Lecture: SCI Outpatient Considerations

Question 1

General Considerations for outpatient SCI

Answer 1

Promote as much recovery as possible, optimize function, attain highest level of independence

Do not miss opportunity to induce functional neuroplasticity

Issues including neuropathic pain, sexuality, and possibly depression become more prominent

Question 2

When does the greatest change in motor ability occur and when is the sharpest rate of improvement

Answer 2

Greatest change in motor ability occurs within the first year after SCI

Sharpest rate of improvement in the first 6 months

Question 3

Can SCI pts make improvement after 1 year

Answer 3

Do not disregard opportunity for exercise-induced plasticity after 1 year

Question 4

What is allodynia

Answer 4

intense pain to a normally innocuous stimulus

Question 5

What is Hyperalgesia:

Answer 5

An exaggerated pain to a noxious stimulus like hot water or a sharp poke.

Question 6

What is Neuropathic pain:
How is it described
When does it emerge
Where does it happen

Answer 6

• It’s an abnormally intense pain responses that become permanent after SCI (or other tissue damage)
• Described as burning, stabbing, shooting, crushing
• Often emerges several months to years after injury
• Can be above, below, or at level of injury

Question 7

What are the two types of neuropathic pain

Answer 7

Allodynia

Hyperalgesia

Question 8

Neuropathic Pain Treatment

Answer 8

Gabapentin
Exercise
Physical Therapy

Question 9

The goal of Conventional Compensatory Gait Training

Answer 9

To strengthen available arm and trunk muscles, stretch the hip to allow hip extension, progress to working with braces, the FES system, or exoskeletons.

Question 10

Physical characteristics required for conventional gait training:

Answer 10

-Absence of hip flexion contracture.
Ideally, hip ROM into hyperextension because this position activates the Central Pattern Generator and initiates swing phase

• Absence of knee flexor or plantar flexor contractures: for alignment, stability and balance
• Good strength in shoulder depressors and ability to support full weight through the arms without pain
• Low levels of spasticity or well-controlled spasticity.

Question 11

How does high tone and spasms affect gait training

Answer 11

High tone restricts movement and spasms or clonus can cause loss of balance or falls.

Question 12

Conventional Compensatory Gait Training and blood pressure

Answer 12

Pt needs to have a Non-erratic blood pressure.

Standing upright will challenge the cardiovascular system more than a seated upright position.

This will be compounded by high physical exertion needed to stabilize with the arms and advance the legs.

Question 13

How is Conventional Compensatory Gait Training

progressed

Answer 13

Initial training will start in the parallel bars with the appropriate braces

Once stable there, the individual will work on mobility skills:

• Transferring from the WC
• Walking with different assistive devices
• Negotiating rough terrain, inclines, stairs

Question 14

Factors that appear to predict a good training effect and improved gait speed include:

Answer 14

• shorter time since injury,
• lower levels of spasticity
• voluntary bowel and bladder voiding
• walking speed before training.

(individuals with greater capacity prior to training are the most likely to become fast walkers.)

Question 15

Locomotor Clinical Practice Guidelines (CPG) for chronic CNS injury - what should clinicians do

Answer 15

improve walking speed and distance

clinicians should use moderate- to high-intensity walking training interventions to improve walking speed and distance in individuals greater than 6 months following acute-onset CNS injury as compared with alternative interventions

*strong evidence for CVA not SCI

Question 16

Locomotor CPG Recommendations:

Clinicians MAY CONSIDER:

Answer 16

Strength training at >/=70% 1 rep max
-Inconsistent evidence on the connection between strength training and improved walking speed and distance, but potential benefits.

Circuit training, cycling, or recumbent stepping at 75-85% HRmax.
-minimal evidence

(walking is better than strength training)

Question 17

Locomotor CPG Recommendations:

Clinicians should NOT perform:

Answer 17

1. Body-weight supported treadmill training
   - however “different results may occur in those who are non ambulatory or unable to ambulate without the use of [body-weight support].”
2. Both static and dynamic (non walking) balance training, including pre-gait
3. Robotic-assisted walking training is Ineffective for individuals with CNS who were already ambulatory,

Question 18

what is Syringomyelia

Answer 18

Is the formation of a cerebrospinal fluid-filled cyst within the center of the spinal cord

Develops within months to many years after traumatic SCI

Symptoms of late-onset syringomyelia: a change in sensorimotor function like radicular pain, sensory loss, segmental weakness, gait ataxia, and increased spasticity.

Development of syringomyelia within the cervical region because it threatens diaphragm innervation and respiration.

Question 19

Typical treatments for syringomyelia

Answer 19

Shunting to remove the CSF from the cyst and slow progression
Untethering the cord, to remove scar adhesions between the cord and the dura

Question 20

The role of the physical therapist concerning syringomyelia

Answer 20

part of a team in early detection

Question 21

Causes of CVD in SCI:

Answer 21

loss of adrenergic control

poor diet

physical inactivity

Question 22

Adrenergic dysfunction is related to the level of the SCI:

Answer 22

T1: No supraspinal sympathetic control

T1–T5: Partial preservation of sympathetic control

Below T5: Full supraspinal sympathetic control

Question 23

Interventions have proven effective in improving cardiac function:

Answer 23

• Treadmill training with body weight support
• FES leg cycling of moderate to high intensity several times a week
• FES leg cycling combined with arm ergometry
• Aerobic arm cycling of moderate intensity several times a week