HESC3592 – NEUROMUSCULAR REHABILITATION - Intro to SCI - 2023.pdf

HESC3592 – NEUROMUSCULAR REHABILITATION An Introduction to Spinal Cord Injury (SCI) Learning Outcomes 1. Describe spinal cord injury and it’s primary features.​ 2. Describe prevalence statistics for spinal cord injury in Australia.​ 3. Describe the structural organisation of the spinal cord....

HESC3592 – NEUROMUSCULAR REHABILITATION An Introduction to Spinal Cord Injury (SCI) Learning Outcomes 1. Describe spinal cord injury and it’s primary features.​ 2. Describe prevalence statistics for spinal cord injury in Australia.​ 3. Describe the structural organisation of the spinal cord.​ 4. Describe the pathophysiology of spinal cord injury.​ 5. Describe the various classifications of spinal cord injury.​ 6. Describe general complications associated with spinal cord injury. 7. Describe the benefits of exercise for persons with spinal cord injury. 8. Describe recommendations and considerations for exercise testing and programming in spinal cord injury. HESC3592 | Intro to SCI SCI – What is it? 24 September 2023 3 A Refresher - The Spinal Cord https://youtu.be/SoSFjaZ-lMs ANATOMY REFRESH - Segments Segmental organisation: Each segment of the spinal cord is connected to a specific region of the periphery by axons travelling through a pair of spinal nerves.​ In the cervical region, spinal nerves are found above the corresponding vertebrae (except the C8 spinal nerve).​ Remaining spinal nerves lie below the corresponding vertebrae. ANATOMY REFRESH Myotome: • Refers to the Muscles innervated by axons from a single spinal segment Dermatome • Refers to the area of the skin innervated by the axon from a single segment Peripheral Nerve Field • Muscle or areas of skin innervated by axon from an individual peripheral nerve. Understanding myotomes, dermatomes, and peripheral nerve fields helps to diagnosis the cause of neural impairments. ANATOMY REFRESH - Myotomes Upper limbs:​ • • • • • C5 - Deltoid.​ C6 - Wrist extensors.​ C7 - Elbow extensors.​ C8 - Long finger flexors.​ T1 - Small hand muscles​ • • • • • L2 - Hip flexors.​ L3,4 - Knee extensors.​ L4,5 - S1 - Knee flexion.​ L5 - Ankle dorsiflexion.​ S1 - Ankle plantar flexion Lower Limbs:​ ANATOMY REFRESH – Myotomoes / Demotomes Level C2 & above C3 C4 C5 C6 C7 C8 T1 T6 L2 L3 L4 L5 S1 S2 S4-5 Muscles innervated Trapezius, SCM Diaphragm Scalenes, Rhoms, RC Biceps, Deltoids Pecs, Latissimus Dorsi, Serratus Ant, Wrist Extensors Triceps, Wrist Flexors, Finger Extensors Finger Flexors Intercostals, Finger interossei Abdominals Hip Flexors, Hip adductors Quadriceps Dorsi Flexors Toe Extensors, Hams, Hip Extensors, Hip adductors Plantar Flexors Toe Flexors Bladder, Bowel function What is an SCI? HESC3592 | Intro to SCI Classifications Tetraplegia 24 September 2023 Paraplegia Classifications Complete 24 September 2023 Incomplete 11 SCI – Classifications (COMPLETE) Complete SCI • Significant impactful trauma SCI – Classifications (INCOMPLETE) Anterior Cord Syndrome SCI – Classifications (INCOMPLETE) Central Cord Syndrome SCI – Classifications (INCOMPLETE) Posterior Cord Syndrome SCI – Classifications (INCOMPLETE) Brown-Sequard’s Syndrome / Hemicord Lesion Aetiology and Epidemiology A Global map for Traumatic Spinal Cord Injury Epidemiology, Cripps, Lee etal Spinal Cord 2010 350 new cases per year in Australia Males: Females = 4:1 Age: <30yrs (15-25 yrs old) ~80% from traumatic causes • 50-75% motor vehicle accidents • Falls, sports, water based activities, work related, falling objects ~20% from non traumatic causes • Secondary to such conditions as vascular disease, infectious diseases, disc herniation Australian Spinal Injury Registry, (2017). Pathophysiology of SCI Pathology Time after Injury Few minutes to few hours Between 4-8 hrs By 24 hours Zhang, Y., Al Mamun, A., Yuan, Y., Lu, Q., Xiong, J., Yang, S. ... Wang, J. (2021). Acute spinal cord injury: Pathophysiology and pharmacological intervention (Review). Molecular Medicine Reports, 23, 417. https://doi.org/10.3892/mmr.2021.12056 Pathophysiology Observed Changes Release of vasoactive agents and cellular enzymes Infiltration of site by neutrophiles and macrophages Increase in intracellular calcium levels Changes to micro vessels in grey matter (processing) Multifocal haemorrhages Postcapillary venule distension Damage to vascular endothelium Leakage of eryrocytes into perivascular spaces Increase in extracellular potassium levels and resulting depolarisation of cells Conduction block Hypoxia induced catecholamine release Further haemorrhage and necrosis Elevated calcium remains Appearance of aneurysms and vessel rupture in lateral columns on the spinal cord Thrombi formation in capillaries Navigating the Slalom 24 September 2023 21 The Importance of Early Intervention 24 September 2023 24 The Golden Window Time is Critical! Emphasis on adequate acute, sub acute and outpatient care Craig Hospital US. NeuroMoves Aus Health system In / out Patient Care • Ditunno 2001 Classification of Spinal Cord Injuries Classification of SCI https://youtu.be/XsgELcLRnnY American Spinal Injury Association Classification of SCI Clinical Presentations Complete C level Complete T level Incomplete C level Incomplete T level Response to Exercise Persons with low level lesions (paraplegia) may have near normal CV responses to exercise.​ Major limitation is related to the smaller muscle mass used for exercise (arms) resulting in lower peak VO2, lower peak power output, and cardiac output (50% of predicted value).​ With higher lesions (tetraplegia) a proportion of the active muscle group is paralysed and ANS sympathetic control may be impaired:​ • Peak exercise capacity values may be 33-50% of estimated.​ • MHR may not exceed 120 bpm.​ • Strenuous exercise may not be tolerated.​ The higher the lesion, the lower the CV capacity and more limited the VO2. Exercise Prescription in SCI Neurological Changes Complications Autonomic Dysreflexia Pressure injury / Skin integrity Hypotension Bone Mineral Density Deep Vein Thrombosis 24 September 2023 Considerations Spasticity / Tone Impaired Thermoregulation Contracture / changes in ROM Pain Bladder / Bowel Function Proprioceptive Changes Sensory / Motor changes Assistive Devices 34 Complications Associated with SCI Loss of bladder and bowel function:​ Spasticity:​ Contractures: Complications Associated with SCI Impaired thermoregulation:​ Postural hypotension: Pressure sores: Chao, C. Y., & Cheing, G. L. (2008). Orthostatic hypotension for people with spinal cord injuries. Hong Kong Physiotherapy Journal, 26(1), 51-58. Complications Associated with SCI Osteoporosis:​ Diminished pulmonary function: ​ Blunted CVD responses and diminished exercise capacity: Complications Associated with SCI – CVD risk Cragg et al. (2013). Neurology, 81; 723-728. Participants: • • • • • Median age= 40-44 yrs. SCI N= 356. Controls N= 60,000. Males 49%. Females 51%. Stroke prevalence higher in SCI (5.7% vs 1.1%). CVD prevalence higher in SCI (17.1% vs 4.9%). SCI is an independent risk factor for CVD and stroke. Autonomic Dysreflexia Complications Associated with SCI Autonomic Dysreflexia: • ​Considered a medical emergency and must be recognised immediately.​ • If left untreated autonomic dysreflexia can cause:​ • • • • • • • • • • • Seizures.​ Retinal haemorrhage.​ Pulmonary edema.​ Renal insufficiency.​ Myocardial infarction.​ Stroke.​ Death. ​ Management of autonomic dysreflexia:​ Sit the client upright (promote blood pooling in lower limbs).​ Loosen tight clothing.​ Find source of instigating cause. Monitor BP every 2-3 mins and seek medical attention. DVT Deep Vein Thrombosis: ​A blood clot in the legs primarily related to physical inactivity and immobility.​ May lead to pulmonary embolism that can be fatal.​ Symptoms:​ Local swelling.​ Redness.​ Heat. Considerations Spinal cord injury facts - SpinalCure Australia Breakout Activity Johnny X SCI Johnny X • • • • • • • • John is a 34 year old male with a Incomplete Spinal Cord Injury. John was injured 10 years ago from a scuba diving accident which led to an air emboli forming on his spinal cord – causing an ischemic lesion on his spinal cord at C 5 Upon discharge 9 months later, Johnny’s ASIA score was C5 ASIA B. Since discharge however, Johnny has witnessed consistent positive neurological changes in function, and believes his AISA score is no longer accurate. John is currently on nil medication and ceased all medication on discharge from the hospital 9 years ago. John is otherwise a healthy person who works, studies and leads a very social life. John can complete all transfers independently, can stand independently and can ambulate with heavy reliance on 2 x walking sicks. John has spacticity bilaterally in HS, RF + Gas. John’s main complaints are uncontrollable spasticity, sporadic sensation through his LL and his balance without his sticks. John regularly climbs to and from his farm machinery and walks over uneven terrain on a regular basis to maintain his farm. John has reported that he falls 1 x per month. John’s goal is to be able to carry 2 x 5L jerry cans on his farm, but would also be happy to be able to walk safely indoors, being able to carry his lunch from the bench to his dining table 24 September 2023 46 24 September 2023 47 Breakout Activity Is John’s ASIA score accurate? Brainstorm why / why not? What are some Therapeutic goals for Johnny? What Assessments are relevant to Johnny’s Goals? What could a 1hr Exercise session look for Johnny? 24 September 2023 48 Benefits of Exercise Prescription in SCI Which should we focus on? Neuroplasticity Experience driven Enhanced Neuronal activity Negative or Positive • we are plastically changing by what we are living. • Houle and Cote 2013, Weiloch et al 2006, Duffau 2006, Mulder and Hochstenback 2001, Voss et al 2013, Muulder et al 2001, Hornby et al 2011, Birkenmeir et al 2010 • • • Core principles = Specificity, repetition, intensity, meaningful, difficulty / challenging, timing • • • • Neurorestoration Unmasking of silent pathways We don’t use all of our brain, all of the time In Clinic vs. In Home • Kleim et al 2004, Kleim and Jones 2008, Kliem et al 2012 • Neuroprotection Brain Derived Neurotrophic factors Reducing axonal dieback Increasing intensities to increase bloodflow to the brain Induced by 70-80% Predicted HRmax • Voss et al 2013, El-Tamawy et al 2014, Vega et al 2010, Houle and Cote 2013, Hornby et al 2011, ferris et al 2006 Neuroplasticity after SCI Behrman, A. L., Bowden, M. G., & Nair, P. M. (2006). Neuroplasticity after spinal cord injury and training: an emerging paradigm shift in rehabilitation and walking recovery. Physical therapy, 86(10), 1406-1425. 24 September 2023 51 Activity Based Training – Locomotor Training (Grillner,1981; Jankowska, 1992; Mc Crea, 2001) 24 September 2023 52 Activity Based Training – Locomotor Training 24 September 2023 53 Activity Based Training Activity Based Therapy Traditional Therapy • • • • • Activate nervous system above the level of lesion Low intensity practice Non-patterned movements Compensates for loss of function Uses compensatory devices 24 September 2023 • • • • • Activate nervous system above and below the level of lesion High intensity practice Patterned movements Restores lost function Minimizes or eliminates compensatory devices 54 Activity Based Training 24 September 2023 55 Activity Based Therapy Activity Based Training – Evidence This study provided preliminary evidence about the positive effects of ABT on functional independence, mobility, and balance in sitting for individuals with SCI. Improvements of greater magnitude happened in earlier phases of ABT exposure, with changes in mobility continuing until 9 months. Individuals experienced benefits regardless their level, severity, or duration postinjury. In conclusion, this systematic review provided evidence that ABT interventions can improve independence and function when applied to the upper limbs in people with SCI. However, they are not superior to conventional physical interventions when applied to the lower limbs. There were no effects on quality of life. Considering the costs involved and labor intensity required to deliver ABT interventions to the lower limbs, it is recommended that clinicians be judicious when delivering ABT interventions. 24 September 2023 58. de Oliveira, C.Q., Middleton, J.W., Refshauge, K. and Davis, G.M., 2019. Activity-Based Therapy in a Community Setting for Independence, Mobility, and Sitting Balance for People With Spinal Cord Injuries. Journal of Central Nervous System Disease, 11, p.1179573519841623. 59. Quel de Oliveira, C., Refshauge, K., Middleton, J., de Jong, L. and Davis, G.M., 2017. Effects of activity-based therapy interventions on mobility, independence, and quality of life for people with spinal cord injuries: A systematic review and meta-analysis. Journal of neurotrauma, 34(9), pp.1726-1743. 56 Benefits of Locomotor Training - SCI Incomplete SCI Increased walking speed Increased walking independence Increased walking endurance Improved balance Decreased asymmetry of gait Improved gross motor skills Improved well being, life satisfaction and perceived health Complete SCI improved trunk control improved bone density improved quality of life improved bladder/bowel sensation and function reduction in muscle spasms and neural pain increased muscle length and joint mobility Improved well being, life satisfaction and perceived health (Anwer et al 2014, Jones et al 2014, De Paleville 2013, Harkema et al 2011, Harkema et al 2010, Gorassini 2009, Ditunno 2009, Dietz 2009, Behrman 2008, Forrest et al 2008, Jayaraman et al 2008, Dobkin 2006, Barbeau 2006, Hannold et al 2006, Berhman et al 2005, Hicks et al 2005, Phillips 2004, Anderson 2004 Wriz 2001, Berhman and Harkema 2000, Ladoceur 2000, Barbeau et al 1998a and 1998b, Wernig et al 1995 and1992.) Locomotor Training Activity Based Training – Locomotor Training NRS is classification focused on task specific recovery providing clinicians with important data for treatment planning and progression. 63. Behrman, A.L., Ardolino, E., VanHiel, L.R., Kern, M., NRS uniquely evaluates functional recovery to achieve a specific task goal without compensation compared with other common SCI Atkinson, D., Lorenz, D.J. and Harkema, S.J., 2012. outcome measures. NRS can effectively discriminate performance and reduce variability between patients with motor incomplete Assessment of functional improvement without spinal cord injury in mobility outcome measures (i.e. balance, gait speed and endurance). NRS offers greater sensitivity in compensation reduces variability of outcome distinguishing the function in patients with motor incomplete SCI in groups compared with AIS grade.NRS is also able to detect measures after human spinal cord injury. Archives of changes in functional improvement in motor incomplete SCI. physical medicine and rehabilitation, 93(9), pp.15181529. Locomotor training was founded on principles rely on the input of sensory information to promote lower limb and trunk activation Harkema, S.J., 2001. Neural plasticity after human consistent with locomotion. To achieve a meaningful level of recovery these principles need to be translated to the overground spinal cord injury: application of locomotor training to environment. Locomotor training principles were developed to maxmise sensory stimulation that closely matches the kinetic and the rehabilitation of walking. The Neuroscientist, 7(5), kinematic phases of stepping. Extensive evidence indicates in the lumo-sacral spinal cord in all other species other than humans lies a pp.455-468. sophisticated neural network that controls locomotion. Due to the evolution of the brain in humans it was concluded that these networks no longer existed or functioned because they were not required due to control from higher centres. Rythmic, alternating lower limb EMG activity in the absence of supraspinal input is evidence that central pattern generation exist in the human spinal cord. The intricate spinal circuitry can integrate and interpret complex sensory input to produce functional efferent output and adapt with repetitive training Locomotor training can improve the potential for functional recovery over conventional therapy in individuals with clinically complete SCI due to repetitive alternating limb loading with appropriate sensory cues. Locomotor Training focuses on the neural plasticity of the spinal cord and has been successful for many people with acute and chronic Harkema, S.J., 2008. Plasticity of interneuronal incomplete spinal cord injury. Patients with a clinically complete spinal cord injury can generate appropriate locomotor patterns during networks of the functionally isolated human spinal stepping with assistance on a treadmill with body weight support. This indicates a significant control of locomotion can occur at the cord. Brain research reviews, 57(1), pp.255-264. level of spinal interneuronal networks. 24 September 2023 58 Activity Based Training – Locomotor Training Significant functional recovery can occur months to years after incomplete SCI with rehabilitation that involves intensive activity-based Harkema, S.J., Schmidt-Read, M., Lorenz, D.J., therapy. Significant improvements in walking distance, speed, and balance were observed when locomotor training was delivered as a Edgerton, V.R. and Behrman, A.L., 2012. Balance and standardised therapy to individuals with clinically incomplete SCI. ambulation improvements in individuals with chronic incomplete spinal cord injury using locomotor training–based rehabilitation. Archives of physical medicine and rehabilitation, 93(9), pp.1508-1517. Locomotor training, as implemented in the NRN, results in significant improvement in functional outcome measures as treatment Lorenz, D.J., Datta, S. and Harkema, S.J., 2012. sessions accumulate. Variability in patterns of recovery over time suggest that time since SCI and patient functional status at Longitudinal patterns of functional recovery in enrollment, as measured by the NRS, are important predictors of performance and recovery as measured by the targeted outcome patients with incomplete spinal cord injury receiving measures. activity-based rehabilitation. Archives of physical medicine and rehabilitation, 93(9), pp.1541-1552. The human spinal cord can use sensory information about ipsilateral limb loading to increase muscle activation even when there is no Ferris, D.P., Gordon, K.E., Beres-Jones, J.A. and limb movement. Results indicates that movement and loading in one limb can produce rhythmic muscle activity in the other limb even Harkema, S.J., 2004. Muscle activation during when it is stationary and unloaded. These findings emphasize the importance of optimizing load-related and contralateral sensory unilateral stepping occurs in the nonstepping limb of input during gait rehabilitation after SCI. humans with clinically complete spinal cord injury. Spinal cord, 42(1), p.14. Several rehabilitative interventions (i.e. active assisted motor training, spinal cord epidural stimulation, and/or administration of Roy, R.R., Harkema, S.J. and Edgerton, V.R., 2012. pharmacologic agents etc) have produced remarkable recovery in motor function. These findings indicate that the spinal cord can use Basic concepts of activity-based interventions for this sensory information to generate appropriatemotor responses without input from supraspinal centres, a property commonly improved recovery of motor function after spinal cord referred to as central pattern generation. This ability of the spinal cord reflects a level of automaticity, that is, the ability of the neural injury. Archives of physical medicine and circuitry of the spinal cord to interpret complex sensory information and to make appropriate decisions to generate successful rehabilitation, 93(9), pp.1487-1497. postural and locomotor tasks. 24 September 2023 59 Activity Based Training - Functional Electrical Stimulation (FES) • Improve strength, resistance to fatigue and contractile properties of the muscle • Enhance levels of fitness • Improve LL circulation • Attenuation of osteopenia, improve bone mass • Incomplete injuries: LL mass, isometric strength and endurance • Improved body composition:  lean mass  fat mass • promote cardiovascular and hemodynamic benefits • prevent muscle atrophy and pressures sores • reduced spasticity and neurogenic pain • Have a positive effect on psychosocial factors such as self- image and depression • 24 September 2023 60 FES Activity Based Training - Functional Electrical Stimulation (FES) • Research has shown that NMES can lead to increased muscle mass, decreased fat mass, increased cardiovascular fitness and improved bone mineral density below the level of injury for people after a spinal cord injury • The use of NMES in the cycling mode has shown to reduce the risk of cardio metabolic diseases in people with spinal cord injuries • The Victorian Spinal Cord Service (Austin Health) holds that 3 x per week of at least 30 minutes is recommended for FES lower limb cycle benefits, and that the effects of the FES cycling are more evident with increased intensity (1). • Research has shown that FES cycling increases muscle volume (2), strength (3), and endurance, and decreases metabolic risk factors (4,5). The benefits of FES cycling appear dose dependent and diminish once the exercise is discontinued (4) • 1.Walter, S. J., Sola, G. P., Sacks, J., Lucero, Y., Langbein, E. & Weaver, F. 1999. Indications for a home standing program for individuals with spinal cord injury. The journal of spinal cord medicine, 22, 152-158 2.Dolbow, D. R., Gorgey, A. S., Recio, A. C., Stiens, S. A., Curry, A. C., Sadowsky, C. L Gater, D. R., Martin, R. & Mcdonald, J. W. 2015. Activity-based restorative therapies after spinal cord injury: inter-institutional conceptions and perceptions. Aging and disease, 6, 254 3.Frotzler, A., Coupaud, S., Perret, C., Kakebeeke, T. H., Hunt, K. J., Donaldson, N. D. N. & Eser, P. 2008. High-volume FES-cycling partially reverses bone loss in people with chronic spinal cord injury. Bone, 43, 169-176. 4.Demchak, T. J., Linderman, J. K., Mysiw, W. J., Jackson, R., Suun, J. & Devor, S. T. 2005. Effects of functional electric stimulation cycle ergometry training on lower limb musculature in acute SCI individuals. Journal of sports science & medicine, 4, 263. 5.Victorian Spinal Cord Service, Austin Health; January 2009. 6.Ke Seiger, A. 2002. Effects of functional electrical stimulation training for six months on body composition and spasticity in motor complete tetraplegic spinal cord-injured individuals. J Rehabil Med, 34, 25-32. 7.Bélanger, M., Stein, R. B., Wheeler, G. D., Gordon, T. & Leduc, B. 2000. Electrical A study by Griffin et.al (2009) reported that 30 minutes of FES cycling per day, 3 times a stimulation: can it increase muscle strength and reverse osteopenia in spinal cord week, for 10 weeks significantly improved lean muscle mass, cycling power, work capacity, injured individuals? Archives of physical medicine and rehabilitation, 81, 1090-1098. endurance, glucose tolerance, insulin levels, inflammatory measures, and motor and sensory neurological function (4). 8.Griffin, L., Decker, M., Hwang, J., Wang, B., Kitchen, K., Ding, Z. & Ivy, J. 2009. Functional electrical stimulation cycling improves body composition, metabolic and 24 September 2023 61 neural factors in persons with spinal cord injury. Journal of Electromyography and Kinesiology, 19, 614-622. Recommendations for Cardiorespiratory Exercise Programming Frequency: 3-5 d/wk.​ • Consider multiple daily bouts for those with very low functional capacity (peripheral fatigue).​ Intensity: Method of intensity monitoring controversial​ • HR responses are variable depending on level of injury; in many 30-80% HRR correlates to 5085% peak VO2.​ • RPE is often used and preferred; RPE of 11 to 14 is likely best.​ Time: Follow physical activity guidelines for general population and work up to 60 min per session.​ Type: Adapted or adaptable equipment may be necessary for appropriate and safe exercise training (e.g. velcro straps, cuffed weights, toe clips, etc). ABT Principles? Recommendations for Resistance Exercise Programming Frequency: 2-3 days/week (never 2 consecutive days).​ Intensity: As tolerated.​ Volume: Initially, 2 sets of 10 reps as tolerated and progress.​ Type: Focus on strength/endurance, maintaining muscular balance, and reducing repetitive strain around the shoulder:​ • Depressors (i.e., infraspinatus, subscapularis, pectoralis major, and latissimus dorsi).​ • Scapular stabilisers (e.g., trapezius and rhomboids).​ • Internal and external rotators.​ • ABT Principles? Mental Acceptance + Goal Setting Goal Setting Managing expectation False Hope? 24 September 2023 64 Mental Acceptance + Goal Setting Goal Setting Managing expectation False Hope? https://youtu.be/ZeC4dHVMCfU 24 September 2023 65 Where things are going https://youtu.be/X9FFzWUInyA 24 September 2023 https://youtu.be/UldL951NGLQ 66 Thank-you [email protected]