SCI 5: Health and Wellness, Shoulder, Locomotor Training

Why is traditional exercise often modified in SCI patients?

• wheelchair vs. ambulatory

• respiration and ventilation affected

• thermoregulation impaired

why is it important to control weight after SCI?

common to gain weight → staying lighter prevents pressure sores, cardiovascular impairments, and easier to manage transfers/mobility

What percentage of the SCI population is overweight or obese?

55 - 68%

What cardiovascular risk factors are elevated in SCI populations?

hypertension and blood cholesterol

overall CVD risk increased

How does SCI impact sleep?

poor sleep and sleep related breathing disorders

Why is polypharmacy a concern in SCI patients?

due to frequent use of high-risk medications like opioids

What are the long-term wellness goals for SCI individuals?

Optimize physical and mental health and wellness t/o the lifespan with physical activity

Decrease CV disease, maintain ROM and strength, slow the decline of BMD Loss

what are special exercise considerations for shoulder pain and UE overuse injuries?

good shoulder health incorporated into POC

education on weight management → obesity correlated with shoulder pain

what education should you include in shoulder pain and UE overuse injuries?

weight management → obesity correlated with shoulder pain

what are exercise special considerations for “fracture risk due to decline in BMD”?

functional e-stim can help for complete injuries

be cautious of falls, over stretching, and more

What increases fracture risk in SCI patients?

decreased BMD from disuse

what are exercise special considerations for “loss of sensation, decreased mobility, and sitting for too long”?

• good nutrition can help heal pressure sores

• wellness program can decrease time spent in wc and improve ROM

loss of sensation, decreased mobility, and sitting for too long leads to?

skin breakdown & joint contractures

Diminished ability to regulate temperature above ___

T6

what are exercise special considerations for “autonomic dysfunction”?

low BP: may require meds, compression stockings, and ab binder

post exercise hypotension

what are the respiration and ventilation considerations for exercise in SCI?

anterior trunk stretching

diaphragmatic breathing, abdominal binder

what is the recommended aerobic exercise per week in SCI?

20-40min of mod/high aerobic exercise

3 x/wk

what are the options for exercise modifications in SCI?

• adaptive sports

• assistive device(s)

• UE focus

• FES cycle and rower

• robotic assisted

shoulder pain incidence ___% people with SCI

30 - 70

shoulder pain __% by 20 years post injury

70

why is shoulder pain so common in SCI?

shoulder becomes a weight-bearing joint for transfers, pressure relief, WC mobility

partial innervation, inability to rest, reaching overhead

what are the risk factors for shoulder pain in SCI?

• increased time since injury

• older age

• higher level of injury

what are the specific structures involved in subacromial impingement?

• supraspinatus

• long head biceps

• bursae

what are the contributing factors for subacromial impingement?

• poor scapular stability/RTC strength

• anatomical abnormalities

• posterior capsule and pec minor tightness

• abnormal kinematics

what muscle imbalances are involved in poor scapular stability/RTC strength?

upper trap over activation

serratus anterior decreased activation

what are the anatomical abnormalities that contribute to subacromial impingement?

flat, curved, hooked acromion

what are the abnormal kinematics that contribute to subacromial impingement?

excess scapular anterior tipping, downward rotation, and internal rotation

GH internal rotation

what should be the main focus for abnormal kinematics?

focus on the opposite

why does upper trap tend to be overactive in SCI?

innervated by spinal accessory and most likely does not get injured in SCI

what is the worst anatomical abnormality to have?

hooked because it can tear the supraspinatus

STOMPS Article: stretching exercises focus on stretching what shoulder structure?

posterior capsule

STOMPS Article: the shoulder HEP consisted of?

stretching phase, a warm-up phase, and a resistive shoulder exercise phase

STOMPS Article: frequency of HEP?

3 x/wk for 12 weeks

what was the one criteria the all patients had in the STOMPS trial?

shoulder pain that interfered with at least one functional activity

what did the control group receive in the STOMPS trial?

educational handout

what outcome measure did they use in the STOMPS trial?

Wheelchair User’s Shoulder Pain Index (WUSPI)

what muscle groups were emphasized in the STOMPS trial for hypertrophy exercises?

8 rep max resistance

shoulder adduction and shoulder external rotation

what muscle groups were emphasized in the STOMPS trial for endurance exercises?

15 rep max resistance

shoulder elevation in the scapular plane and scapular retraction

modify surface heights to be _____ as often as possible

lower than the target surface

move height of ________ whenever possible

transfer surfaces to make the 2 surfaces level

lean trunk ________ during the transfer

forward

lead with the ________ shoulder whenever possible

painful

avoid _________ for pressure relief. Use an alternate technique such as forward or side-to-side lean

depression raises

turn hand ______ whenever possible when transferring

outward

use an _____________when moving between non level surfaces

sliding board for painful transfers

_____, smooth strokes are best for propulsion → rather than short, frequent strokes when propelling your wheelchair

long

finish the push by letting the hand go down OR rapidly changing direction when finishing the push stroke (select one answer)

letting the hand naturally drift downward

push on the _____ for better shock absorption (vs the _______)

tire

vs the pushrim

avoid ___________ terrain

(for WC propulsion modification recommendations)

rough or uneven

_______ when needed

(for WC propulsion modification recommendations)

stop and rest → have to push over uneven terrain for a long distance

turn ____________ on a steep incline when going up to rest

chair to the side to rest arms

Move axel _______ to minimize shoulder extension component

forward

what’s the best wheelchair stroke technique for propulsion?

semicircle

what are some modifications you can make to the WC to ensure good postural alignment?

‘dump” the chair for improved trunk stability → switching seat ankle

solid footplate/rigid frame

what were the results from the STOMPS trial?

• strength gain - increased torque in every shoulder plane

• reduction of pain - measured by WUSPI and VAS

• improved QOL

how long was the intervention in the STOMPS trial?

8 weeks

what muscles were targeted for strengthening (EMG biofeedback) in the STOMPS trial?

• serratus anterior

• middle and lower trapezius

• shoulder external rotators

Reduce Upper Trap Activation

how often was the strengthening program supposed to be performed in the STOMPS trial?

every other day

what structures were targeted for stretching (everyday) in the STOMPS trial?

• posterior capsule

• upper trapezius

• pectorals

• biceps

Teach/modify transfer techniques and wheelchair propulsion techniques to maximize _____ health

shoulder

Prescribe stretching and strengthening exercises to optimize…

scapular and glenohumeral kinematics and muscle activation

when should you modify the shoulder program?

when the scapula is not fully innervated

If pain persists and is not remediated through intervention, recommend that the patient consider…

power mobility

what are the requirements for functional ambulation?

• adequate muscle strength

• postural alignment

• range of motion

• cardiovascular endurance

what are some walking outcome measures for SCI?

spinal cord independence measure

walking index for SCI

percentage that AIS A will walk?

5% → requiring substantial external support

percentage that AIS B will walk?

33%

percentage that AIS C will walk?

65%

percentage that AIS D will walk?

nearly 100%

Functional ambulation is defined as…

ability to walk independently in the community, with or without the use of devices and braces

prognosis percentage of thoracic/lumbar AIS A for walking?

8% with devices, bracing, and limited distance

prognosis percentage of cervical AIS A for walking?

~ 0%

prognosis percentage of cervical AIS B for walking?

2/3 if intact PP

S4-5, or L2-S1

prognosis percentage of thoracic/lumbar AIS B for walking?

1/8 if intact L

S4-5

prognosis percentage of > 50y/o, thoracic/lumbar AIS C for walking?

30-40%

prognosis percentage of cervical AIS C for walking if < 50 y/o?

80-90%

prognosis percentage of cervical/thoracic/lumbar AIS D for walking if increased age?

decreased chance by 20%

walking recovery for central cord syndrome?

97%

decreases to 41% over 50 yo

walking recovery for brown sequard?

75 - 100%

what are other factors to consider for walking recovery?

• Psychosocial support

• Insurance Coverage

• Patient psychological status

• Motivation

what is the CPR for indoor walking?

under 65, if sensation at S1 (any kind), motor score at L3 (knee extension, quad) = higher likelihood of walking

the CPR for indoor walking is able to discriminate between ________ better than AIS alone

independent and dependent ambulators

what is the CPR to determine outdoor walking 1 year after SCI?

the higher the grade for L3, L5, and S1, the better chance of walking after SCI

≥ 3 predicted walking recovery

what is the single dermatome CPR for Independent walking 1 year after SCI - indoor and outdoor

pinprick at S1 indicates independent walking

why do CPRs for walking after SCI matter?

• determines responders to different interventions

• time in rehab is short → optimize tx

• DME needs and complex rehab technology has to be ordered very early after SCI

what are the motor incomplete SCI goals?

• ambulation and stairs

• balance

• standing

• transfers

• strength training

• w/c mobility

need to incorporate gait training in AIS ___ and ____ → what approach should you use?

C and D → restorative

what is the theory behind walking recovery after SCI?

intrinsic capacity of the spinal cord to respond to sensory input with a motor output

• Intact feedback loop

• Task specificity! (stand and step)

• guided by central pattern generators

what are central pattern generators?

intrinsic circuits that can produce rhythmic motor patterns without descending inputs

ex) breathing, walking

what muscle angle is important for the initiation of swing?

hip extension → muscle spindle response to hip flexor stretch

what sensory inputs contribute to central pattern generators in SCI?

hip extension angle (stretch) and ankle PF load

how does ankle PF load contribute to central patter generators?

amplitude of extensor muscle activation is directly related to weight bearing

GTOs sense the load → increase extensor activation in stance phase for push-off