SCI rehab mgmt of impairments and exercise Flashcards
Goals of rehab
Optimise function, independence and participation in society
Within context of the individual’s level and severity of injury, and associated predicted outcomes:
Paraplegia – independent at all levels Tetraplegia :
High tetraplegia C1-4, most C5 – dependence
Low tetraplegia C6 or below: assistance of 1 to independent
(Not so clear cut for incomplete injuries)
Consider ICF personal and environmental factors
managment of impairments
Respiratory function Strength training Contracture management Pain management Cardiovascular fitness training Spasticity management
respiratory management
Major cause of morbidity and mortality in SCI
Common respiratory complications
Hypoventilation Atelectasis Secretion retention Pneumonia
Ventilation / perfusion mismatch
Tetraplegia more vulnerable than paraplegia
Below what level can we deem respiratory function to be normal?
innervation
Levels of innervation for the sternocleidomastoid, diaphragm, scalene,
pectoralis, intercostal and abdominal muscles
Cranial Nerve XI
Sternocleidomastoid
C3-C5
Diaphragm
C3-C8
Scalene
abdominals intercostals - all the way down to T12
may have some impairment
not as productive a cough
C5-T1
Pectoralis
T1-T11
Intercostals
T6-T12
Abdominals
respiratory complications
Respiratory muscle fatigue or paralysis Prolonged bed rest Pain and sedation Aspiration Paralytic ileus Associated respiratory injuries
assessment of respiratory function
NOT ON EXAM
NOT ON EXAM Level of distress / anxiety Shortness of breath Alertness Pattern of breathing Effectiveness of cough Respiratory rate Breath sounds Body temperature Heart rate
Need for additional oxygen Volume of secretions Tenacity of secretions Vital capacity FEV1 ABGs Oxygen saturation End-tidal CO2 X-ray changes
respiratory treatment options
Exercise training of the upper and lower limbs Inspiratory muscle training Pharmacological interventions Assistive devices Secretion removal Electrical stimulation
exercise training for respiratory function: UL and LL
Exercise training might improve resting and exercising respiratory function in
people with SCI
FES-induced cycle ergometry increased peak O2 uptake, CO2 production and
pulmonary ventilation
To achieve respiratory benefit, training intensity must be relatively high (70- 80% of maximum heart rate) and performed 3 times per week for at least 6 weeks
inspiratory muscle training
Improves respiratory muscle strength and endurance in people with SCI
Might decrease dyspnoea and respiratory infections in some
assistive devices
Mechanical ventilation
Ventilator weaning should be considered through a progressive protocol where appropriate
Resistance and endurance training should be considered in patients who are candidates for ventilator weaning
Other methods of ventilation
Non-invasive ventilation
Phrenic nerve pacing
Intermittent Positive Pressure Breathing
Little evidence for its effect
Abdominal binder
Can be used to achieve immediate improvements in respiratory function but long term effects have not been established (Wadsworth et al., 2012)
Tracheostomy decannulation
Should be considered where possible
Indications and criteria in SCI have not been established
secretion removal
Common practice but limited evidence
Manual assisted cough
Mechanical insufflation / exsufflation
cough assist- compression force applied to aid expulsion of secretions - not much evidence
mechanical insufflation or exsufflation is better
electrical stimulation
Phrenic nerve pacing (PNP) for diaphgram stimulation
Higher survival rate, better power wheelchair management, phonation success and patient satisfaction compared to mechanical ventilation
Can be used as long-term alternative to
mechanical ventilation
Abdominal neuromuscular stimulation
Can improve cough pressure
strength training
Performance of motor tasks can be limited by the strength of
Completely paralysed muscles
Partially paralysed muscles
Non-paralysed / neurally intact muscles There are different considerations for each (treatment and evidence)
Consider power and endurance functions related to the task
Principles of specificity and load
Importance of goal setting
assessment of strength
Manual muscle test Individual muscles Groups of muscles
Oxford scale / MRC Scale (part of AIS assessment)
One repetition maximum (1RM) Relevant for exercise prescription
Hand-held dynamometers Standardisation required
strength training of neurally intact muscles
Progressive resistance training of non- paralysed muscles improves voluntary strength and quality of life in people with SCI
Follow the principles of strengthening as you
would for any healthy muscle
Key aspects: resistance, reps and sets, and progression
60-80% 1RM, about 8-12 reps (Rhea et al
2003)
Specificity of training: Consider functional tasks facing the person with SCI (for example, getting up from the floor to the wheelchair)
strength training of partially paralysed muscles
Few clinical trials in this area
Partially paralysed muscles may improve strength with recovery over time
Generally assumed that similar principles to non- paralyzed muscles can be adopted
Muscle grade 2: gravity eliminated position Overhead cages
Sliding sheets Adjunctive equipment
Consider a combination of PRE + E-Stim
other considerations
Strength training usually won’t increase spasticity in partially paralysed muscles
If antagonist is completely paralysed, gradually strengthen agonist (being mindful of agonist / antagonist imbalance)
Pre-injury activity levels are relevant
Carryover to home: consider barriers in the community
contracture management
Contracture = loss of joint mobility
Neural versus non-neural component
Affects up to 66% of all SCI survivors within one year
(Diong, 2012)
70% of people with tetraplegia will have loss of shoulder ROM within one year
prevention and treatment of contractures
Stretching and passive movements
Standard practice in many SCI units
2-10 minutes of passive movements and stretch a day to each affected joint
(Harvey, 2008)
Evidence is not convincing, however long term benefits are unknown and may be important
Benefits are not just for ROM
Passive or active movement: how do we give the opportunity to move?
allowing muscle contracture
reducing muscle extensibility
Excessive extensibility of the paralysed extrinsic finger and thumb flexor muscles will negatively impact hand function in people with C6 and C7 level injuries who need a tenodesis grip
Excessive extensibility in the hamstring muscles is undesirable for wheelchair-dependent patients who rely on passive tension to prevent falling out
Difficult for physiotherapists to allow structures to tighten up!
pain management
Pain is a common complication after SCI with a reported prevalence range from 25%-96% (Dijkers et al., 2009)
Limits ability to perform motor tasks, and has important implications for
quality of life, well-being and general feelings of happiness (Kennedy et al., 2006)
Severe pain more likely in low spinal cord or cauda equina lesions (SCIRE
project)
Pain often begins early post-injury
Commonly divided into neuropathic or nociceptive / musculoskeletal pain
pain assessment
Always ensure no reason for serious concern e.g. fractures, infections, tumours
Remember red flags
Patients with SCI are typically osteoporotic so minor injuries can cause fractures
Use objective measures e.g. VAS, NRS, McGill Pain Questionnaire
Link pain assessment to activity limitations and participation restrictions
The Wheelchair Users Shoulder Pain Index
pain type subtype primary source and/ pathology
type:nociceptive
subtype:MSK Visceral
other nociceptive pain
primary source: GH arthritis
lateral epicondylitis
visceral: myocardial infarction
abdominal pain due to bowel impaction
other nociceptive pain - autonomic dysreflexia headache, migraine headache
neuropathic
At SCI level - Spinal cord compression, nerve root compression
below SCI pain: spinal cord ischaemia
spinal cord compression
other neuropathic pain: trigeminal neuralgia, carpal tunnel syndrome
other pain: fibromyalgia, CRPS
neuropathic pain
Can be above, at or below the level of the lesion
Typically: ‘burning’, ‘electric’ or ‘stabbing’ pain; difficult to alleviate by activity or change of position
Difficult to treat
Largely managed pharmacologically (albeit with conflicting results)
TENS widely advocated, but currently without good evidence
Largest role for physiotherapy: education and support with regards to graded exercise and activity to minimise secondary complications
mechanical / nociceptive pain
Back or neck pain associated with initial injury
Persistent back or neck pain
Shoulder pain in patient with tetraplegia
Upper and lower limb musculoskeletal pain associated with functional demands
non-pharm management of post SCI pain
Helps reduce pain
Acupuncture
Electrostimulation acupuncture (neuropathic pain)
Regular exercise
A shoulder exercise protocol Hypnosis
Biofeedback
CBT + pharmacological treatments Visual imagery
Transcranial electrical stimulation
TENS (in thoracic lesions but not cervical lesions) Transcranial magnetic stimulation
may not be helpful in reducing pain
massage
osteopathy
CBT programs alone
pharm management in post-SCI pain
Surgical interventions also possible for disabling neuropathic pain that is resistant to pharm / non pharm management
CV fitness training
Performing functional tasks after SCI is more inefficient and therefore more physically demanding
People with SCI tend to be inactive compared to the general population
Lack of CV fitness becomes evident as activity or participation requirements increase
Evidence-based guidelines for adults with SCI published 2018 (Martin Ginis et al, 2018)
Achieving target amounts of exercise is very hard
Biggest barrier = time burden of participation (de Groot & Cowan, 2021)
Crucial to develop time-efficient and effective exercise programs that
can be done at home
CV fitness guidelines
For cardiorespiratory fitness and muscle strength benefits, adults with a SCI should engage in at least:
20 minutes of moderate to vigorous intensity aerobic exercise 2 times per week
AND
3 sets of strength exercise for each major functioning muscle group, at
moderate to vigorous intensity, 2 times per week
For cardiometabolic health benefits, adults with a SCI are suggested to engage in at least 30 minutes of moderate to vigorous intensity aerobic exercise 3 times
per week
options for CV training
Body weight supported treadmill training can improve indicators of cardiovascular health in individuals with complete and incomplete tetraplegia and paraplegia
Aerobic arm cycling of moderate intensity, 20-60mins/day, at least 3 days/week, for a minimum of 6-8 weeks can improve cardiovascular fitness
(e.g. Bresnahan et al 2018)
Interventions that involve FES training (minimum 3 days/week for 2 months) may improve muscular endurance, oxidative metabolism, exercise tolerance and cardiovascular fitness (Janssen & Pringle 2008)
Other forms of exercise interventions (e.g. quad rugby, wheelchair skills + weight training, prolonged intense multi-modal exercise) need more evidence
spasticity
Present in up to 80% of patients with SCI (Priebe et al., 2002)
Can help with some functional activities but can also hinder them
Sudden increase in severity of positive features of the upper motor neurone syndrome may indicate illness or injury
Management: combination of pharmacology (oral antispasmodics, intrathecal baclofen) and physiotherapy (exercise, weight bearing, passive movements, aquatic physiotherapy
