SCI Interventions

What AIS lvl will likely never walk again?

AIS A

__% of people with AIS A with cervical injuries are likely to get 1 lvl of motor recovery below the original NLI

70%

What percentage of people who are AIS B will be able to walk again?

33%

What percentage of people who are AIS C will regain the ability to walk again?

65%

What percentage of people who are AIS D will regain the ability to walk?

Almost 100%

The preservation of what in the LEs or sacral region is a good prognosis 1 year post SCI for the ability to regain the ability to walk?

Preservation of pinprick in LEs or sacral region

At what months post SCI does the recovery of motor function often plateau?

12-18 months

A pt’s score on the CPR for recovery of outdoor walking predicts the likelihood of outdoor walking how long after a SCI?

1 year post SCI

If CPR for recovery of outdoor walking is over ___, we have an increased confidence that they will recover outdoor walking ability

33+

If someone’s CPR for outdoor walking is less than ___, there’s a poor chance they will recover the ability to walk outdoors

Less than 33

What qualifies as outdoor walking according to the CPR for recovery of outdoor walking?

Walking 100m+ with one cane, leg orthosis only, or no AD (taken from SCIM III)

You are working with a pt who is a chronic, incomplete SCI who is already ambulatory but wants to work on improving their ambulatory ability. What type of interventions SHOULD you do with the pt?

• Moderate to HIGT

• VR based training

You are working with a pt who is a chronic, incomplete SCI who is already ambulatory but wants to work on improving their ambulatory ability. What type of interventions MAY you do with the pt?

• Strength training

• Moderate to high intensity circuit or cycling

• VR balance training

You are working with a pt who is a chronic, incomplete SCI who is already ambulatory but wants to work on improving their ambulatory ability. What type of interventions should you NOT do with the pt?

• Body weight supported treadmill training

• Robot assisted training

• Balance training w/o VR

What are the requirements for functional walking recovery post SCI?

• Adequate muscle strength

• Postural alignment

• ROM (hip extension in particular)

• Cardiovascular endurance

What are the benefits of compensatory based walking recovery?

• Osteoporosis prevention

• Aerobic capacity improvements

• Maintaining skin integrity

In order for someone to have compensatory based walking recovery, they need full ROM in what?

Hip extension

In order for someone to have compensatory based walking recovery, they need to not have contractures where?

• Knee flexion contracture

• Plantar flexion contracture

You are working on compensatory based walking recovery with a pt post SCI. You notice that they stand with their trunk extended. Why is that?

They are leaning into their hip ligaments to stabilize their trunk and pelvis

What is a common AD when someone is working on compensatory based walking recovery post SCI? Why is that?

Lofstrands because they are lightweight, allow for full ROM at the shoulder and hip, and allow for a free hand

What are the two common gait patterns for someone working on compensatory based walking recovery?

• Swing through

• Four point

What are some interventions for recovery based walking recovery?

• Body weight supported treadmill training with manual facilitation

• Body weight supported gait training overground

• Exoskeletons

When doing recovery based walking recovery, what principles of neuroplasticity should you focus on?

• Repetition matters

• Use it to improve it

What are some UE based exercises to improve cardiovascular training for someone who has had a SCI?

• Arm ergometry

• Wheelchair propulsion

• Swimming

If the ___ is damaged, it can be hard to do cardiovascular training for someone with a SCI

The sympathetic nervous system

How many days a week should someone with a SCI be doing endurance training? How long should each session be? At what intensity?

• 3-5 days/wk

• 20-60 min each session

• 50-80% HRmax

  • 13-17 on 6-20 Borg/RPE scale if they have sympathetic nervous system damage

You are just beginning cardiovascular and strength training with someone who has suffered a SCI. How many times a week should you be doing each kind of activity? How long? At what intensity?

• Aerobic

  • 2x/wk for 20 min at a moderate to vigorous intensity

• Strength

  • 3×10 for each major muscle group 2x/wk

You have been doing cardiovascular and strength training with someone who has suffered a SCI. How many times a week should you be doing each kind of activity? How long? At what intensity?

• Aerobic

  • 3x/wk for 30 min at a moderate to vigorous intensity

• Strength

  • 3×10 for each major muscle group 2x wk

The lower trunk muscles of someone with a SCI should be loose to improve sitting posture and trunk stability during transfers. True or false?

False! They should be tight

How much ROM should someone with a SCI have during a SLR? Why that much? Why not more or less?

They should have 100° to allow for long sitting. They shouldn’t have more than that tho because they need some tightness to provide pelvic stability in sitting

What are some key UE muscles for someone who has suffered a SCI?

• Serratus anterior

• Lats

• Pec major

• SITS

• Triceps

When working on strengthening with someone with a SCI, you should be doing it at what percentage of their 1RM?

60-80%

What are the primary goals of respiratory interventions when working with someone who has suffered a SCI?

• Improve their ventilation

• Increase the effectiveness of their cough

• Prevent chest tightness

• Prevent ineffective substitute breathing patterns

What inspiratory muscles are innervated by C1-2?

• SCM

• Upper trap

What inspiratory muscles are innervated by C3-4?

• Partial diaphragm (C3-5)

• Levator scap (C3-5)

• Scalenes (C3-8)

What inspiratory muscles are innervated by C5?

Diaphragm

What inspiratory muscles are innervated by C6-8?

• Pec major (sternal) (C7-T1)

• Pec minor (C6-T1)

• Serratus anterior (C5-7)

What inspiratory muscles are innervated by T1-5?

• Intercostals (T1-11)

• Serratus posterior superior (T1-3)

What inspiratory muscles are innervated by T6-10?

Abdominals (T6-L1)

What forced expiratory muscles are innervated by C5-6?

Pec major (clavicle)

What forced expiratory muscles are innervated by T1-11?

Intercostals

What forced expiratory muscles are innervated by T6-L1?

Abdominals

What forced expiratory muscles are innervated by T9-12?

Serratus posterior inferior

What forced expiratory muscles are innervated by T12-L4?

Quadratus lumborum

During normal breathing, the epigastric region should do what?

Rise

When in supine, what should the chest wall do during inhalation?

Expand

What are some signs of weakness in respiratory muscles?

• Use of accessory muscles

• Paradoxical breathing patterns

• RR increase

Why does a lack of abdominal muscle innervation make it hard to breath in sitting?

Because the abdominal contents fall forward which pulls on the central tendon of the diaphragm which results in an inefficient breathing pattern

How can an abdominal binder help if someone has a lack of abdominal muscle innervation?

• Can increase intra-abdominal pressure

• Moves diaphragm superiorly

What are the benefits of respiratory muscle training?

• Improved respiratory muscle strength

• Improved vital capacity

• Improved maximal inspiratory pressure

• Improved MEP

• Decrease in residual volume

Where can you apply pressure to encourage diaphragmatic breathing?

Just below the sternum

What are the benefits of IMT?

• Improved pulmonary function

• Reduced dyspnea

• Improved cough

During IMT, where can you apply resistance?

Epigastric area

What are the benefits of EMT?

Improve pulmonary function

If someone has a functional cough, how many coughs can they get in one exhalation?

2+

If someone has a weak functional cough, how many coughs should they be able to generate in one exhalation?

1

What is the best position to do a manually assisted cough?

Seated

Describe how you would perform a manually assisted cough

Place hands right below the xiphoid process → have the pt take a deep breath in → apply a manual pressure inward and superiorly → have pt get in a flexed posture and cough

What is the most effective intervention for skin care?

Prevention of skin breakdown

Pressure relief should be performed every ___ minutes in a w/c for at least ___ seconds

Every 15 minutes for at least 60 seconds

What are some pressure relieving techniques?

• Push up maneuver

• Leaning onto one side

• Leaning forward (needs to be more than a 45° lean)

• Tipping w/c back (needs to be tilted at least 65°)

What percentage of people with a SCI have spasticity?

65%

Spasticity is more common in ___ level injuries

Cervical level

What are some stimuli that could cause spasticity in someone with a SCI?

• Positional changes

• Cutaneous stimuli

• Environmental temps

• Tight clothing

• Bladder or kidney stones

• Fecal impaction

• Catheter blockage, UTI

• Pressure injury

• Emotional triggers

Stretching is the best thing you can do to help reduce spasticity. True or false?

That be false

After someone has a SCI, for how many months afterwords do they have a rapid bone mineral loss?

4-6 months

How many years after a SCI does bone mineral density decrease?

Up to 3 years

What percentage of people who’ve had a SCI suffer a bone fracture?

46%

What are some ways you can prevent osteoporosis for someone who has had a SCI?

• Standing frame

• Standing in orthoses

• FES for muscle action on bone

What is heterotropic ossification?

Osteogenesis in soft tissues

For people who’ve suffered a SCI, does heterotopic ossification typically happen above or below the lvl of the injury?

Below

What are the early symptoms of heterotopic ossification?

• Swelling

• Joint and muscle pain

• Decrease ROM (big sign)

• Erythema (reddening of the skin)

• Local warmth over joint

Why do we care about heterotopic ossification?

Because it can lead to contractures, impaired ROM, impaired mobility, and impaired ability to do ADLs

What medications is someone with heterotopic ossification given?

• NSAIDs (for prevention)

• Bisphosphonates (for treatment)

The parasympathetic nervous system controls the cardiovascular system through what nerve?

Vagus

What spinal segments provide sympathetic innervation to the cardiovascular system?

T1-L2

Above what spinal level does sympathetic innervation impact the heart and blood vessels of the upper body?

Above T6

At what spinal level and below does sympathetic innervation go to the blood vessels of the lower body?

Below T5

What impact to the cardiovascular system would a lesion between T1-L2 have?

• Reduced exercise tolerance

• Lower stroke volume

• Reduced CO

What impact would a cervical lesion have on the cardiovascular system?

• Lower peak HR

• Post exercise hypotension (because ya not getting input to peripheral blood vessels)

• Abnormal cardiovascular response to exercise (need to use RPE to grade intensity)

Autonomic dysreflexia can happen in lesions above what level?

Above T6

What is the incidence of autonomic dysreflexia in people with SCI with the NLI above T6?

45%

What factors make the likelihood of suffering from autonomic dysreflexia more likely?

• Chronic SCI

• Complete injury

Autonomic reflexia is considered a medical emergency. True or false?

True!

What is autonomic dysreflexia?

A noxious stimulus that originates below the level of a lesion that triggers an acute onset of autonomic activity that results in an elevated BP and can lead to seizures, cardiac arrest, SAH, CVA, and death

What are some triggers for autonomic dysreflexia?

• Distended bladder

• Blocked catheter, UTI

• Kidney stones

• Distended bowel

• Pressure injuries

• Estim below the lvl of the lesion

• Sexual activity

• Labor

• Skeletal fracture

What are the S/S of autonomic dysreflexia?

• HTN (increase in SBP by 20-30 mmHg

  • Hallmark sign

• Bradycardia

  • Hallmark sign

• Severe H/A

  • Hallmark sign

• Feeling of anxiety

• Constricted pupils

• Blurred vision

• Flushing and piloerection above the area of the lesion

• Dry, pale skin below the lvl of the lesion (vasoconstriction)

• nasal congestion

• Increased spasticity

• Could be asymptomatic

You are working with a pt who has a SCI when all of a sudden, they start to show autonomic dysreflexia. How would you respond?

1. Bring pt into an upright, short sitting position (will lower BP)

2. Try to ID the trigger

3. Loosen tight clothing or restrictive devices

4. Closely monitor VS and if BP does not calm down, get medical attention

What causes OH?

An impaired sympathetic/parasympathetic balance that is combined with an early prolonged time in bed

What are the S/S of OH?

• Blurred vision

• Ringing in ears

• Light-headedness

• Fainting

OH is normally only significant in SCI injuries above what level?

Above T6

What are some different ways we can manage OH?

• Slow progression from horizontal to vertical

• Compression stockings and/or ACE wraps on legs

• Abdominal binder

• Drugs

  • Ephedrine (increases BP)

  • Diuretics (decrease persistent LE edema)

Why do some people who’ve had a SCI have impaired temperature control?

Because the hypothalamus can’t control cutaneous blood flor or sweating because of the loos of sympathetic control

Does someone with a SCI lose the ability to shiver above or below the level of the lesion?

Below the lesion

Which is common in early recovery from a SCI, hypothermia or hyperthermia? Why?

Hypothermia because of peripheral vasodilation

What is common in late recovery from a SCI, hypothermia or hyperthermia? Why?

Hyperthermia because of the loss of sympathetic control over sweat glands

The spinal control of micturition is at what segments?

S2-4

Someone with a SCI will have a spastic/hyperreflexic bladder if they have a lesion where? Why is that?

Lesion above the conus medullaris and sacral segments. Result of the bladder not being able to store urine cuz the detrusor muscle is having spasms

Someone with a SCI will have a flaccid/areflexic bladder if they have a lesion where? Why is that?

If they have a lesion at the conus medullaris or sacral segments. Detrusor muscle not innervated and therefore won’t empty the bladder

If someone has a UMN/spastic/hyperreflexic bladder, will they have normal to lower or high bladder capacity?

Normal to lower bladder capacity