evidence-based PT interventions for persons with SCI

restorative

using the same muscles in the same way to complete the task

- acute stroke, incomplete SCI

compensatory

using substitution to complete the task

- complete SCI

therapeutic walking

used in PT session but not at home or in community setting

- aphysiologic & non-functional

- ex: using long leg braces to lock the knees out and using trunk and arms to swing legs through

physiologic walking

using normal mechanisms (muscles) to walk

- functional

locomotor training

involves BW support and B/L facilitation

- done quickly at a higher intensity

which automatic reflex occurs at the spinal cord level to facilitate gait?

central pattern generators

- assists with locomotor training

which principles of neuroplasticity does locomotor training incorporate?

- repetition

- task specific

- use it or lose it

- timing

- intensity

- salience

what SCI grades use compensation?

ASIA A and B

- a little bit of ASIA C

- function not returning

what SCI grades use restoration?

ASIA D

- a little bit of ASIA C

- voluntary motor function below lesion

2 choices for gait pattern for traditional gait training after a SCI

- swing through

- 4 point gait (slow, not efficient)

what strength do your quads need to have for knee control?

≥ 4

- knee control present with L4 level

- may need KAFOs with L3 level

acute care priorities - respiratory management

- assisted coughing techniques

- glossopharyngeal breathing

- incentive spirometry

* critical for C-spine/ high T-spine injuries

acute care priorities - integumentary protection

turning schedules and pressure relief

acute care priorities - early mobilization

follow any precautions/bracing

- may need tilt table

acute care priorities - ROM and contracture prevention

- daily PROM'

- maintain hamstrings length for long-sitting balance

- preserve tenodesis grip for C6/C7 tetraplegia

- do not overstretch wrist/finger flexor or low back

how do secondary complications relate to prognosis?

prevention of secondary complications in week 1 directly predicts functional outcomes in year 1

acute care SCI EDGE - recommended OMs

- 6 min walk

- 10 meter walk

- ASIA impairment scale

- hand held myometry

- timed up and go

- walking index for SCI II

what are the core OMs?

- 6 min walk

- 10 meter walk

- TUG

in-patient rehab priorities - respiratory management

- assisted cough techniques

- percussion/vibration for airway clearance

in-patient rehab priorities - prevention of secondary complications

- ROM to prevent contractures/loss of ROM and heterotrophic ossification

- ANS regulation (acclimation to upright)

in-patient rehab priorities - functional mobility

- bed mobility

- transfers

- gait (when applicable)

- W/C training with emphasis on type and basics

in-patient rehab priorities - neuromuscular facilitation and strengthening

maximize strength of partially paralyzed and preserved muscles

in-patient rehab priorities - patient and family education

- precautions (autonomic dysreflexia, UTI, orthostatic hypotension, temp regulation)

- discharge planning

- caregiver training

sub-acute SCI EDGE recommended OMs

- ASIA impairment scale (ISNSCI)

- Spinal cord injury dependence measure (SCIM)- version III

- 10 meter walk test

- 6 min walk test

- handheld dynamometry

- TUG

Spinal cord injury dependence measure (SCIM)- version III

scores ares like feeding, bathing, dressing, bowel/bladder management and basic transfers

home care priorities

- home accessibility and environmental modification

- functional mobility within the home to enter/exit

- prevention of complications

- caregiver training within home environment

- initiate community recreational reintegration

out-patient priorities

- community mobility

- neurological recovery and activity-based interventions

- secondary complication management

- assistive technology

- community re-entry

out-patient - community mobility

advanced W/C mobility

- ramps, curbs, wheelies, stairs

- gait training (locomotor vs traditional)

outpatient - neurological recovery and activity-based interventions

- locomotor training

- FES (muscle activation with bike and/or orthosis) to augment function

- functional mobility training

outpatient - secondary complication management

- ROM, strengthening under-used muscles to maintain balance

- over-use injury prevention/education/ergonomic assessment

- caregiver education/training

outpatient - assistive technology

- durable medical equipment assessment

- DME re-evaluation

- DME training

- DME maintenance

outpatient - community re-entry

- vocational rehab

- job training, training to drive/adaptive vehicle

- adaptive sports

out-patient (chronic >6 months) SCI EDGE recommended OMs

- 6 min and 10 meter walk

- ASIA impairment scale

- handheld myometry

- numeric pain rating scale

- world health organization QOL (BREF)

other recommended out-patient OMs

- spinal cord injury independence measure (SCIM III)

- timed up and go (TUG) - dynamic balance and risk of falls

- wheelchair skills test (WST) - score pts mastery of manual/power W/C maneuvers

- craig handicap assessment and reporting technique (CHART) - measure social, economic, community participation

categories of exercise interventions for people with SCI

- cardiovascular training

- strength training

- functional mobility training

- stretching and ROM

- patient and family education

- assistive technology

physical activity guidelines for people with SCI - aerobic activity starting level

20 mins 2x/week

- mod to vigorous intensity

physical activity guidelines for people with SCI - strength-training activity starting level

3 sets x 10 reps, 2x/week

- for each major muscle group

physical activity guidelines for people with SCI - aerobic activity advanced level

30 mins 3x/week

- of moderate to vigorous intensity

physical activity guidelines for people with SCI - strength-training activity advanced level

3 sets x10 reps, 2x/week

- for each major muscle group

should do recommendations based on CPG to improve locomotor function following chronic stroke, incomplete SCI and brain injury

distance and walking speed primary OMs

- high-intensity gait training (65-85% HRmax) or (RPE 15-17 on the Borg scale)

- virtual reality (VR) walking (augment feedback, task variability, real-world environmental engagement)

may do recommendations based on CPG to improve locomotor function following chronic stroke, incomplete SCI and brain injury

- strength training (high load resistance at >70% 1RM to target specific muscle groups

- circuit/cycling training (or FES) at mod-high intensities

- BW support TM training (BWSTT) with rapid progress to minimized support

- robotic assisted gait training (RAGT) may be used to give high reps of steps in severely weak patients

should not do based on CPG to improve locomotor function following chronic stroke, incomplete SCI and brain injury

- sitting/standing balance matrix (static or dynamic balance; lacks specificity for walking)

- BW support with low intensity (<45% HRmax) using BW support or robotics

strength training

- target muscle groups that are innervated (balance pushing vs pulling)

- strengthen muscles that aren't used during functional mobility to prevent overuse injuries

strength training recommendations

70% of 1RM via circuit training, cycling or recumbent stepping at 75-80% of HR max

- strength training major muscle groups 2x/week

- 8-10 reps of mod-vigorous intensity

principles of practice to consider

- massed, distributed, constant, variable, random, blocked

- whole vs part training

motor learning to consider

- cognitive (trial and error with high cognitive activity)

- associative (can start to challenge conditions)

- autonomous (give feedback realtime and make it variable)

ASCM stretching and ROM recommendations for persons with SCI - frequency and duration

stretch daily

- holding 30-60 secs per stretch

- 2-4 reps

- slow, gentle, pain-free intensity

ASCM stretching and ROM recommendations for persons with SCI - focus areas

shoulders, pecs, elbows, hips, hamstrings, ankles

- avoid PF contracture

- for C6 NLI, don't stretch finger flexors

- for tetraplegia avoid over-stretching low back

ASCM stretching and ROM recommendations for persons with SCI - techniques

- may use strapping for self stretching

- avoid bouncing

assistive technology

- wheelchair and seating (add-ons, power assist)

- robotic exoskeletons (wearable robotic systems, powered support to help those with paralysis stand and walk

- electronic aids to help daily living (smart home tech)

- computer and communication access (voice control and speech generating devices)

- FES (bike, bioness H200)

precautions for exercising persons with SCI

- autonomic dysreflexia awareness

- blunted HR response

- thermoregulation deficits

- postural and core support

autonomic dysreflexia awareness

for injuries at or above T6

- ensure trainee empties their neurogenic bladder/bowel equipment before exercise to prevent dangerous sudden spikes in BP

blunted HR response

individuals with cervical or upper thoracic injuries (tetraplegia)

- SNS may be compromised

- max HR may be naturally capped around 110-130 bpm

- use RPE to guide intensity

thermoregulation deficits

reduced sweating capacity below NLI

- exercise environments must remain climate-controlled to avoid overheating

postural and core support

for those with limited trunk stability

- use chest straps