI pts= common in the SCI population -can become a systemic infection --> chronic
Chronic Phase following SCI- Therapy Considerations
-car training, driving -exercise program carryover to home and equipment needs -scoliosis -gait training- good vs bad habits developed over time -WC- do they fit? upgrade/downgrade? its been 5 years? -asymmetries- atrophy from surgery or specific dermatomal weakness, orthotics (may need update from recovery)
Treatments in Patients with Spasticity should be:
-context-relevent/meaningful activities (spasticity will actually be lower) -skill training has improved outcomes as compared to closed kinetic chain or NDT exercises
Scoliosis in SCI -why -treatment
-due to poor posture/sitting position and abnormal muscle activity (tone, spasticity) -treatment- Schroth method out of Germany: -stretch tight mm -mobilize tight structures -put into correct posture -strengthening to stabilize there *for SCI, start in siting with pelvis and work your way up
Shoulder Pain in SCI Risk Factors
-duration of injury (worse of 12-15yrs) -increased age -higher BMI (a 0.5 increase in weight= 5lbs extra effort) -females (maybe due to less overall mm mass, increased BMI) -poor WC set-up (excessive reaching for manual propulsion) -depression lift for pressure relief -more active and indep individuals use arms more= increased shoulder pain
Medication Management of Spasticity 3. Benzodiazapides
-enhance GABA -used primarily as a mm relaxant
Anterior Cord Syndrome
-flexion injuries of cervical spine, falling backward/head goes forward, aneurysm or ischemic and ant radicular artery (AVM or AAA) damage to anterior cord= loss of motor function, pain and temperature sensation (primarily motor deficit) preservation of light touch, proprioception and positional sense
Risk Factors in SCI
-general issues (spinal shock, spasticity/spasms 65%, UTI, autonomic dysreflexia) -cardiovascular compromise -skin integrity compromise -respiratory compromise -musculoskeletal conditions
Musculoskeletal
-heterotpoic ossification (abnormal bone growth in soft tissue- watch for swelling/pain, redness- tend to be near large joints such as hip flexors, elbow or shoulder), as this progresses= calcification occurs Lack of WB-> LE jt degeneration -atrophy of mm -osteoporosis -overuse injuries are common -contractures *use PROM/AAROM to help prevent, watch positioning in WC to prevent contractures (consider splinting as needed) *selective stretching to preserve function (tenodesis grip)
DVT Risk in SCI
-hoehman sign -check for edema, increased tenderness
Medication Management of Spasticity 6. Botox
-inhibits Ach release= partially paralyzes the mm... -leading to flaccid paralysis -only lasts for a few months -minimal side effects: excessive weakness of injected mm, fatigue, nausea, headache
Spinal Shock
-initial transient period of reflex depression where LEs are flaccid -may last a few hours to 24hours of no activity -with gradual return over next few days -then period of hyper-reflexia ~1-24wks -"learned non-use" within 72 hours is a concern
Posterior Cord Syndrome
-loss of posterior columns -deep touch and proprioception most affected -preservation of motor function, sense of pain and light touch due to abscess, tumor trauma
CV Disease in SCI -3 risk factors?
-low HDL -higher triglycerides levels -decreased ability to clear triglycerides -higher rates of vascular inflammation (can reduce by reducing adipose tissue)
Study on Benefits of FES (Christopher Reeves)
-many other variables in addition to FES (BWS treadmill training, ongoing therapy, aquatic therapy in this study identified benefits of FES: -improved motor and sensory scores -decreased hx time -improved QOL
WISCI II
-measures improvement in walking ability in SCI -good to get a baselineobjective 'quantitative' measure and then measure change over time -assesses amount of physical assistance and AD necessary to walk over 10M -0-20pts 0= inability to ambulate 20= ability to ambulate without AD or assist for 10M -excellent test-re-test reliability, and excellent inter/intra-rater reliability across all clinical settings -validity is excellent, and.. -corresponds well with FIM, TUG, 10MWT and 6MWT
Autonomic Dysreflexia
-medical emergency! -some sort of noxious stimulus causes a pathologic autonomic reflex -symptoms: HTN, bradycardia, pounding headache, diaphoresis, flushing of skin, diplopia, sometimes convulsions -ask pt if they know their triggers (most common one is need to empty bladder/be cathed), can also be uncomfortable sitting position or tight shoe **sit and/or stand them up! BP is too high -occurs in pts who have injury of T6 and above, 50% of these pts, typically >6 months out from injury
Stretching- effectiveness in spastic muscles
-minimal long term effects , short term only with passive stretching (may be good at beginning of therapy session for temporary ROM improvements for ie gait training) -if you're stretching: best to do an active stretch by engaging antagonist mm, or perform a short passive stretch -static stretch should be very long periods of time- greater than an hour per day
Medication Management of Spasticity 5. Baclofen
-most common anti-spasmotic used -specific to GABA B Receptors (agonist) -prevents release of neurotransmitters, inhibits/decreases activation threshold of the nerves -as it decreases neuronal firing, it also dampens the CNS generally- systemic response, not spastic areas only -potential for neuroplasticity is actually decraesed with this medication side effects: drowsiness, confusion, nausea, decreased neural signs... -can actually lead to respiratory distress (with a pump/higher doses)
Brown Sequard Syndrome
-most common with penetration wounds, gunshot or knife, also MVA or tumor resection -ipsilateral paralysis and sensory loss at level of injury -loss of discriminative touch, paralysis and proprioception below level of injury -contralateral loss of pain and temp. sensation below level of injury
Back and Neck Pain in SCI
-often may require fusions for fracture or damaged area, to stabilize -skin/mm/tendon/ligament develop scar tissue= tightness -scar tissue, myofacial pain, may never be painfree -soft tissue, scar mobs, DTM, kineseotape, relax UT mm
Floor to WC Transfer in SCI
-one of the most challenging -fragment first; start with uphill WC to mat transfers up and down hill, then mat to floor then WC to floor -consider pt's ability to: lift own body weight, (10 dips in // bars, if back technique requires sufficient shoulder hyperextension -head/hips relationship is crucial!
Skin Integrity
-pressure relief is necessary -heel offloading boots, specialty cushion -lateral, A/P lean or reclining to decrease pressure -refer skin breakdown as needed
SCI-FAI
-qualitative -assesses functional walking ability in SCI -observational analysis (can use video analysis for accuracy) over 3 domains: 1.specific parameters (0-20pts) (weight shift, step width, step length, step rhythm, step height, foot contact) 2. distance (0-5 pts) 3. AD level (0-14pts)- RW, SPC, crutches, //bars, AFO, KAFO -scored from 0-39pts -MDC is 1.9 pts (no MCID yet) -no test-retest yet -inter-rater for live assessment is adequate-excellent, and excellent with video assessment -intra-rater is excellent with both -validity is excellent -correlates with WISCI, TUG, 2MWT, 10MWT
Seated Balance with HHD
-research on better outcome measure of sitting balance -good inter-rater reliability
Rat Study: Spinalized rats -WC bound vs passive stretching vs WC+ stretching vs returned to return to normal group no intervention
-return to group did best (controls) -passive stretching only did no change- we should ask why we would stretch this population (ie: initiation of hamstring stretches to be able to achieve long sitting- probably does damage!!- maybe should use circle sit or EOB sitting) -WC group got worse once in chairs-did most poorly, even after taken out of WC they improved but did not catch up to other group (this is what we do to humans basically)
Research on transcutaneous SC stimulators (tSCS)
-small group (3) -stimulation at T11-T12 -decreased overall exaggerated reflexes when assessing gait -gait speed increased by average of 39% -more studies happening now
Cardiovascular Function and COmpromise
-typically with relatively low BP -high cholesteral and DM common (sedentary pts) -decreased circulation- less muscles working and pumping -vascular support- TEDs or abdominal binder
Medication Management of Spasticity 1. Dantrolene
-used for less severe spasticity -short term, low frequency such as clonus -blocks Ca+ release from the sarcoplasmic reticulum -interferes with excitation contraction coupling of the skeletal mm -side effects: drowsiness, dizziness, weakness, malaise and fatigue
Respiratory Compromise
-varies greatly in SCI -T10 and lower= should have fairly normal capacity -anything above T10= abdominal control and intercostal loss needed for normal breathing -10% of tetraplegics develop PNA after 1yr post injury -deep breathing exercises, respiratory strengthening, assisted coughing/quad coughing, IS, pulm. hygiene, postural draining/CPT, suctioning -abd support brace to assist with breathing
Research on Hand Cycling: Effect of Physical Capacity -effective?
162 people with C5 and lower injuries monitored peak VO2, peak power UE strength and pulm function -hand cycle >1/week vs <1/week and + normal therapy results: -power, VO2 and strength all improved in cycling groups, no change noted in pulm function
Study: old 24mo versus young 6mo knockout mice (does not express GSNF production) -short term exercise and GDNF
2 week training sessions- young vs old of sedentary, voluntary/non-voluntary running and swimming, **moderate intensity exercise programs were best at simulating and enhancing neurotrophic factors= better recovery
Research on Epidural Stimulation
23yo male with C7-T1 subluxation 170 manual assisted locomotor training sessions over 26 months with a epidural stimulation at L1-S1 segments turned on *C7 complete with stimulator getting mass quantities of locomotor training... -7mp= coluntary motor control when turned on -26mo= active control of full WB, and rhythmic stepping pattern, voluntary control of bilat LE mm activation (all with stmulator on) -improved overall muscle mass, normalized BP and body temperature regulation *also bowel and bladder with stimulator off! and improved sexual function
Chronic Shoulder Pain- Research on use of EMG and Biofeedback
8 week protocol for chronic shoulder pain -WUSPI and SRQ (shoulder rating questionaire as outcome measures) -used visual biofeedback to ensure correct activation -UT, post capsule, long head bicep, pectoralis major stretching -strengthening: serratus, ER, mid/low traps, -results: 20% improvement on the WUSPI, and 29% on the SRQ, overall satisfaction improved 2%
Neurotrophic Factors and Effect on Exercise -BDNF -GDNF
BDNF- brain derived neurotrophic factor GDNF- glial derived neurotrophic factor Insulin-like growth factor-1 vascular endothelial growth factor *GDNF: -most potent survival factor for motor neurons -increases axonal braching and motor unit size -prevents motor neuron degeneration -stops somatic motor neuron cell death
Most Common Location of SCI
C5, C7, T12, L1
Top 5 SCI Clinical Syndromes
Central Cord Brown Sequard Anterior Cord Syndrome Posterior Cord Syndrome Cauda Equina Syndrome
ASIA A
Complete Injury -no motor or sensory below level of injury -no motor or sensory in sacral segments S4-S5 (no rectal)
Body Weight Support Gait Training -parameters -sensory cues
Expectations: -maintain normal speed (1.7-2.9 MPH or 0.75-1.32M/S) -off-loading at less than 35% BWS (they carry 65% of their weight) -maintain proper kinematics -at least 30 minutes or 3000 steps minimum (3000-4500) Sensory Cues: -symmetric stepping and inter-limb coordination -approximation of normal hip/knee/ankle kinematics -minimize UE WB and normal arm swing -minimize extraneous sensory information/conflicting info which distracts from goal of normal stimulation to brain
Intensity of training in SCI- Summary*
Feel free to train at higher intensities • Their vascular system will appreciate it • Even a little bit of exercise is better than nothing • Sometimes its more about getting them on the right path • Aerobic Training - At least 20 minutes of moderate to vigorous activity 2(+) times per week - OR train the patient like they aren't a patient (ACSM guidelines- know how to modify as needed)
Motor Incomplete (ASIA C/D0
Highly -6MWT -10MWT -ASIA -handheld myometry -TUG -WISCI-II -WHO QOL-BREF Recommended Outcomes -BERG --Capabilities of UE functioning -FIM -LISAT-9 -MMT -SCI-FAI -SF-36 -SCIM-III
EDGE Task Force- Recommended OMs -for Complete ASIA A/B
Highly recommended -ASIA -handheld myometry -WHO QOL-BREF Recommended -Capabilities of UE functioning -FIM -LISAT-9 (good for acute, fair for chronic) -MMT -SF-36 -SCIM III -WISCI-II (yes, an amb measure- why here? idk)
ASIA C
Incomplete Injury -some sensory AND motor function below level of injury -MOST muscles below level of injury <3/5 'less than' -sacral sparing
ASIA D
Incomplete Injury -some sensory AND motor function below level of injury -MOST muslces below level of injury >3/5 'greater than' -sacral sparing
ASIA B
Incomplete Injury -some sensory function only below level of injury -NO motor function below level of injury -sacral sparing (MUST have some function to be a 'B')
Causes of traumatic SCI
MVA (most common), cervical injury (flexion-rotation most common) compression injury hyperextension
Does vigorous exercise aggrevate spasticity?
NO -stronger mm though mean the spasticity is working on stronger muscles
RCT: exercise and EMG versus exercise alone
RCT Pilot Study: C6 or lower injury, 15 pts for 8 weeks -exercises x1/day, x5/week- 2 stretches and 3 strengthening -EMG with exercise= 64% pain reduction- -exercise alone reduced pain by 27% with EMG= 37% greater reduction in pain than exercise alone
SCIM
Spinal Cord Independence Measure -6 self-care items (0-20pts) -4- respiration items (0-40 pts) -9 mobility items (0-40 pts) *can formally assess or complete verbal assessment (faster) -inter/intrarater reliability is adequate-excellent -no test-retest information -correlates well to FIM, River-Mead MObility Index, Barthel Index *benefit is that it is specific to SCI population
STOMPS Program
Strengthening and Optimal Movement for Painful Shoulders -basic protocol for individuals with shoulder dysfunction and for prevention of shoulder issues -good to add as part of a HEP -do x3/week with rest every other day or alternate days of exercises, use a calendar to track
WUSPI
WC User Shoulder Pain Index -self report, 15 items, 0-10 points each (0 no pain, 10 worst) -0-150 points -high test-retest reliability -valid- shows -increased shoulder pain= correlated with decreased ROM
Complete vs Incomplete SCI
complete= no motor or sensory function below level of injury incomplete= preservation of motor or sensory function below the level of injury, may be mixed and generally inconsistent
Cauda Equina Syndrome
damage to the lumbar and sacral routes BELOW the level of the conus medullaris -sensory impairment and flaccid paralysis/paresis of LE mm -bowel and bladder dysfunction -consdiered a LMN injury! -common in post-op (laminectomy wtih remaining swelling) or following trauma
what defines the SCI injury "level"
lowest fully functioning/non-impaired level
Pain : nociceptive vs neuropathic
nociceptive- typical orthopedic pain neuropathic- at or below level of injury -doesn't respond well to therapy -can try TENs, massage -pharmacological options like gabapentin, tramadol, lyrica, neurontin
ASIA E
normal motor and sensory below level of injury