Week 9 iSCI Flashcards
Incomplete sci – so much room for growth and improvement.
Incomplete – either ASIA B,C, or D.
Voluntary anal contraction – automatically asia (B/C)
Incomplete – sensation in s4 /s5.
We have the ability with muscles that are working to promote recovery. We have the opportunity with therapy to maximize that opportunity. If muscles are a 0 we might have to compensate for that lost function.
If someone has muscles that work, try and promote recovery.
What muscles are/aren’t working are pt dependent which makes it challenging for the therapist.
C
Go back to the ICF – Where are the impairments?
Where are the activity limitations? Are they walking up and down stairs by themselves?
Have to prioritize the highest priority for the person.
Task specificity still applies.
Don’t have to teach new skills pts don’t need to know (turn head, protract scapula bed mobility for tetra pts- some pts who are incomplete might be able to get out of bed like normal ppl)
Promote the intensity through aerobic capacity.
CPG – based on people that are already walking and don’t need physical assist.
People that need max assist or total assist – maybe robotics are okay
C7 ASIA B
Posture – posture is not good. Rounded shoulders, reduced lumbar lordosis, posterior pelvic tilt, forward head.
He has no choice in the way he sits. Consequences of this – potential pain component in thoracic spine, forward shoulders – muscles will tighten –pecs, harder to breathe due to kyphotic posture, lose ROM within the shoulders, pressure injuries – sacrum,
Want lumbar extensors to be tight to aid in movement.
STOMPS program: Strengthening and stretching program for SCI – cross body adduction, shoulder ER, rows, shoulder scaption/abduction with thumb up
Strengthening and Optimal Movements for Painful Shoulders
Higher risk for deformities in this population.
Many neurologic diagnoses lead to hypertonicity of muscles due to decreased muscle strength and volitional control available: SCI CVA
If a muscle improves in strength in a week, it wasn’t weak to begin with. It was inhibited
Prolonged positioning can result in muscle inhibition
Squat pivot transfer will incorporate more symmetrical weight bearing through bilateral LEs compared to a compensatory stand pivot transfer
Inhibition – power is still there but something is in the way – pain, posture, etc
Is it true weakness – estim or strengthening program or is it a case of taking away the inhibitory factors and their strength will return ?
Strengthening principles – overload – if the person fails you know that they were challenged enough. Make sure to follow what the science tells you to do – push the person – RPE, HR, Rep maximums.
True weakness- focusing on cortical input might not work.
Electrical stimulation
Vibration – has shown to be helpful – information is getting to the brain – message is going to the brain and you are getting an efferent input to activate the muscle.
Weightbearing – put someone in a wb position to give afferent input.
This population is at high risk for shoulder pain because the shoulder is not a wb joint. Now these people rely on it and develop pain.
STOMPS – a series of fairly simple stretching and strengthening exercises.
These individuals – if they are wheelchair users long term – having an orthopedic program will give them a lot of value – start it early on so they set themselves up for success.
People with SCI need good orthopedic training.
Fiber Type Transitions
Following SCI, the following structural changes occur within muscle tissue:
Results in fiber type transitions to Type IIx - Very (high/low) oxidative capacity – (high/low) fatigability
Fiber type transitions occur when beginning a strength and conditioning program: Fibers become (less/more) oxidative and fatigue resistant as training is progressed.
In SCI, the level and extent of injury influence VO2peak, and training effect measured as increased VO2 peak is inversely proportional to level of injury, and degree of completeness
1) Baechle T.R. and Earle R. W. (2008) Essentials of Strength and Conditioning – National Strength and Conditioning Association. Third Edition. Champaign, IL. Human Kinetics
2) Malisoux L, Jamart C, Delplace K, Nielens H, Francaux M, and Theisen D. (2006) Effect of long-term muscle paralysis on human single fiber mechanics. J Appl Physiol 102: 340 –349, doi:10.1152/japplphysiol.00609.2006
Type IIx fibers deemed “strength and power fibers” begin to transition to Type IIA with consistent resistant training as they become more oxidative in nature
Muscle atrophy induced by unloading is associated with several structural changes, such as modifications of the myosin heavy chain (MHC) isoform expression, inducing fiber-type transitions toward a higher proportion of fast type II fibers.
Lower limb muscle paralysis as a consequence of spinal cord injury (SCI) is a typical situation of severe, long-term muscle disuse. However, it differs from spaceflight or bed-rest models, since the muscles concerned are not only unloaded, but their neuromuscular activity is also chronically reduced or eliminated.
Muscle tissue starts to change to type II fibers which are anaerobic – fast twitch. They get a lot of strength but the aerobic ability is lost. If transfers take more than 20 seconds muscles might not perform as well because the muscles are anaerobic in nature. Can have muscles become more aerobic if you treat them more appropriately.
If they don’t lack power and are complaining of shoulder pain – consider more endurance strength program – less weight more reps. Can tell them do as many reps as you can before you poop out – building oxidative stress.
low; high ; more
Potentially working on APT – if someone has bad posture and kyphotic position, could potentially do this exercise. Triceps training – super important – have to be 4/5 to use for transfers. This exercise is essentially a pushup. UE mobility – nice thoracic extension, nice shoulder flexion.
One exercise to address multiple impairments.
Tall kneeling position and lifting arms – working on stability of the pelvis – put them in a wb position and force brain to figure it out, if posture is a concern this can promote expansion to have a nice wheelchair posture, floor transfers – still need to learn how to get up
Chris has hands on muscles that aren’t working
C5-C6 ASIA A
WB – bone health benefits, postural demands are different in a sitting vs standing position. Have a lot of bony stability sitting and you lose that in standing. Might be doing good sitting wise and then when standing it all changes. Might never stand again but there is an emotional component to standing.
C4/C5 injury
Both are cardiac exercises in nature
Arm bike – could potentially allow for compensatory measures and you don’t want that.
Pic to the right – more functional. Requires more trunk stability.
Ski ergometer – triceps, traps, lats, grip strength, rotator cuff, any back muscle,
C4 ASIA A
Has no grip strength, using the muscles he has, still working cardiovascular wise.
Have to be creative in how you compensate in pts who have next to nothing in terms of strength/weakness and muscles that are working.
If they cant cough on their own – have to help them.
Lateral rib compression – take their ribs and push to create the expiratory pressure to cough
Manual stretching – if pecs are tight to the point they cant expand, stretch
Diaphragmatic – stacked, hand on belly
Accessory – soft tissue mobs if stretching isn’t working
West CR, Mills P, and Krassioukov AV. (2012). Influence of the neurological level of spinal cord injury on cardiovascular outcomes in humans: a meta-analysis. Spinal Cord 50: 484–492.
This is the gold standard measure of maximal aerobic capacity and depends of the integrated health and effort of the lungs, cardiovascular system, and skeletal musculature
CO is the result of heart rate (HR) x stroke volume (SV) and accounts for the supply part of the oxygen transport [19] A-vO2diff describes the amount of oxygen extracted from the skeletal musculature, and is the difference in oxygen content between arterial and venous blood, which accounts for the demand part of the oxygen transport.
In SCI, the level and extent of injury influence VO2peak, and training effect measured as increased VO2 peak is inversely proportional to level of injury, and degree of completeness
The presence of impaired CV control among individuals with SCI and the latest data indicating CV dysfunctions are responsible for the greatest proportion of morbidity and mortality in this population,6 highlight the need for an evaluation of CV control in these individuals
A lot of these individuals will have impaired heart and lung function.
The heart autonomic ends – T6. individuals above T6 are at a disadvantage.
How can I work these muscles?
Muscle groups of high priority – triceps (need brute power to lift body weight), scapular depressors (low traps, lats), glutes
Anaerobic – think power and strength.
Posterior back muscles are important
Pulling based exercises
CV component to this, perturbations due to the swinging of the arm,
Body supported treadmill training with physical assist is how all of these things started.
Leg in flexion – hands on anterior hip
Leg in stance- hands on anterior knee
No strength in his legs
Addressing strength and sensory deficits.
Facilitating recovery
Manual locomotor training
Step retraining – steps steps steps
Take them overground and see if anything changes and then see how they can integrate that in the community.
Take someone who as a sci and put them in the right environment and see what happens.
These cats on the treadmills could generate a reciprocal stepping pattern – no connection from the brain to the muscle and could still generate this
Damaged nervous system following a sci with the appropriate sensory input can facilitate movement even with supraspinal input that is gone.
When you touch a muscle that should be working you are facilitating the input to the spinal cord to help generate a recovery pattern.
Manual locomotor training
Step retraining – steps steps steps
Take them overground and see if anything changes and then see how they can integrate that in the community.
Take someone who as a sci and put them in the right environment and see what happens.
Impairments that this might address – Bone density, emotional component by walking, reduced risk of DVTs, trunk control (trunk was swaying), CV component, maximize weight in the LES,
Manual locomotor training is fading out and not seen as much.
These are all neuroplasticity goals.
This works if you put people in the right neuroplastic environment – for some people it has done amazing things.
T8 ASIA B with bad spasticity – used manual locomotor training to improve spasticity (got WB through the limbs)
Incomplete injuries – pathways from the brain to the muscle is there.
People who aren’t walking can’t start walking by using this device.
Advantages: Use of partial body weight support removes biomechanical and equilibrium constraints Allows for repetitive practice of complex gait cycles Specificity of training Dynamic environment Disadvantages: Resource utilization Cost of equipment Limited availability Intensity of program Commitment of patient and caregivers Training of staff
Disadvantage – takes time to set up. Need a lot of hands on deck. Not available to everyone.
One in the middle – exoskeleton
Bottom right – ondogo – three tiered clip on system – really scifi
Bottom left – rewalk
These devices are meant to be a supportive system for individuals not walking on their own.
Advantages:
Use of partial body weight support removes biomechanical and equilibrium constraints
Allows for repetitive practice of complex gait cycles
Some patients with increased pain tolerate better than manual system
Specificity of training
Requires fewer personnel
Provides patient with visual Feedback
Disadvantages: Does not allow for pelvic rotation Increased time for initial set up- not appropriate if patient hypotensive Lack of dynamic guidance adjustment Cost of equipment Limited availability Commitment of patient and caregivers Training of staff
Advantages – can take/use them anywhere, one therapist to one patient, they can be independent and potentially take it out in the community, to physically get up and take steps like they used to has a huge psychological/emotional component
Disadvantages – expensive (100k), they can potentially break and have many malfunctions, these are slow (moving at .1m/s),
Decker MJ, Griffin L, Abraham LD, and Brandt L. (2010) Alternating stimulation of synergistic muscles during functional electrical stimulation cycling improves endurance in persons with spinal cord injury. Journal of Electromyography and Kinesiology 20:1163–1169.
Fes bike that has pedaling attached to it where the pads turn on and off when the leg is in the pedaling cycle.
Fes does the best job of turning muscles on and off in the context of pedaling.
Barrier for these devices – set up (12 pads on one leg and 12 pads on the other leg), it takes a lot of time to set up, lots of trial and error, risk of burns especially if they lack sensation, contraindication with DC current and estim for those who don’t have sensation (okay for alternating current).
Advantages – cardio,
Not testing material
https://www.youtube.com/watch?v=mp8wFYu4l4w&t=252s
Have to administer balance outcomes for those at falls risk.
Balance- vision, vestibular, somatosensation
6 different components or themes or constructs to balance and where someone might be unstable. If someone’s balance is off have to dig one layer deeper and decide which one of these systems is involved in someone’s lack of balance
If someone has deficits with reactionary balance – treat them with reactionary balance
If someone struggles with anticipatory balance - sit to stands, rising on toes,
If someone has biomechanical constraints – treat that
If someone is struggling stepping over obstacles – practice stepping over obstacles
Just work on the task that the pt struggles with, don’t just do generic balance training.
Can you get your body in the position it needs to be in to maintain COM and have the strength to be able to do it? If they are lacking in these two areas balance will be off. If ankles are tight and can’t get COM over their toes will cause a lack of balance.
The body can tip outside of the BOS to a certain extent before losing balance. Michael Jackson has large stability limits
Functional reach – reaching as far as you can before losing balance.
Bodies ability to detect a balance challenge before it actually happens.
When you do some of these activities – know you have to shift weight so you don’t fall over.
Can you react quickly and not fall. If someone bumps into you, can you keep your balance?
Majority of those who struggle with balance struggle with reactionary balance.
10/20/70?
Ability for body to detect where it is in space when you start to alter those three systems
Test of sensory integration and balance
WILL BE ON TEST
Condition 1 – eyes open – hard surface- all three systems are available – if someone falls in condition 1 have to know which of the three systems are impaired
Condition 2 – eyes closed and hard surface – somatosensory and vestibular are left, while vision is gone. What systems are available, look at their PMH and see if it makes sense. Could really fall in condition two if have decreased sensation (stroke, diabetics, sci)
Condition 3 – eyes open foam surface – took away somatosensory, have vision and vestibular to rely on. Those with somatosensory deficits will struggle, those who have visual impairments (stroke, retinopathy pts, vertigo pts could potentially struggle), people with concussions,
Condition 4 – eyes closed foam surface – only system available is vestibular – those who have concussion and vertigo will suffer.
Old school - called foam and dome testing
Condition 1 – have all three conditions
Condition 2 – Vision is removed
Condition 3 – wall moves – change visual input
Condition 4 – plate starts to move, takes away somatosensation
Condition 5 – Vision is gone and somatosensation is still gone
Individuals with balance deficits may struggle with ^^^
So many outcome measures its BONKERS!!!
Core set – 6 outcome measures that are appropriate for all neurological diagnoses’
Don’t just do the same outcome measure for each pt. make sure it is appropriate for each pt.
Do outcome measurements for reimbursement especially for medicare – if pt isn’t showing progress the pt can be kicked out of therapy. You show progress through outcome measures.
https://www.sralab.org/rehabilitation-measures
Has like all 500 outcome measures about what the test is, links to pdfs, cutoffs, etc
Berg Balance Score
Purpose: assess sitting and standing, static and dynamic balance.
14 sub components
Score: total / 56points
Assistive device use NOT allowed
Clinical Meaning:
Cutoff Score for Falls
≤_ almost 100% fall risk - Non-Specific/Older Adults
<_ /56 at risk for falling – Stroke population
The most referred / referenced outcome measure in PT.
No walking is involved
Certain scores mean certain things to different populations
Need to identify these people at falls risk before something traumatic happens
40; 44
Activity Balance-specific Confidence Scale
Purpose: self-report measure of balance confidence in performing various activities without losing balance or experiencing a sense of unsteadiness.
Scoring: total percentage of 16 items / 16 = ______%
Clinical Meaning
Older Adults
Scores < _% indicate risk for falling; accurately classify people who fall 84% of the time
Subjective outcome measure
Asks individuals to emotionally rate their confidence on certain tasks related to balance.
If having low confidence – probably won’t do very well
ABC scale – gives ticket to someones brain emotionally and psychologically
To tx low efficacy for balance – do what they are fearful of – TASK SPECIFICITY
67;
Functional Gait Assessment
Purpose: assess postural stability during walking and assesses an individual’s ability to perform multiple motor tasks while walking.
***The tool is a modification of the 8-item Dynamic Gait Index, developed to improve reliability and reduce ceiling effect.
Score: total / 30 points
Assistive devices many be used however will have ceiling effect!
Clinical Meaning:
Non-Specific Older Adults
Cutoff Score: ≤_/30 = risk of falls
Looking at balance in the spirit of walking tasks.
It attempts to look at balance in more real world conditions.
Tandem walking, changing speed, turning head
This is more of a higher level assessment
Keep using assistive device and the highest score you can get is 22ish.
22;
Ben’s favourite
Gait speed – 6th vital sign
The time is measured for the middle 6 m to allow for patient acceleration and deceleration.1,4
o The time is started when any part of the leading foot crosses the plane of the 2-m mark.
o The time is stopped when any part of the leading foot crosses the plane of the 8-m mark.1
Highlighted the falls risk cutoff. _ m/s is at risk for falls.
1;
Looking at distance within a 6 minute time frame. Can take breaks and use devices.
Listed here are norms.
6mwt does not look at falls risk!!!
Can derive gait speed from a 6mwt though. Can add support if someone is at a falls risk based on this knowledge.
5 Times Sit to Stand
Purpose: Measures one aspect of transfer skill.
The test provides a method to quantify functional lower extremity strength and/or identify movement strategies a patient uses to complete transitional movements.
Score: duration to complete without UE support
Clinical significance:
Community dwelling older adults ¡
Cutoff scores: ≥_ seconds identifies the need to further assess for falls
If someone is using their arms to stand up you don’t know how strong their legs are.
12;
If not concerned about balance – don’t do a balance outcome measure.
What is the environment where someone is falling ? If falling getting gout of bed – find an outcome measure that mimics it.
If there is change from week to week, is there a real change? Know the MDC and MCID.
Let pts know if they are getting better based on the numbers – helps promote salience.
LOF – Level of function
Pick 2-3 outcome measures that are the most helpful when working with pts. Pick maybe 2-3.
MOD I – no physical assist.
Berg Balance Score – CORRECT! Look at where the pt fell and where did they feel unsteady? They fell in the shower – static smaller environment scenario so it is task specific to what the berg can offer. Different components for the berg so helps choose which components they struggle with. It has falls risk information. MOD I with single point cane - can have them balance without the cane - can truly see if static balance is where it needs to be.
When you assess balance need more than 1 outcome measure to back you up. Cant diagnose someone for falls risk if only did one outcome measure. Need 2-3 tests to support someone being at falls risk.
6 Minute walk test – doesn’t assess falls risk
FGA – She can walk, can use an AD.
Draw back – cap on the score if using an AD and might not be all encompassing on what her deficits are. There is a ceiling effect when using the AD.
Can get off of the rolling walker and see what happens without the rolling walker and see if she can survive.
TUG – falls risk data with tug – yeah.
Drawback – she can walk a lot farther than that already – higher level than what the test calls for. Can use AD on the TUG.
6MWT – pro – can use the AD. Want to look at endurance if goal is to ween off the AD. She might not get far in the 6MWT. Not the highest priority test to do until she is more cardiovascularly fit.
Berg –
Drawback – it takes a long time to complete. Takes the longest out of all four outcome measures. Berg doesn’t incorporate walking. If person is already walking at a high level this could be too remedial for her.
Start with the Berg !!! Then ramp it up to do the FGA. Start with more static and then move to dynamic. If that’s all you get, that’ll probably give you good information. 6MWT in third and then the TUG last.
If she is walking 100 feet mod I TUG would probably be too remedial for her.
TUG – 12-13 seconds – not at falls risk.
10MWT – flirting with the falls risk already with the walker, so if take the walker off she is probably fucked. Gives best implication on should she still use the device. In the context of the goal without the device –walking is borderline. Berg is a static standing balanced so can’t safely assume what she is like based on that score to a walking situation
BERG – if below 40 = falls risk. Wont give the best info with this pt because doesn’t give a lot of info into what she is like when moving.
