SCI rehab mgmt of impairments and exercise

Question 1

Goals of rehab

Answer 1

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

Question 2

managment of impairments

Answer 2

Respiratory function
Strength training
Contracture management
Pain management
Cardiovascular fitness training
Spasticity management

Question 3

respiratory management

Answer 3

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?

Question 4

innervation

Answer 4

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

Question 5

respiratory complications

Answer 5

Respiratory muscle fatigue or paralysis
Prolonged bed rest
Pain and sedation
Aspiration
Paralytic ileus
Associated respiratory injuries

Question 6

assessment of respiratory function

NOT ON EXAM

Answer 6

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

Question 7

respiratory treatment options

Answer 7

Exercise training of the upper and lower limbs
Inspiratory muscle training
Pharmacological interventions
Assistive devices
Secretion removal
Electrical stimulation

Question 8

exercise training for respiratory function: UL and LL

Answer 8

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

Question 9

inspiratory muscle training

Answer 9

Improves respiratory muscle strength and endurance in people with SCI

Might decrease dyspnoea and respiratory infections in some

Question 10

assistive devices

Answer 10

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

Question 11

secretion removal

Answer 11

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

Question 12

electrical stimulation

Answer 12

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

Question 13

strength training

Answer 13

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

Question 14

assessment of strength

Answer 14

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

Question 15

strength training of neurally intact muscles

Answer 15

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)

Question 16

strength training of partially paralysed muscles

Answer 16

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

Question 17

other considerations

Answer 17

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

Question 18

contracture management

Answer 18

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

Question 19

prevention and treatment of contractures

Answer 19

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?

Question 20

allowing muscle contracture

reducing muscle extensibility

Answer 20

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!

Question 21

pain management

Answer 21

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

Question 22

pain assessment

Answer 22

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

Question 23

pain type subtype primary source and/ pathology

Answer 23

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

Question 24

neuropathic pain

Answer 24

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

Question 25

mechanical / nociceptive pain

Answer 25

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

Question 26

non-pharm management of post SCI pain

Answer 26

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

Question 27

pharm management in post-SCI pain

Answer 27

Surgical interventions also possible for disabling neuropathic pain that is resistant to pharm / non pharm management

Question 28

CV fitness training

Answer 28

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

Question 29

CV fitness guidelines

Answer 29

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

Question 30

options for CV training

Answer 30

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

Question 31

spasticity

Answer 31

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