NM III Unit 3: Compensatory treatment strategies for upright and wheelchair mobility

what SCI population is a sit to stand critical for

pts with incomplete SCI to rebuild mobility and promote independence

what is required for a successful STS (4)

LE strength

trunk stability

motor coordination

dynamic postural control

what does performing a STS allow (4)

progression to functional ambulation

toileting

transferring

participation in daily life

how can a STS help prevent LE contractures

it promoted full joint ROM especially at the hips, knees, and ankles

what is the focus of STS training for a complete SCI (3)

compensatory strategies, assisted technology, or supported standing frames

what body structure and function impairments may be seen making a STS difficult with a SCI (7)

impaired movement initiation

loss of LE motor recruitment

reduced muscle strength/power of LE

restricted ROM

hypertonicity

impaired movement coordination

abnormal postural alignment

what are the four phases of a STS

flexion momentum

momentum transfer

extension

stabilization

what is the flexion momentum phase

forward trunk flexion to shift the COM anteriorly over the BOS

what is required for the flexion momentum phase

adequate trunk control and momentum generation

what is the momentum transfer phase

when the body transfers from sitting to lifting off the seat as the COM moves vertically and weight is transferred to the LE

what is the most critical and unstable moment of a STS

momentum transfer

what is the key to a successful momentum transfer

timing and control to prevent balance loss or reliance on compensatory strategies

what is the extension phase

the hips, knees, and ankles extend to bring the body to an upright standing position

what is required in the extension phase

significant LE strength and coordination

what is the stabilization phase of a STS

after standing the body needs to stabilize and balance

what influences quiet standing or standing still (static standing balance) (4)

body alignment which affects COM and jt loading

muscle tone to maintain postural readiness

postural tone of antigravity muscles

muscle strength providing the force needed to make postural adjustments

what treatment approach is often effective in SCI

a hybrid approach with recovery promotion while implementing compensatory strategies to support function, safety, and independence

what is the goal of treatment for movement in SCI

not perfection of the movement but meaningful participation, quality of life, and mobility

what are the physiological benefits of standing (3)

bone health

CV function

prevention of complications like pressure injuries and contractures

what compensatory strategies are used for a STS with high level complete SCI

passive supports like tilt tables or standing frames

what compensatory strategies are used for a STS with mid to low thoracic or lumbar complete SCI

KAFOs with walkers or parallel bars

what is the goal of STS with mid to low thoracic or lumbar complete SCI (3)

weight bearing

improving orthostatic tolerance

maintaining joint integrity

what is the focus of restorative interventions for a STS with an incomplete SCI (3)

task specific repetition

external cueing

tools like FES or body weight supported treadmill training

what equipment is used for standing with complete thoracic level SCI's (3)

standing frames

KAFOs

parallel bars

what interventions are used for standing with complete lumbar level SCI's

upright training and functional transfers

what may be seen in a STS with spasticity (3)

difficulty bending forward

difficulty weight shifting

difficulty extending the hips and knees smoothly

what is seen in a STS with hypotonia (3)

difficulty with trunk control

difficulty with pelvic alignment

difficulty with sufficient muscle activation to initiate movement

what are the consequences of a poor initial set up with a STS (3)

it can trigger abnormal tone patterns, increase effort, and reduce efficiency

how should the trunk and pelvis be aligned

the trunk should be upright and aligned with the pelvis in neutral or slight anterior pelvic tilt

why should a neutral or slight anterior tilt of the pelvis be mantained

it helps reduce extensor tone and allows for efficient weight shifting forward

how should the feet be positioned in sitting

they should be flat on the floor for a stable base and loading of the LE

how should the knees be positioned in sitting and why

at 90 degrees to support effective momentum generation and preventing overreliance on the UE for push up

what is one of the most effective wats to reduce hypertonicity

prolonged stretch to allow the muscle spindle to adapt and quiet down its response

what can gentle slow movements or PROM do for tone

it can reduce excitatory input to the nervous system to reduce relaxation and smoother movements

what can be done to help increase tone in hypotonia (3)

tapping the muscle belly

quick stretch

vibration

what can weight shifting do for for a pt with a SCI

they help to normalize tone, encourage equal loading, and increase body awareness

helps initiate movement using their BOS

what are the benefit of rhythmic rocking anterior and posterior

it can reduce spasticity especially in the trunk and hip flexors

what can rhythmic rocking do for a STS

it calms the nervous system and prepares the pt for the forward momentum

what does standing with UE support do for a pt (2)

it allows the pt to engage postural muscles without bearing full wt independently

it facilitates extensor activation while reducing the fear of falling

what are the benefits of deep pressure and massage

they are applied to the joint through weight bearing to inhibit spasticity and provide proprioceptive feedback

what can massage do for tone

slow and form strokes can reduce muscle guarding and relax hypertonia

how can AROM reduce tone

through reciprocal inhibition causing relaxation

what can reflex inhibition patterns like Bobath and NDT based postures do

reduce abnormal reflex activity to help reset muscle tone

what can splints and orthotics provide for pts

they help to stabilize joints ad reduce abnormal tone patterns

what can a slight anterior wedge promote

forward trunk lean and reduced extensor tone

what can lateral wedges provide

prevention of asymmetrical postures that can reinforce tone imbalances

how can we teach pts to relearn the pattern of a STS

through breaking the movement into parts, cueing trunk lean, and supporting proper loading through the legs

what helps to make a movement stick for pts

making it functional and repetition

how should the therapist position themselves when performing STS with a pt with a SCI (4)

use a wide BOS with one foot slightly forward

back straight and hips down

keep COM close

use proximal contact points

what is the CPR of walking indoor for at least 10 meters (5)

age <65

motor score L3 for knee extensors

motor score S1 for PF

Light touch score L3 for dermatome

light touch score S1 for dermatome

how is the CPR for walking scored

age 65 or over has -10 weighted coefficient (under 65 is 0)

motor scores are multiplied by 2

sensory scores are multiplied by 5

40 is the highest

what is the compensatory approach to gait called

non physiological walking or ambulation due to no muscles below the lesion level

how can ambulation be achieved with complete SCI (3)

use of an AD

brace

technology

what is the focus of rehabilitation in pts with complete SCI (2)

strengthen the UE and trunk

maintain ROM in the LE

what are the precautions for compensatory based gait training (3)

orthopedic precautions

pressure injuries and skin abrasions from bracing

injury from falls

what are the benefits of a compensatory approach to standing (6)

circulation and CV health

improved skin integrity

improved bowel and bladder function

improved sleep

improved well being

improved bone health

what may occur to the UE in compensatory gait training

there is reliance on the UE to lift the body or swing the extremity resulting in excessive stress and potentially pain in the UE

what are the negatives of using braces and ADs for compensatory gait training

they lead to high energy expenditure and fatigue

what are the chances of independent ambulation with ASIA A or B and a motor level of C8 or above

they will not be able to functionally ambulate

what are the chances of independent ambulation with ASIA A or B and a motor level of T1-T9

they will only be able to walk with bilateral forearm crutches or walker and braces like HKAFOs, RGOs, or KAFOs

what are the chances of independent ambulation with ASIA A or B and a motor level of T10-L1

they are capable of walking limited distances using KAFOs or HKAFOs

what are the chances of independent ambulation with ASIA A or B and a motor level of L2

due to preserved hip flexion to help with the swing phase they can use forearm crutches or walker and a KAFO or floor reaction AFO

what are the chances of independent ambulation with ASIA A or B and a motor level of L3

due to preserved quadriceps function there is control of the knee at stance they can use forearm crutches or walker with AFOs with PF stop and DF assist or a floor reaction AFO

what are the chances of independent ambulation with ASIA A or B and a motor level of L4

there is innervation to the DF allowing independent community ambulation using forearm crutches and cane and an AFO with DF stops for an unopposed contraction of the DF

what are the chances of independent ambulation with ASIA A or B and a motor level of L5

there is limited ankle stability so an AFO with DF is needed but they can ambulate with a standard cane independently in the community

what are the chances of independent ambulation with ASIA A or B and a motor level of S1

due to innervation of the PF they can ambulate in the community with o AD or brace

what are the requirements of compensatory based gait training (6)

full hip hyperextension to hand on the Y ligament during a parastance position

no hip flexion, knee flexion, of PF contracture

full strength of UE especially shoulder depressors and triceps

able to support fill wt through UE without pain

well controlled spasticity

trunk control

what allows for the advancement of ADs and LE in compensatory based gait

trunk control for maintaining static and dynamic balance

what does the Y ligament do for SCI pts walking

it restricts hyperextension allowing more stabilization in a hyperextended position

how can a pt with a SCI keep the pelvis forward during standing balance

retracting the shoulder blades and throwing the head back

what does wt shifting allow for in compensatory gait

it allows the pt to move the AD or limb

what are the benefits of push ups for a SCI pt

it improves their ability to lift the body off the floor

what are the two gait patterns taught in compensatory gait

four point

swing through gait pattern

what are the benefits of a 4 pt gait pattern in compensatory gait

it is slower, safer, and requires less energy

what muscles are used in the 4 pt gait pattern in compensatory gait (3)

lats

quadratus lumborum

abdominals for hip hiking to swing limb

what is required for the swing through compensatory gait pattern

skillful head-hips relation and balance to swing the body forward while balancing on the AD

how is the 4 pt compensatory gait pattern performed

one crutch advanced

lift leg through hip hike, head tucked, and away from swing leg

leg swings forward

balanced standing posture

other leg advanced

how is the swing through compensatory gait pattern performed

crutches ahead

lift pelvis and legs through elbow extension, depressed shoulders, and protraction with head tuck

torso and legs swing forward

heel strike

balance regained

once a pt can ambulate on level surfaces what is introduced (3)

advanced skills such as negotiating obstacles

ascending and descending ramps, curbs, stairs

standing from the floor for fall recovery

what should be avoided when ascending and descending a ramp

jackknifing

how can you ascend a ramp with a compensatory gait pattern

keep the crutches well forward and keep the pelvis well forward

how can you descend a ramp with a compensatory gait pattern

the pt should step past the crutches

how should you ascend stairs with a compensatory gait pattern

place the crutch on the curb or step then lean on the crutches and lift yourself through depressing the scap, extending the elbows, and tucking the head

how should you descend stairs with a compensatory gait pattern

place the crutch on top of the curb or step, lean on the crutch then lift using elbow extension, scap depression, and head tuck

what should a pt do with the crutches if they fall

throw them laterally and posteriorly to avoid the crutch becoming a fulcrum

how can the pt break the fall with crutches

landing on the palms of the hand allowing the shoulders and the elbows to give and not holding the arms rigid

what should be practiced when standing from the floor for SCI pts after ambulation

standing using their braces since they create a risk for falls

how should a pt stand from the floor after ambulation with a SCI

get into prone with the braces locked in extension

walk the hands back into plantigrade

grasp one crutch at a time then push up into a standing position

what is an epidural stimulation

an implantable neural stimulator in the SC that send an impulse to the dorsal afferent which improves function in motor complete SCIs when combined with task specific activity

what is a transcutaneous spinal cord stimulator

a non invasive device that stimulates the dorsal afferent of the spinal cord

what is required from a WC for pts with a C4 and higher complete SCI

a power wheelchair controlled by chin movements, sip and puff, or head array

what WC is used for pts with a C5 complete SCI

usually a power wheelchair with hand controlled movements

they may be able to propel a manual wheelchair for limited distances

what WC is used for pts with a C6 complete SCI

most choose to use a manual wheelchair for household and community disctances

what WC is used for pts with a C7 and lower complete SCI

manual wheelchair

what is the first step for seating a custom wheelchair

determine postural support and seating needs

what is considered when determining the back, cushion, and positioning of a WC (6)

the sitting posture and skeletal deformities

level of balance and trunk strength

vertical tolerance

stability for operation of input device

need for positional changes

need for intermittent catheterization

what are the benefits of tilt and recline seated systems

they assist with vertical tolerance, need for positional change, and redistribution of pressure

what is the tilt function

it changes the orientation in space while maintaining the angles at the hips, knees, and ankles to redistribute pressure from one area to another

what is a recline feature

changing the orientation by opening the seatback to an angle

the knee angle can be changed if elevating leg rests are present

what are the consequences of a recline function

it is not as effective in redistributing pressure and may introduce a shearing force