Special Pops: SCI

How are spinal cord injuries classified?

• by the lowest segment of the spinal cord with normal function on both sides of the body

complete

• without sensory function

incomplete

• partial preservation of sensory or motor function

Tetraplegia

• impairment or loss of function in the cervical segments, including dysfunction of arms, trunk, legs, and pelvic organs

Paraplegia

• impairment or loss of function in the trunk, legs, and pelvic organs

What causes paraplegia?

• lower spine injuries

What causes tetraplegia?

• upper spine injuries

What is the somatic nervous system?

• subdivision of peripheral nervous system

• allows you to move and control muscles

Efferent vs. Afferent neurons

• afferent neurons carry sensory info. to central nervous system

• efferent neurons send motor commands from CNS

What is autonomic dysreflexia?

• potentially life-threatening syndrome

• uncontrolled outflow of sympathetic activity in response to stimuli below the SCI

Where does autonomic dysreflexia occur?

• SCI at or below T6

What does autonomic dysreflexia cause?

• distended bowel or bladder, UTIs, lacerations, fractures, pressure sores

• paroxysmal hypertension

What is paroxysmal HTN?

• episodic and volatile high blood pressure

What is the result of reflex bradycardia and vasodilation (autonomic dysreflexia)?

• flushing, headache, piloerection (goosebumps), blurred vision, sweating

If not treated immediately, what can autonomic dysreflexia lead to?

• intracerebral hemorrhage (stroke/permanent brain damage), seizure, arrhythmia, death

Which systems are impacted by SCI?

• cardiovascular

• pulmonary

• bowel/bladder

• hyperreflexia

• thermoregulation

• endocrine

• osteopenia/osteoporosis

How is the cardiovascular system impacted by SCI?

• Bradycardia due to loss of sympathetic nervous system (resolved within 2-6 weeks)

• reduced peripheral vascular resistance —→ enhances venous pooling and orthostatic hypotension

What are pulmonary effects from SCI?

• impaired ventilation —→ paralysis of rib cage and abdominal muscles

• reduced pulmonary compliance

• reduced diaphragmatic excursion

• some may require ventilator assistance

• ventilation worsens as disability increases

How are bowels/bladder impacted by SCI?

• increased risk of gastric ulcers

• increased bowel mobility and hyperreflexia

• voluntary control of defecation decreased

• higher risk for UTI, renal/bladder stones

Reflex bowel

• occurs in injuries at or above T12

• results in fecal incontinence, waste is excreted involuntarily when the bowel is full

Flaccid Bowel

• occurs in injuries below T12

• waste excretion is not triggered naturally, leaking out when rectum is full

How is thermoregulation impacted by SCI?

• reduced ability to dissipate environmental and internally generated heat by sweating and skin vasodilation

• sweat response limited to regions above the level of SCI

How is endocrine system impacted by SCI?

• glucose intolerance resulting in hyperinsulinemia

• testosterone levels decrease in men

• following acute phase of SCI, ovulatory menstrual cycles well preserved

How are bones impacted by SCI?

• Bone mineral loss rapid during first 4 months—→stabilizes—→16 months (67% of original bone mass)

• risk of fracture increases

What considerations need to be made with patients that have SCI?

• respiratory complications

• CAD

• PAD

• circulatory hypokinesis (hypotensive responses)

• obesity

• heterotopic ossificans

• Type 2 diabetes

• amputations

What are the cardio testing special considerations?

• empty bowel and bladder

• handgrip and postural stability

• skin protection

• adjust loads according to degree of training and paralysis and other impairments

Strength testing special considerations

• same as cardio

• higher joint angular velocities may be impeded by spasticity

What are the absolute contraindications?

• autonomic dysreflexia

• orthostatic hypotension with risk of syncope

• recent DVT or pulmonary embolism

• pressure ulcers (>2)—→ increased risk of autonomic dysreflexia during exercise

What are the relative contraindications?

• active tendinitis

• chronic heterotopic ossificans

• peripheral neuropathy

• low grade pressure ulcers (<2)

• spasticity

Aerobic ExRx considerations

• avoid exertional hypotension

• sets of 5 to 10 minutes

• include warmup and cooldown

Strength ExRx considerations

• avoid valsalva maneuver

• provide spotter

• use seat belt and chest strap for balance

ROM ExRx considerations

• stretch to strain, no pain

• avoid valsalva maneuver

Aerobic FITT

• F: 3-7 days/week

• I: 50-85% vo2 peak, 30-80% HRR, 60-90% HR peak

• T: 20-60 min, continuous or interval

• T: arm cycle, WC ergometry, aquatics, FES cycle ergometry

How should aerobic prescription progress?

• less than 5% per week

What are the goals of the aerobic prescription?

• improve functional capacity

Resistance FITT

• F: 2-3 days/week

• I: 60-75% 1RM

• T: 30-60 min, 1-3 sets of 8-12 reps

• T: bands, wrist weights, body weight, free weights, machines

How should strength prescription progress?

• increase when 12 reps achieved

What are the strength prescription goals?

• improve strength

• improve ability to ambulate with arms

ROM FITT

• F: 7 days/week

• I: 2 sets, 30-60 sec per set, gentle/slow/painless

• T: 5-15 min

• T: active assisted, passive assisted

What are the benefits of exercise training?

• increase VO2 peak

• reverse myocardial disuse atrophy

• increased strength

• increased fatigue resistance

• temporary decrease in spasticity

• decreased body fat %

• increased lean body mass

What is Function electrical stimulation (FES)?

• applies small electrical pulses to paralyzed muscles to restore or improve their function

• commonly used in exercise

What can happen when FES is used on lower extremities?

• stimulate skeletal muscle strength and endurance

• increase energy expenditure and stroke volume

• increase total body peak power, vo2 peak, ventilatory rate

• reverse myocardial disuse atrophy

• increase HDL levels and improve body comp

• increase lower extremity bone mineral density