Lecture: SCI Outpatient Considerations Flashcards
General Considerations for outpatient SCI
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
When does the greatest change in motor ability occur and when is the sharpest rate of improvement
Greatest change in motor ability occurs within the first year after SCI
Sharpest rate of improvement in the first 6 months
Can SCI pts make improvement after 1 year
Do not disregard opportunity for exercise-induced plasticity after 1 year
What is allodynia
intense pain to a normally innocuous stimulus
What is Hyperalgesia:
An exaggerated pain to a noxious stimulus like hot water or a sharp poke.
What is Neuropathic pain:
How is it described
When does it emerge
Where does it happen
- 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
What are the two types of neuropathic pain
Allodynia
Hyperalgesia
Neuropathic Pain Treatment
Gabapentin
Exercise
Physical Therapy
The goal of Conventional Compensatory Gait Training
To strengthen available arm and trunk muscles, stretch the hip to allow hip extension, progress to working with braces, the FES system, or exoskeletons.
Physical characteristics required for conventional gait training:
-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.
How does high tone and spasms affect gait training
High tone restricts movement and spasms or clonus can cause loss of balance or falls.
Conventional Compensatory Gait Training and blood pressure
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.
How is Conventional Compensatory Gait Training
progressed
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
Factors that appear to predict a good training effect and improved gait speed include:
- 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.)
Locomotor Clinical Practice Guidelines (CPG) for chronic CNS injury - what should clinicians do
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
Locomotor CPG Recommendations:
Clinicians MAY CONSIDER:
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)
Locomotor CPG Recommendations:
Clinicians should NOT perform:
- 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].” - Both static and dynamic (non walking) balance training, including pre-gait
- Robotic-assisted walking training is Ineffective for individuals with CNS who were already ambulatory,
what is Syringomyelia
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.
Typical treatments for syringomyelia
Shunting to remove the CSF from the cyst and slow progression
Untethering the cord, to remove scar adhesions between the cord and the dura
The role of the physical therapist concerning syringomyelia
part of a team in early detection
Causes of CVD in SCI:
loss of adrenergic control
poor diet
physical inactivity
Adrenergic dysfunction is related to the level of the SCI:
T1: No supraspinal sympathetic control
T1–T5: Partial preservation of sympathetic control
Below T5: Full supraspinal sympathetic control
Interventions have proven effective in improving cardiac function:
- 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
