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Neuro Dev/Control II > Incomplete SCI & Recovery of Ambulation > Flashcards

Incomplete SCI & Recovery of Ambulation Flashcards

1
Q

Describe homeostatic plasticity

A
  • The ability of neurons to increase excitability after a period of low synaptic activity & is related to changes in postsynaptic glutamate receptors
  • The time scale of homeostatic metaplasticity, in comparison to gating, is protracted, & hence the resting state of neurons is modulated prior to motor training in order to induce synaptic plasticity
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2
Q

How can we prime the central nervous system

A
  • Peripheral electrical nerve stimulation
  • Repetitive movements: unilateral/Bilateral symmetrical, active/passive, and aerobic exercise
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3
Q

Describe gating

A
  • Occurs by disinhibition of intracortical inhibitory circuits as a result of increase in calcium in the targeted cortical neurons
  • Gating occurs instantaneously & its achieved concurrently with motor training
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4
Q

Describe neuromodulation

A
  • Alteration (stimulate/suppress) of CNS activity through a targeted delivery of a stimulus such as: physical agent/modality, movement/sensory based activity, & electrical stimulation
  • Electrically isolate neuronal circuitry below the injury site, which remains intact but can no longer efficiently receive supra spinal input or transmit sensory info for processing by higher centers
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5
Q

What are the 10 principles of neuroplasticity

A

1) Use it or lose it
2) Use it and improve it
3) Specificity
4) Repetition matters
5) Intensity matters
6) Time matters
7) Salience matters
8) Age matters
9) Transference
10) Interference

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6
Q

What type of feedback is better for learning?

A
  • Implicit: having the patient reflect
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7
Q

Which type of feedback schedule is better for learning?

A
  • Summary
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8
Q

What type of practice schedule is better for learning?

A
  • Blocked is best for skill acquisition
  • Random is best for long term retention and learning
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9
Q

Goals of task specific training

A
  • Goal directed practice of functional tasks instead of focusing on impairment reduction exercises
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10
Q

Define locomotor training

A
  • Training emphasizing activation of the neuromuscular system below the level of the lesion to induce neuroplasticity and promote recovery of function
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11
Q

What are the guiding principles for locomotor training

A
  • Maximize weight-bearing on the lower extremities and minimize weight bearing on the upper extremities
  • Optimize sensory input consistent with each activity
  • Optimize the proper kinematics for each task
  • Maximize independence and recovery of movements while minimizing compensation
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12
Q

Describe the goals of locomotor training

A
  • The premise of locomotor training is to provide the damaged nervous system with appropriate sensory input to stimulate remaining spinal cord networks to facilitate their continued involvement even when supraspinal input is compromised
  • The spinal circuitry responds to sensory input, adapts behavioral output appropriately, and can induce permanent modifications in this system with repetition
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13
Q

What should clinicians not do to improve locomotor function

A
  • Static or dynamic balance activities including pre-gait
  • Body weight support treadmill training with emphasis on kinematics
  • Robot assisted gait training
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14
Q

What are the common push backs for gait training with incomplete SCI

A
  • Increased risks for pts: no increased risk above conventional therapy
  • You’re ignoring their impairments/they aren’t ready for walking: Strength, balance, transfers improve with variable HIT
  • Their gait patterns look horrible/you’re reinforcing bad habits: greater improvements in paretic limb kinematics & kinetics with HIT
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15
Q

What are the parameters for high intensity variable gait training

A
  • Frequency: 4x per week
  • Intensity: ~75-85% of HRmax
  • Time: as much time walking as possible in a one hour session
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16
Q

How to maximize repetitions of stepping practice

A
  • Reciprocal stepping in a specific direction for ≤ 40min with rest breaks as needed
  • Successful stepping: generating positive step lengths w/o foot drag & absence of limb collapse while maintaining sagittal/frontal plane stability
  • Verbal feedback was provided to ensure stepping at targeted intensities
  • Ankle foot orthoses & posterior knee braces were allowed to minimize orthopedic concerns
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17
Q

What is the goal of speed dependent treadmill training

A
  • To achieve the highest possible speed during forward treadmill stepping while maintaining target aerobic intensities of 70-80% hR reserve
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18
Q

What is the goal of skill dependent treadmill training

A
  • To maximize repetitions of treadmill stepping while challenging biomechanical subcomponents of walking in variable contexts & maintain targeted HR reserve
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19
Q

What is the goal of overgrown stepping

A
  • To maximize repetitions of stepping overground while challenging the biomechanical subcomponents of walking in different contexts & maintaining targeted HR reserve
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20
Q

What is the goal of stair climbing

A
  • Maximize repetitions of stepping on stairs while maintaining targeted HR reserve
21
Q

What are the active ingredients for high intensity gait training

A
  • Specificity
  • Intensity
  • Repetition
  • Salience
22
Q

What are some intensity strategies to increase RPE

A
  • Hardest activity first
  • Stairs
  • Weights
  • Resisted walking
  • Walk without a device
  • Walk on unstable surfaces: mats, objects under mats, outside grass/woodchips/sand
  • Monitor vitals: older adults report “inaccurate” RPEs
23
Q

What are the principles for HIGT (high intensity gait training)

A
  • Variable reciprocal stepping practice
  • Maintain HR 70-85% of max HR
  • Maintain rating of perceived exertion (RPE) ≥ 14/20 or ≥ 7/10
  • High repetition
  • High frequency & duration
24
Q

Predictors of outcomes from HIGT

A
  • BBS of 10.5 by 2nd week of IPR can predict walking at CGA or better at discharge
  • For those non ambulatory initially: stepping activity, BBS, & paretic leg strength predict walking outcomes for HIT; BBS >5 predicts walking recovery w/o assistance & achieving >0.4 or >0.8 m/s at discharge
25
Q

Why should we advocate for patients to go to a SCI model system

A
  • They have better access to robotic technology that can be very beneficial for SCI patients
26
Q

What is Project Walk

A
  • Originated from a sports training philosophy of designing programs around returning athletes to their respective competition
27
Q

What are the requirements to participate in the Project Walk program

A
  • SCI at C2 or lower
  • Non-ventilator dependent
  • Physician’s clearance for intensive exercise
28
Q

What are the 5 phases of recovery & associated intervention approaches fro Project Walk

A
  • Phase I/II Reactivation/Reorganization & Development/Stabilization: Stimulate the NS with active assistive exercise & use developmental sequencing to develop joint stabilization
  • Phase III Strength: initiate eccentric & concentric muscle contractions through positional movement or stimulation
  • Phase IV Function and Coordination: improve coordinated movement through all planes of movement & motion; most exercises are performed in a load-bearing position mainly free standing
  • Phase V Gait Training: focus on proper gait mechanics & the ability to move over ground in multiple planes of motion
29
Q

Activity dependent plasticity can be driven by

A
  • Neuromuscular activation below the injury either intrinsically using task specific sensory cues or extrinsically by using stimulation which is the basis for locomotor training
30
Q

Activity dependent therapy requires neural retraining, with

A
  • Task specificity predominantly provided by appropriate sensory cues & intense, repetitive practiice
31
Q

Describe active nervous system recruitment (ANSR)

A
  • Most basic modality
  • used when clients have little to no voluntary movement & consists of helping the client through different ROMs & providing a resistance less than gravity
  • Clients are instructed to attempt or visualize actively assisting or resisting the movement performed
  • ANSR attempts to provide a sensory stimulus & elicit a motor response
  • The goal is to generate patterned neural activity & ultimately using a high number of reps, long-term potentiation
32
Q

What are the 3 major guidelines for activity based therapy (ABT)

A
  • Emphasis on recovery versus compensation
  • Concentration of treatment below the level of injury
  • High dosage/intensity of physical rehab
33
Q

The overall goal of ABT is to facilitate neural plasticity using treatment activities based on

A
  • Forced use of involved areas
  • Central pattern generation
  • Enriched environment
34
Q

Greater responsiveness to activity based therapy was associated with the following participant characteristics

A
  • Paraplegia
  • ASIS impairment scale grade D
  • American Spinal Injury Association lower extremity motor score (LEMS) >25
  • Time since injury <3 yrs
  • Participants who were walking at speeds >0.4 m/s at baseline
35
Q

Describe the clinically meaningful changes in a activity based therapy program

A
  • Small gains in distance or speed and/or functional improvement which lead to the use of a less restrictive assistive device, could be of great personal relevance to these individuals
  • Program appears to have a greater impact on walking endurance than on walking speed
  • It is not likely that walking will become an individual’s primary means of community mobility if it was not so before treatment
36
Q

What is the scoring for modified Ashworth scale for spasticity

A
  • 0: No increase in tone
  • 1: Slight increase in tone (catch & release at end of ROM)
  • 1+: Slight increase in tone (catch followed by minimal resistance throughout remainder ROM/less than half of ROM)
  • 2: Marked increase in tone through most of ROM
  • 3: Considerable increase in tone/passive movement difficult
  • 4: Affected part(s) are rigid in flexion or extension
37
Q

Positive and negative signs of upper motor neuron syndrome

A
  • Positive: excessive normal resting state, spasticity, rigidity, hyperreflexia, primitive reflexes, clonus
  • Negative: less than normal resting state, lack of strength, lack of motor control, lack of coordination (this is what we treat)
38
Q

List the advantages of spasticity

A
  • Maintains muscle bulk
  • Supports circulatory function
  • Provides postural control
39
Q

List the disadvantages of spasticity

A
  • May interfere with mobility, exercise, joint ROM
  • May impact endurance, energy expenditure
  • May interfere with activities of daily living
  • May cause discomfort or pain
  • May cause sleep disturbances
  • May make patient care more difficult (ex: transfers, hygiene)
40
Q

Evidence supported techniques for spasticity management

A
  • Botox for upper extremity and lower extremity targeted focal spasticity
  • Intrathecal baclofen
  • Oral medications
  • Selective dorsal rhizotomy (SDR)
41
Q

Spasticity management techniques that evidence does NOT support

A
  • Splinting and/or taping for wrist and finger flexor spasticity
  • NMES and vibration (only temporary relief)
  • Postural and task oriented training to decrease spasticity
42
Q

Overdose symptoms of intrathecal Baclofen

A
  • Drowsiness
  • Light headedness
  • Respiratory depression
  • Seizures
  • Loss of consciousness
  • Hypotonia moving proximally
43
Q

Intrathecal Baclofen withdrawal symptoms

A
  • Rash (itching)
  • Hypotension
  • Fever
  • Paresthesias
  • Altered mental state
  • Autonomic dysreflexia like symptoms
  • Increased spasticity/rigidity
44
Q

Describe serial casting

A
  • A sequence of casts applied in progressively greater range over a period of several weeks
  • Cast supplies a constant stretch to the muscle over time
  • Muscle fatigues and elongates
  • Typically the cast is changed every 2wks with a new casting in the new lengthened position until the desired muscle length is achieved
45
Q

Describe the role of orthoses for spasticity management

A
  • Some are made to elevate/extend the toes to reduce the LE spasticity
  • Others may incorporate prominences in specific areas of the footplate particularly under the 1st metatarsal head to apply mild pressure to the ball of the foot to decrease spasticity
  • All methods will position & maintain the joint & associated muscles in a lengthened position. in attempt to gain ROM & decrease tone
46
Q

Helpful positions that may reduce spasticity include dissociation of upper and lower extremities like

A
  • In sitting or tall kneeling
  • Proper weight bearing through feet
  • Sidelying with flexion of the upper & lower extremity on one side & extension of the contralateral extremities
47
Q

Define deep pressure

A
  • Non-noxious sustained compressive pressure over the longitudinal axis of the tendon of a hypertonic muscle to elicit increased activation of the Golgi tendon organ (GTO)
  • Increased activation of GTO could help induce an elongation to the muscle thereby reducing tone
48
Q

What are the most common riggers for spasticity in SCI

A
  • Bladder
  • Bowel
  • Skin

Neuro Dev/Control II (19 decks)

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