Exam 3: SCI Gait and Advocacy Flashcards
What is an alternate name for the ASIA Exam?
International Standards for Neurological Classification of Spinal Cord Injury examination
This is the new terminology
Spinal cord Injury Epidemiology info from Shepherd & Dr. Bringman
Most Common Age at injury:
Average Age at injury:
Gender (percentage):
Most Common Age at injury: 18-27
Average Age at injury: 42
Gender (percentages):
- Males 80%,
- Female 20%.
When defining levels of injury, what is the difference between the Orthopedic level and the Neurological level?
Orthopedic Level: The leve where the greates vertebral damage is found (via radiographic exam)
- Often does not correlate with the neurological level
- Not all spinal cord injuries have a bony injury (i.e. tumor)
Neurological level: The most caudal segment of the spinal cord with normal sensory and antigravity motor function on both sides of the body (with normal function above).
Teteraplegia incidence
total incidence:
Incidence of Complete:
Incidence of incomplete:
total incidence: 59%
Incidence of Complete: 14%
Incidence of incomplete: 45%
Paraplegia incidence
total incidence:
Incidence of Complete:
Incidence of incomplete:
total incidence: 41%
Incidence of Complete: 20%
Incidence of incomplete: 21%
What dose ISNCSCI stand for?
International Standards for Neurological Classification of Spinal Cord Injury
(new terminology for ASIA)
6 spinal cord injury syndromes
- Central Cord Syndrome
- Anterior Spinal Artery Syndrome
- Brown-Sequard Syndrome
- Posterior Cord Syndrome
- Cauda Equina Syndrome
- Conus Medullaris Syndrome
Brown-Sequard Syndrome: potential for ambulation
(Also, Quck reveiw on characteristics of the syndrome - optional)
Most gain some level of ambulation
- Caused by penetrating injuries (ie gun shot or stab wounds
- Hemisection of teh spinal cord
- loss of movement, position sense (proprioception) on the same side; loss of pain, light touch on opposite side
Posterior cord syndrome: potential for ambulation
(Also, Quck reveiw on characteristics of the syndrome - optional)
Funcitional ambulation is difficult despite strong muscles
- Very rare
- Motor function is intact
- sensation is lost below the level of injury
- (used to be associated with syphallus)
Central Cord syndrome: potential for ambulation
(Also, Quck reveiw on characteristics of the syndrome - optional)
77% of these clients will ambulate
- Hyperextension injury
- Arms more affected than legs
- majority of incomplete lesions result in this syndrome
- most common clinical syndrome, but only about 10% of all SCI
Anterior Spinal Artery Syndrome: potential for ambulation
(Also, Quck reveiw on characteristics of the syndrome - optional)
Prognosis poor for ambulation
- Anterior spinal artery lesion or retropulsed disc or bone frament
- Loss of motor functions, pain and temperature sensation
Cauda Equina syndrome: potential for ambulation
(Also, Quck reveiw on characteristics of the syndrome - optional)
Very good potential for ambulation
- Injury to the L1 vertebral level and below
- Lower motor neuron lesion
- In most cases a complete lesion
- Ambulation is probable (quadriceps are spared)
Conus Medullaris syndrome: potential for ambulation
(Also, Quck reveiw on characteristics of the syndrome - optional)
Very good potential for ambulation
- Injury to the sacral cord and lumbar nerve roots within the neural canal
- Lower extremity motor and sensory loss
- Areflexive bladder and bowel
- Can usually ambulate
What are 6 prognostic factors that help predict who will walk after a SCI?
- AIS impairment level at 72 hours (AISA level I think)
- Pin prick preservation
- Age
- Syndromes
- LE strength at 1 month
- Spinal cord hemorrhage
What are 7 impairments that may impact gait that you should treat early on in patients who may walk again?
- Strength
- Somatosensation
- Spasticity
- Joint tightness and/or contractures
- Balance
- Cardiorespiratory function
- Obesity/body type
10 principles of Neural Plasticity
- use it or lose it
- use it and improve it
- specificity
- repetition matters
- intensity matters
- time matters
- don’t wait to treat, but realize recovery takes time.
- Salience matters (how much the pt cares about the task)
- age matters
- transference
- interference
Explain eveidence for somatosensory treatements (general)
- Findings suggest that consistant use of afferent input improves the motor output of the control mechanisms that have been impaired after SCI
- There is evidence that a single session of afferent stimuli may be sufficient to induce neuroplastic changes in spinal cord and cortex.
Evidence for Somatosensory treatments: Vibration
- localized wibration to TFL causes a stepping pattern
- 12 sessions of whole body vibration improved gait speed, cadence, step length and intralimb coordination
Evidence for Somatosensory treatments: Somatosensory Stimulation (SS)
- SS + massed practice –> cortical changes and improvements in sensation, strength, and hand function.
What are three types of somatosensory treatments?
- Vibration
- Somatosensory Stimulation (SS)
- Weightbearing
4 Locomotor Training Modalities
- Bodyweight-support Treadmill
- Robotic Gait Training
- Overground Gait Training
- Exoskeletons
BWSTT stands for
Bodyweight-Support Treadmill Training
Details about BWSTT
How is it set up?
Where is manual facilitation required?
How many trainers are needed?
What can it be combined with?
- Adjustable overhead BWS attaches to harness
- Manual facilitation at hips, knees, ankles
- Requires up to 3-4 trainers
- Can combine with e-stim and LE orthotics
RGT stands for
Robotic Gait Training
What is a Lokomat?
A type of robotic gait training (RGT) device
Robotic Gait Training (RGT): Lokomat details
Indications
adjustibility
support it provides
how it is powered
what PT does
- Indicated for patients with any LE activity
- Adjustible for a variety of body types
- Trunk and hips well supported
- motors and sensors at hip and knee oints power gait pattern
- PT controls weight bearing, speed, joint angles, cadence, and amount of robotic assistance
OGT stands for
Overground Gait Training (OGT)
Overground gait training (OGT) details (3 things)
- Can be performed using bodyweight-support systems, assistive devices, orthotics/braces, FES, or any combination therein
- Frequently requires multiple therapists/technicians for safety and facilitation
- Can result in fewer repetitions due to patient fatigue
What is FES?
Stands for Functional Electrical Stimulation
Functional Electrical Stimulation (FES) applies small electrical pulses to paralyzed muscles to restore or improve their function. FES is commonly used for exercise, but also to assist with breathing, grasping, transferring, standing and walking. FES can help some to improve bladder and bowel function. There’s evidence that FES helps reduce the frequency of pressure sores. (http://www.christopherreeve.org/site/c.mtKZKgMWKwG/b.4453425/k.27A5/Functional_Electrical_Stimulation.htm)
Seems the same as NMES to me
What does the literature say about the use of OGT vs BWSTT vs RGT? (6)
- BWSTT and RGT can provide appropriate, task-specific, high-intensity afferent input to stimulate spinal and suprasipnal plasticity
- Individuals with slowest gait speeds show greates timprovements
- Both BWSTT and RGT can increase walking speed, level of independence, and interlimb coordination
- OGT may be as effective as BWSTT and RGT
- Improvements in gait speed, distance, LE strength, quality of life, and dependence on assistive devices were similar regardless of the locomotr approach
- insufficient evidence to conclude that one is more effective than another
- Combining electrical stimulation may improve outcomes of all locomotor training
What are four types of Robotic Exoskeletons?
- ReWalk
- Ekso
- Rex
- Indego
Which of the four mentioned exoskeletons is less common in the USA?
Rex
Which of the four mentioned exoskeletons is the only freestanding model?
Rex
Which of the four mentioned exoskeletons is the only one currently approved by the FDA?
The ReWalk
Which two of the four mentioned exoskeletons are about to receive FDA approval?
- Ekso
- Indego
(I think)
Characteristics of Robotic Exoskeletons:
- How much they weigh?
- Do they need other equipment to work?
- Describe appropriate patients
- 3 ways they operate
- Speed they can go
- 26-106 lbs
- Most have to e used with assistive device
- C6 and below SCI
- Operate in a number of ways
- Posture change
- PT or user triggered step
- joystick
- Speeds from 0.1 m/s-0.45 m/s
Are other developers eager to produce exoskeletons?
Yes!
Many more are being developed for future release.
Examples: Honda Walking Assist, Fortis.
What does the literature say about Exoskeletons? (4)
- Generally found to be safe, effective in getting people with SCI up and walking
- Monor skin abrasions common, more serious issues rare
- Speeds vary widely with injury level and other factors
- flrequently mouch slower than able-bodies speeds
- Questionable ability to reach community ambulation speeds
- FDA currently requires a companion for use outside of rehabilitation setting
Potential Benefits for use of Locomotor Technologies (4)
- Allows earlier interveintion with more acute/medically involved clients
- Allows for increased intensity and number of repetitions
- Allows gait training in safe, fall-free environment
- Promotes additional benefits besides gait
Potential Barriers for use of Locomotor Technologies (6)
- Cost
- Space
- What your facility has
- Staffing requirments/training
- Specificity of training
- Differences between biomechanics of walking overground vs. treadmill, robot exoskeleton
Locomotor Technologies: Limitations in Current Literature (5 points)
- Lack of large scale randomized control trials (RCT’s)
- Studies often done in a limited, chronic SCI population
- Often difficult ot match training intensity/duration
- Comparisons of technologies not true to how commonly used in rehab
- Currently-available literature does not negate clinical reasoning, judgement, and experience
Two conclusions/take-home messages about Locomotor Training
- Locomotor training should begin as soon as possible, should always be challenging, with only minimal support from therapists or robotic devices, and with full patient participation
- Aim to optimize task-specific sensory cues to facilitate spinal and supraspinal plasticity, including arm movemenets and appropriate manual cuing
Who declared disabled persons a “menace to the happiness . . . of the community.”
Alabama legislature
Who called disabled person “unfit for citizenship.”
A Mississippi statue
Who madated segration [of disabled people] to relieve society of “the heavy economic and moral losses arrising from the existence at large of these unfortunate persons.”
A Texas law
Who wrote the hand-out we had called “A Little History Worth Knowing”?
Timothy M. Cook
Was government mandated segregation, exclusion, and degradation of people with disabilities limited to the South?
No
In every state the policy was to keep [disabled persons] out of society
Where were disabled people officially termed “anti-social beings”?
Pennsylvania
Where were disabled people considered “unfitted for companionship with other children?
Washington
Where were disabled people called a “blight on mankind”?
Vermont
Where were disabled people called a “danger to the race”?
Wisconsin
Where were disabled people called “a misfortue both to themselves and to the public”?
Kansas
Where were disabled people required to be “segregate[d] from the world”?
Indiana
In which state did a government report say that a “defect . . . woulnds our citizenry a thousand times more than any plague”?
Utah
Where did disabled people simply not have the “rights and liberties of normal people”?
South Dakota
Have physicians, health workers, and social workers been part of segregation of disabled persons?
State officials actively inculcated fear of disabled persons, especially retarded persons, directed their identification and removal form the community, and coerced the assistance of physicians, health workers, social works, and a variety of others to do so.
Who was the Supreme Court justice who wrote an opinoin that upheld the constitutionality of a Virginioa law atthorizing the involontary sterilization of disabled persons, ratified the view of disabled persons as “a menace.”
Justic Oliver Wendall Holmes
He justaposed the country’s “best citizens” (nondisabled persons) with those who “sap the strength of the state” (disabled people), and to avoid “being swamped with incompetence,” ruled “It is better for all the world, if instead of waiting to execute degenerate offspring for crime, or to let them starve for their imbecility, society can prevent those who are manifestly unfit from continuing their kind.”
What should you do next time someone tries to explain to you that handicappism is a more “benign” form of discrimination?
- Tell them how the segregation and exclusion of people with disabilities all began.
- Tell them how, historically, a lot of important decision-makers passed laws sending disabled persons away.
- Lastly tell them progress is being made.
- Congress has enacted the Architectural and Transportation Barriers ACt, The Rehabiltation Act, the Education for All Handicapped Children ACti, Air Carriers Access Act, Fair Housing Act, and the Americans with Disabilities Act. These laws require integration.
What are the 6 laws passed by Congress that require integration of disabled people that were mentioned in our hand out (and what was the date each was passed)
- Architectural and Transportation Barriers Act (ABA) (1968 as just the Architectural Barriers Act)
- The Rehabiltation Act (for vocational issues) (1973)
- Education for All Handicapped Children Act (1975)
- Air Carriers Access Act (1986)
- Fair Housing Act (1968, 1988 disability was added)
- Americans with Disabilities Act (1990)
Date Congress Passed: Architectural and Transportation Barriers Act (ABA)
(1968 as just the Architectural Barriers Act)
Date Congress Passed: The Rehabiltation Act (and what did it address?)
1973
for vocational issues
Date Congress Passed: Education for All Handicapped Children Act
1975
Date Congress Passed: Air Carriers Access Act
1986
Date Congress Passed: Fair Housing Act
1968
1988 disability was added
Date congress passed: Americans with Disabilities Act
1990
What was the advocacy speaker’s name?
What level was his injury?
Mark Johnson
C5/6
What did Mr. Johnson suggest we do when buying a house in order to advocate for disabled people
Refuse to buy it if it is not ADA compliant
(all houses should be bulit ADA compliant from the begining in his opinion)
