Week 9 Summary Neuro (PDF)

9.1 sci fxnal prognosis prognosis ais classification & neurological level: significant predictors of outcome asia motor scores and ais classifications 72 hrs after injury pts w greater potential for fxnal recovery: present w early neurological return & have incomplete injuries conflicting evidence a...

9.1 sci fxnal prognosis prognosis ais classification & neurological level: significant predictors of outcome asia motor scores and ais classifications 72 hrs after injury pts w greater potential for fxnal recovery: present w early neurological return & have incomplete injuries conflicting evidence a. age b. surgical timing c. pattern of injury d. associated trauma surgeries 12-24 or days later linked to more positive outcomes no impact in sex, use of methylpresnisolone, MOI on recovery ais level conversion pt either improves, or declines pt can go from ASI A to B conversion shows poor correlation and predictive validity w or from AIS D to C fxnal ambulation marino 2020 increase rate of conversion from complete to incomplete (motor) increased rates for pts w tetraplegia, cervical level injuries, non violent etiology, & old age improve ais level conversion: 1 yr 1999 study 1 yr follow up: 15% of pts a AIS A able to convert to higher level 71% w AIS b improved motor strength>> changed to AIS C,D or E 67 % AIS C >> AIS D pts w AIS B, C, D or E able to fully recover recovery 3 months post injury continued recovery even at 5 yr follow up present w no sensory or motor differences motor recovery pts recover at least antigravity straight to full ROM in key muscle group, 1 level below their designated ASIA level of injury 65% complete tetra able to recovery greater than 3/5 strength ^^ stat significant bc fxnal use of one motor level can drastically increase fxn if MMT 0… 25% will have greater than 3/5 by a year if MMT is 2.5/5…100% will gain if mmt 1-2.5/5…75% if pts will recover greater than or equal to 3/5 strength prognosis for ambulation van middendorp 2011 indicators for fxnal ambulation: age strength sensation to 2 levels of sc prediction rule for ambulation using age less than 65, strength and sensation to light touch in L3 or the quadriceps, strength and sensation to light touch an S1 the gastrocsoleus muscle. used a total score of 40 where age greater than 65 merits a deduction of 10 points and the best motor and light touch scores in L3 and S1 are multiplied by 2 and then summed. 85% accurate rate w 79% SN and 90% SP some researchers say prediction rule did not apply for pts w traumatic etiology in their sci fxnal outcomes by neuro level C1-4 designed for pts who have limited to no fxn below stated level zone of partial preservation: drastically alter fxnal prog keep in mind for goal setting and pt education C1-4 limited to no use in UE (depending on zone of partial preservation) possible assistance w ventilation and no hand fxn require total assist w bed mobility, transfers, self care and ADLs no fxnal ambulation potential power wc using chin, head, mouth or breath control assistance w positional changes when in power fxnal outcomes by neuro level C6 wc use tilt and recline fxns fxnal outcomes by neuro level C5 ↓ biceps volitional mvmntmore distal muscles - have wrist extensors and biceps fxnal outcomes by neuro level C7-8 use of elbow extension ↳ manipulate objects gained c7-8 key for rehab fxnal outcomes by neuro level T1-9 more core strength and sensation gained at each level - may gain further trunk control some degree of hip flexors - summary there is significant potential for motor and functional recovery post-spinal cord injury ambulation potential appears to rely heavily on strength in quadriceps and gastrocsoleus muscles, along with age 9.2 SCI rehab management mobility mobility tasks initial strategies increase upright tolerance maintain ROM minimize secondary impairments progression (PT) a. assess pts ability to roll, sit up, transfer, mobilize in a WC, stand and potentially walk base of fxnal tasks transfers: clinical practice guidelines gagnon suggests level sitting pivot transfers avoid positions of impingement of shldr trailing hand- as close to ER as possible leading hand: provide enough room for transfer and minimal IR of shldr wrist stability: fisted hand and wrist in neutral painful shldr= use as leading arm bc less impact during transfer both feet on ground strengthen shldr flexors, ADD and scapular stabilizers transfers: car 1. most demanding transfer due to seat height, lifting we in n out of car and gap bw we and seat bc of door 2. some transfer w single leg, both or none 3. pts who placed leafing limb on steering wheel during transfer tend to have higher rates of shldr pain standing rehabilitation benefits ROM increase in bone mineral density limited evidence normalize tone spasticity improve BB jnt integrity via capsule or muscle length pressure relief from sitting recommended 5x/week for 30 mins challenging to induce benefits on bone strength or other impairment more active interventions become the focus of clinical practice and investigation activity based therapy locomotor training using: a. specific tasks b. sensory cues c. stimulation ^drives neuroplasticity training needs to be repetitive and task specific w an intense frequency of 60 sessions last 1.5 hrs technologies -platform walkers -body wt support treadmill training -ceiling tracts used across multiple dx ambulation in sci important to remember activity requires high energy consumption requires extent of trunk control and ability to initiate flex of hip pts w T10-L2 require assistance of trunk musculature for independent home ambulation L3 or lower: potential for independent ambulation w/in community probably use of orthosis & depend on LE strength and coordination summary general rehabilitation for individuals with SCI will focus on basic mobility tasks and should progress to high-intensity individualized activity-based therapy 9.3 sci wheelchair mobility why? wc mobility primary mode of mobility for individuals w sci & for others who are unable to ambulate safely adequate distances. important to remember that wc use is associated w high percentages of shoulder pain. shldr pain linked to poor propulsion biomechanics, and a higher impact of forces applied to the shoulder (more pain) those w higher level SCI will have less ability to efficiently and safely perform manual wc skills and propel greater distances. pts w hemiplegia: developing shldr pain in the non-paretic arm can further limit their ability to perform activities of daily living, transfers, and participation levels. stages of wc propulsion 2 phases 1. contact phase: hand touching wheel 2. recovery phase contract phase (2 points) a. initial contact b. propulsion then release recovery phase: time period where arm is preparing for next initial contact wheelchair propulsion technique: position raquelo 2015 increasing push arch results in increases in velocity and decreased frequency of pushed (more post initial contact on hand rim) higher post force-> increases demand on shldr flexors more ant hand release angle is associated w increased peak shldr forces in all direction (more demand on ADD and IR) want to decrease forces applied to shldr increase speed and decrease reps of strokes wheelchair propulsion techniques arcing when the hand makes contact and recovers from the stroke either above or at the level of the push rim Y - associated w higher shldr forces and joint compression. single loop double loop I semi circular allow for the hand to drop below the level of the top of the wheel during the recovery period, providing some degree of shldr joint relief double loop requires less muscle activity, lower cadence and braking mvmnts wheelchair mobility: rotator cuff injuries Madasingh at al. in 2020 observed scapula-thoracic ant tilt and GH joint IR at the end of contact phase (shldr pain) highest compression forces supraspinatus tendon was most commonly compressed regardless of the propulsion technique clincal practice guidelines for wc propulsion paralyzed vets of america 2005 recs: minimize frequency and force require in repetitive mvmnts avoid extreme shldr IR appropriate sized wc w good propulsion technique appropriate seated position and stabilization power or power assisted wc for high risk pts manual mf customized and composed of high strength but light wt materials rear axle adjusted as far forward as possible w/o compromising one’s stability allow elbow to be 100-120 degrees of flex when resting on wheel clinical practice guidelines for wc propulsion update In 2015, Sawatsky upgraded recommendations to include the propulsion technique. recommended users taught proper technique for propulsion bc pts use arc or single loop technique wc training should aim for velocity similar to gait for community fxn at a speed of 1.06 meters per second, -ontact angle of 85 to 100 degrees - frequency of one stroke per second summary wheelchair propulsion and setup education and training essential for long-term users to enhance function and minimize secondary impairments 9.4 SCI rehab management shldr health shldr pain 30-70% prevalance of shldr pain and sci pain due to chronic shldr impingement/ RC tears significant impact: fxn, independence, QoL factors leading to pain not clear weakly linked to -poor strength in shldr ADD -UE for higher impact activities -poor shldr ROM at discharge risk factors for shldr pain after sci risk factors: a. older age b. higher body mass index c. use of manual wc d. poor seating posture e. improper wc setup f. decreased muscle flexibility g. imbalance and strength bw rc and scapular stabilization m’s shldr pain: significant muscles pec major supraspinous deltoids lats target strength and endurance training of these muscles research sawatsky 2015 -education for pts and caregivers on risk of UE pain and injury, prevention, tx options and maintaining fitness clinicians regularly assess transfer, wc propulsion techniques, adaptive equipment and pts health status recommendations -mods to minimizes frequency, force required, extreme jnt positions in various tasks exercise programs incorporate flexibility and strengthening exercise to UE wc considerations stand w those w and w/o sci’s differences -resting shldr or hand is less likely/impossible for sci pts resting night splints for carpal tunnel home modifications/adaptive equipment temporary admission to facility/caregiver (maybe) pts should consider using power wc for fxnal mobility to decrease lifelong repetitive stress stomps study mulroy 2011 (randomized study) stomps: strengthening and optimal mvmnts for painful shldrs pts in study: paraplegia and shldr pain 12 wk home program for shldr strengthening and stretching exercises optimize transfers, pressure release and wc propulsion other group -hypertrophy training of shldr flex in scapular plane groups had significant improved levels of pain improvements: strength and QoL stomps study: education pts provided recommendations for transfers and wc propulsion endurance training: shldr flexors in scaption plane & retractors resistance training: shldr adductors & ER summary shldr pain is a common secondary condition in sci that pt must address to optimize fxn and participation 9.5 sci rehab management secondary skeletal conditions heterotopic ossification :formation of mature lamellar bone outside the skeletal system (around jnts usually) incidence: 10-53% - 2-3 wks post injury below level of injury highest incidence in hip>>knees>>elbows>>shldrs limits jnt ROM pain hinder fxnal mobility rehab process ex: hip: loss of sitting and balance -leads to decreased ability to to perform transfers, dress and self care activities clinical presentation sensation: jnt/muscle pain w/o sensation: sudden decrease in PROM. tissue swelling, redness or heat @ jnt, low grade fevers sudden decrease in ROM: VERY NOTICABLE risk and associated factors for heterotopic ossification yolcu 2020 (SR and MA) risk factors for developing HO maile asia a complete pneunomia pressure ulcers smoking urinary tract infections spasticity 9x more at risk management of heterotopic ossification -having UTI: most impactful factor a. prophylactics use of NSAIDs (early) -less than 3 wks after sci common meds: rofecoxib or indomethacin -bisphosphonates: to slow/halt progression most effective: 3-6 wks after sci monitor: ROM avoid rigorous stretch to affected jnt continue gentle stretches to minimize continued bone formation or loss of ROM pathophysiology of bone loss in sci 2nd complication: osteoporosis or osteopenia causes decreased bone density (multifactorial) disuse of LE limited mobility poor nutrition ^ factors due to autonomic. dysregulation and innervation no connection bw level of injury DVT tracheostomy changes changes in hormon metabolic levels disordered vasoregulation predispose the skeletal system towards an imbalance between osteoclast and osteoblast activity bone loss after sci high calcium levels level 4-6 months= high bone resorption acute & subacute: 1% bone loss/wk bone loss 1-3 yrs after injury -levels range 25-50% below age match norms at hip and knee -bones look like a 70 yo female density levels= high risk of fractures negative sequelae of limited mobility, pain and decrease fxn osteoporosis and sci target trabecular bone— rather than cortical bone -significant decreased bone density in lower and upper 1/3 of femur and upper 1/3 of tibia sublesional oestoporosis (SLOP) cortical bone loss more evident management of bone loss in sci sci pts= high risk of fragility fx fragility fx fx occurring spontaneously or following minor trauma 1-4% of sci population have fx w/in given yr typically affect proc tibia or distal femur delayed healing post fx and increase 5 yr mortality rate injury: contribute to limited mobility, independence w daily activities and overall participation summary bone loss and heterotopic ossification are more common msk complications for individuals w sci PT role is to educate, monitor, prevent, and treat both conditions legs 9.6 SCI Rehab Management Secondary Conditions GI most significant hindrance in SCI 32% world wide 36% developing one pressure ulcer in acute/rehab 17.7% rehospitalized within a year of dx 37.4% hospitalized w/in 20 yrs of dx acute care locations: calcaneus, occipital, sacral regions rehab setting: ischium most common can delay recovery, result in hospitalization, infxn, death m glutes more prone to pressure ulcers AIS A AIS B ASIA A: 4.5x more likely further risk prior hx of pressure ulcer pneumonia pulmonary conditions (including mechanical vent) incontinence * age, gender, steroid use in acute phase, diabetes, urinary infxns dont impact development of pressure ulcers * male w/ low edu or longer time since injury, DVT, pneumonia or hx of pressure ulcers = risk factors acute phase pressure relief is key minimize sitting in bed in reclined pos greater than 90 degrees fwd lean over knees most effective at relieving ischial pressure followed by fwd diagonal lean reclining can add shear forces leading to ulcers push up method: poor compliance = ineffective!! - 1 min every 15 min of siting for 45 sec to 1 min education best! (risk, self mod, reduction of risks) Interventions fxnal mob training, skin checks, weight shift, exercise, jt range, glute EMS Neurogenic bladder in SCI: autonomic n signaling abnormal control of bladder resulting in urinary dysfxn affects 80% trauma SCI pts What happens poor voiding incontinence UTI retro flow kidney failure Impacts length of hospitalization fxnal recovery mental & physical QOL How to asses bowel and bladder control in SCI 1. Catheter to manage urinary output while stabilizing injury bc bladder atonic 2. voluntary anal contraction consistently checked to remove catheter 3. trial voiding with bladder scans 4. determine if option or not If cant void voluntarily clean intermittent catheterization (CIC) - medically stable pt - urinary outputs stabilized less than 1.5 liters per day & can be done indep or caregiver - cost effective, improves QOL, better than the other one above Hydrophilic coated catheters decreases of UTI & hematuria minimize infection!! - wash hands, genital area, sterilized supplies, lube pts w/neurogenic bladder drugs anticholinergic for urinary incontinence & involuntary detrusor contraction neuropathic pain in SCI = common direct damage to nervous system itself typically described as burning, shooting pain, skin can be numb, tingling, extremely sensitive to light touch most common 37% below level pain 42% at level Factors increasing chances of neuropathic pain psychological distress older age light touch vs prin prick discrepancy allodynia more likely to develop pain Summary bladder dysfxn, pressure ulcers, and neuropathic pain common complications for individuals w/ sci PT role varies, education most important 9.7 SCI rehab management: cardiometabolic health & health promotion remember: SCI has immediate impact on autonomic fxn ↓ HDL choles higher chance of hypercholestremia orthostatic hypotension, autonomic dysrefflexia 20% higher 5 year incidence of cardiometabolic morbidity in SCI dysarhymias heart failure atherosclerosis nonalcoholic fatty liver disease chronic kidney disease type 2 diabetes hypercholestorlemia hypertension cardiometabolic disease leading death after 1 yr of injury secondary lifestyle and reduced activity makes it worse ↑ in order to diagnose w/ CMD 3 or more of abdominal obesity insulin resistance dyslipedmia high density lipoproteins development = combo of cardiovascular, renal, metabolic, prothrombotic, and inflammatory risk aka energy expenditure unbalance w/ daily energy intake = E cardiometabolic syndrome management multidisciplinary approach - nutrition, PT, pharmacological, bariatric surgery caloric assesment to see how much energy used DASH helpful pharmacological avoid prescription of herbals, nutraceuticals, or others for weight management consider anti hyperglycemia medications (metformin) anti hypertensive medication (manage diabetes, HTN, C hypercholesterolemia) bariatric last resort efficacy of exercise in SCI for cardiometabolic health PA improve all of these in younger people and older people - but just not as much! - exercise has low impact on bone health - - I - know this chart!!! decreases risk of heart disease and diabetes exercises · - arm cranking/ergometry wc ergometry wc propulsion hand cycling FES cycling/rowing summary cardiometabolic dysfxn long term impact on health and wellness in individuals w/ sci 9.8 SCI advances in research neuro modulation w/ brain computer interfaces implanted electroencephalopathy / EEG readings of sensory motor cortex (UE/LE mvmt) during pt tactile or visual cues to intact sensory segments - increases correlation of mvmt w/ sensory cues transcranial magnetic stim to enhance cortical signaling How it works EEG reads computer sends signal EMS for muscle contraction in response pt coordinates what want to do regardless if can voluntary do that motion triggers stepping w/ 8 electrodes on legs tactic cues on forearms graded dependent on leg mvmt and visual feedback helps build connections!! increased neuroplasticity: sensation, muscle strength, cv fxn, gait SC stim using FES/NMES high freq = 10 kilohertz transmitting up to 100 milliamps of current typical freq for non SCI: 20-80 Hz intraspinal stim - directly implanted in SC - direct activation of motor neurons or ventral root axons suprathreshold or subthreshold stimulation with lil machine on back E subthreshold stim (L) stim strong enough for excitation potentials above threshold & initiate involuntary mvmts in muscles suprathreshold stim (R) raise potential of excitation in motor neurons to close gap voluntary signals needed to raise potential to activate voluntary motion can strengthen connection b/w proprioceptive afferent & motor neurons reorganize appropriate spinal neurons or neurons above level of injury reorganize output of spinal neurons in brain via reticulospinal tract motor system more likely to active motor control for neuroplasticity and fxnal recovery stem cell therapy - invasive injected intraspinal at level of injury stem cells & growth factors & biomaterial scaffolding (hydrogel) for cell differentiation survival and engaftment induce neuroplasticity/ connect severed signaling stem cell sites embryonic: differentiate into dif types of cells in body, most adaptable SCI: neurostem & progenitor cells possible to use (in sc or adult brain) stem cells of skin (astrocytes, oligodendrocytes, neurons): support nervous system adipose tissue: develop interneural cells Potential mechanisms for stem cell therapy facilitation of axon regeneration/sprouting replacing/transplanting cells promoting remyelination reduction of cavitation/gliosis inducing new blood supply facilitate expression of neutrophils & cytokines evidence in humans 13 individuals with stem cells higher rate of conversion with Asia A, B, C compared to those who didn’t do stem cell summary research efforts on the use of stem cells and neuromodulation using brain computer interfaces and sc stim have potential in enhancing recovery from SCI 9.9 DME & orthotics introduction ankle foot orthotics training AFO in hospital adjustable to size, ROM, strength of assistance needed hard for long term use post leaf spring ankle (R): most common for foot clearance, no support during stance, PF tone may pop out ankle foot orthosis (L) rigid custom more assist w/ foot drop/clearance/stability in stance bc thick post shank rigid so no DF or tibial advancement in stance phase weight can limit swing limb advancement (R) Hinged custom & adjust at ankle control foot clearance, stab in stance, controlled fwd progression during gait more expensive dorsiblock - post jt spring pushed foot into DF and help w/ foot clearance during swing dorsiblock important in SL stance to prevent excessive tibial advancement/ knee collapse plantarstop - ant jt limit excessive PF in stance and hyper extension of knee if impair proprioception limits ROM into PF during pre - swing double adjustable ankle jt - trial orthotics ant channel: dorsiblock post channel: spring provides dorsiassist or rigid PF block knee ankle foot orthosis - KFO improved control of knee stability & stance & lat hip stab proves ankle knee jt stab strap across knee prevents knee flexion during stance rely more on hip/trunk flexion during gait knee ankle foot orthosis - training appropriateness can control degree of ankle ROM prove dorsi assist knee bilateral struts prevent knee flexion in stance have to unlock before sitting down alters gait in swing phase increase LLD & decreased knee flexion in swing hip knee ankle foot orthosis stab at hip unilaterally more expensive rigid gait orthosis - RGO harder to work with, donning/doffing fxnal gait speed/distance limited opportunity to stand & walk w/ bilateral LE impairments through hip CL hip ext CL hip flexion swing initiated by person knee and ankles rigid bc voluntary control lacking have to be able to independently intiate some hip flexion but have energy depletion Summary appropriate adjustments to orthosis at the ankle jt facilitate improved gait kinematics and kinetic LE orthosis facilitate fxn and mob based on extend of impairment requiring proper prescription 9.10 DME & Orthotic prescription not enough DF in terminal stance = hip ER, early knee flexion/ early heel rise, less use of stretch of PF for propelling in swing too much DF = decrease stab in terminal stance increasing muscle demand on hip/knee extensors, limits forward progression in foot rockers not enough assistance into DF = not enough foot clearance in swing, excessive PF can make clearance worse, hyperextend knee, or extension thrust in stance (mid to terminal) too much DF/limited PF = instability in loading response pushing into mid stance before muscles ready Lat decreased flex at knee = decreased foot clearance in swing, med rough transition from stance/swing not enough ext ROM = instability during loading response in stance, increased demand on knee/hip extensors med/lat struts = stability, too long = compression/ discomfort in groin LLD on side that has orthosis bc hardware and limited knee flexion ROM causing gait dev, may need to fix orthosis or fix shoe on CL side considerations uni/bi don/doff independently hand fxn/available ROM cognitively use device finances skin breakdown compliance disease breakdown weight of orthosis to muscle strength appearance motivation/goal Physical Evaluation for orthosis higher SCI: normally more motivation for gait training - eventually go WC bc energy cost gait obs strength of LE to determine support needed ROM presence/extent of tone & spasticity sensation endurance don/doff Fitting Guidelines: done by orthotist check for skin breakdown after use check for pressure points & add pads (peroneal n) remove insert of shoes or half size increase in size ortho knee jt bar must line up 2 inch below lat strut - decreases irritation of adductor/groin rot lat upright bar slightly below GT RLA recommendations for orthotic assessment decision making and prescription (ROADMAP) AFO vs KFO - strength of quads - KFO if quads less than 3+/5 RLA ROADMAP, KAFO algorithm pt 3+/5 or less use bilateral KFO/RGO adapt more if needed to ROM UNI KFO: depends on proprioception of knee, ROM/hyperextension MMT 4 or higher BERG less than 43, excessive ankle spas, contracture, proprioception = locked/rigid AFO if these aren’t present = articulating jt to help w/ DF Dorsiassist/dorsiblock = pt 4/5 or less of DF/PF Research Evidence 1B evidence for fixing foot drop 4 evidence enable slow walking but not fxnal speed injuries t4-t11 level 4 evidence of FES for walking speed/distance high evidence of FES for foot drop, AFO use in sc for meaningful ambulation gains not as good for higher level injuries higher at overall non compliance w/ KFO summary orthotics can alter kinematics, kinetics, and energy cost of gait effective use of orthotics is reliant on individual goals, proper firm and individual capabilities 9.11 DME orthotics CPG research 2021 johnston clinical practice guidelines for the use of ankle foot orthoses and fxnal electrical stimulation recommendations focus on individuals w acute or chronic post-stroke hemiplegia can apply to other pt pops that present w foot drop effects of AFO usage academy of neurological PT 2021 compare effects of an orthosis on a gait pattern immediate effect when a change is noted bw testing w/o and AFO and FES followed by immediate testing after donning off AFO and FES training effect indicated change noted w use of an AFO or FES followed by a period of of use or training then reset using the technology improvement after training w/o afo or fes combines effect if both immediate and training on walking w use of afo or device recommendations: gait speed and endurance for pts post stroke those w acute hemiplegia and moderate or chronic hemiplegia to use an afo or fes to improve gait speed and walking endurance authors state: afo or fes during acute phase result in faster increases in gait participation, and decreased length of hospitalization increase community and work participation, decrease the need for gait aid and improve cardiovascular health recommendations: mobility and balance dynamic balance good for those w decreased LE motor control for walking on variable surfaces: transfers, stairs= increased safety, independence w exercise participation and discharge home decrease falls improve gait kinematics improve appropriate dynamic balanced reactions both interventions have improved walking economy w better foot placement for loading response recommendations: spasticity and muscle activation a. decreased plantar flexor spasticity to impact gait kinematics b. support use to impact muscle activation of ant tib and gastroc and soleus while walking c. moderate recs are made for both to improve motor control and muscle activation recommendations: gait kinematics and QOL albeit weak: use of interventions can improve gait kinematics mod eveidence for their ability to improve QoL for pts w foot drop which afo to use? PTs help determine which afo is best for pt daryl or in 2018 (systematic review) concluded that all afros included in their study had a positive impact on ankle kinematics in first rocker or heel and swing phases no or negative impact on knee kinematics in swing, hip kins and 3rd rocker fxn or over metatarsals afros minimize push off or alter load transfer during late stance concluded that articulating AFOs w PF stops or oil damper are able to address foot drop and pre- swing articulating joints allow for a more normal ROM at the ankle thru out the gait cycle, while also facilitating kinematics better than non-articulating AFOs. foot drop to improve foot clearance during swing. summary usage of an AFO can have a therapeutic, immediate, and/or training effect extensive evidence supports AFO usage, particularly for an individual with hemiparesis 9.12 DME: WC Cushions important for those w/ neurological conditions purpose: postural support, fxn, balance pressure redist away from ischial tubes & sacrum toward larger contact area foam structure/stab adjust to body sizes lightweight, cheap, easy to maintain, dif thickness poor temp regulation/moisture, least effective at pressure redistribution, freq replacement cant wash least medical justification air cushions most effective at pressure redistribution dual compartments for altering lat, ant, post air pressure shock absorption, expensive, pumping a lot over pump = use;es poor trunk posture/sitting balance: not stable for trunk most pop gel based improved thermo/moisture reg better redistribution than foam stab/pressure redistribution Hybrid Cushions stab of foam at base of cushion, gel under ischial tubs pressure redistribution remember: no single cushion better than other multiple factors like cost, stab, pressure red, shear forces, temp need to be considered use pressure mapping to help decide WC setup and appropriate cushion help w/ alignment A: want - shoulders symmetrical, 3 finger room from iliac crest to lower rib B: pelvic obliquely - pelvis higher than other, asym shldr, angling of sternum, one side has more room than other for iliac crest/rib C: pelvic rotation causing malalignment of trunk, leg, shldr end goal of WC set up poor seating - excessive hip IR and add - PPT - pelvic obliquity leading to scoliosis - thoracic kyphosis: insufficient trunk support - need for increased knee flexion & cerv spine decreasing visual field poor postural alignment - postural pain and faulty WC propulsion can occur - leading to shldr pain, poor QOL, limiting participation Summary WC cushions have dif advantages/disadvantages end goal = optimize pt well being/fxn 9.13 Durable Medical Equipment - Wheelchair Components Wheelchair Base - 3 Main Bases - Manual - Lighter & cheaper - Provide more mobility & accessibility - More demands by the user - Different Options to consider - Folding capacity, removable wheels, type & weight of material composition - Power Assist - Possible decrease in risk in UE pathology - Can be costly, heavier, & more maintenance - Fully Powered - Can support ventilator use - Can be adapted in controls for users w/ limited motion - Heavy & require significant maintenance - Limits in community access/participation - Seating frame is the most bulk - Can be folded in different ways to allow for easy removal of wheels for transport Wheelchair Components Seating Frame - Standard initial setup: Sling Back - Doesn’t provide enough trunk support - Cushioned hard backs for increased trunk support - Can be contoured to increase lateral trunk support - More expensive & can add more weight to chair, making it harder to transport the chair - Can come with support - High support, typically towards neck - Low support, lower lumbar region Sitting Surface - Seating surface typically sling material, can have hard back - Standard height for most chairs - Hemi-height, slightly lower height surface - Beneficial for those who use legs for propulsion - Custom ordered wheelchairs can adjust height for ideal transfers & accommodate different leg lengths - Depth needs to provide adequate support surface in sitting & pressure distribution - Not too long, or it will compromise posterior aspect of the knee - Width should accommodate persons size & clothing they wear - Too wide will increase weight & width making doorways less accessible - Angle of seating surface is called dump - Acute angles increases individuals stability while sitting but decrease stability when transferring - Usually find acute angles in sport wheelchairs Positional Changes - Recline - Can recline to relieve pressure or rest w/o getting out of wheelchair - Power & high back chairs have ability to recline - Tilt in space - Whole seating & back surface are tilted to keep same relative angle of hip flex - Chairs that recline are not designed for self propulsion due to heavier weight - Wheel axle is typically more posterior Wheel Placement - Important for stability, turning radius, & propulsion - Mid-Wheel - High end independent users - Mid-wheel position is easier to pop into wheelie & improve propulsion dynamics - Rear-Wheel - More for stability - Front-wheel - Common in power chairs - Decreases turning radius Wheelchair Components Wheels - Wheel size plays important role in propulsion efficiency & ability to cross various surfaces - Caster Wheels - Larger wheels recommended for uneven terrain - Wheel Material - Pneumatic - Filled with air, lighter w/ higher shock absorption - More prone to damage & need for maintenance - Solid-Insert Wheels - Middle ground w/ weight & maintenance - Solid - Camber - Wheels placed at an angle - Increases BoS, improves stability & brings top of wheel closer for improved propulsion dynamics Accessories - Hand Rims - Different or no push rims can be placed on wheels, accommodates hand/grasping function - Reduce overall width of chair - Arm Rests - Allows for removal or swing away - Foot Rests - Can be angled to decrease turning radius - Can be solid or swing away to make transfers easier - Brakes - Can have different locations - Accessories - Anti-tippers - High level power chairs may have capacity to assist people to standing or navigating stairs Power Wheelchair Controls - Types of Controls - Hand - Arm - Head/Facial - Sip & puff controls (Using breath) - Different controls are available based on finger, wrist, elbow, or shoulder function - Can be gauged by the degree of force someone can apply Seating Unit - Provides stable base for sitting posture, trunk stability, proper propulsion technique - Seat angle orients pelvis - Backrest angle helps trunk alignment - Use of recline increases stability & pressure relief - Use of dump, or angled, seat increases stability in high energy activities 9.14 Durable Medical Equipment - Wheelchair Prescription Wheelchair Prescription - End goal is to provide stable base for propulsion & participation in functional activities - Select appropriate surface to decrease risk of skin breakdown - Adjust seating for optimal trunk & pelvic alignment, lateral lean, or sliding out - Make accommodations to prevent deformity & pathology associated w/ long term sitting Assessment - Physical - Can the person mobilize the chair, control it, propel it, transfer to & from it - Is adequate support provided - Is it for dependent mobility or need to lift it on their own - Is additional equipment needed - Cognitive - Does the person know how to use the chair, set brakes, or use controls - Functional/Participation Considerations for Power Function - To determine options available in power seating - Table is used to justify the need for tilted space, power recline, leg lifting, seat raise - Table of things needed to be considered Power vs. Power-Assist > - Wheelchair Measurements - Focus on seat width & depth in this class - Seat Width - 1-2 inches wider than persons width - Taken at point of greater trochanters - Seat Depth - 2 in shorter than a distance taken - Back of soft tissue to posterior knee - This helps to not compress blood flow & nerves - Seat Height - Based on various measurements - Depends on trunk or neck support needed 9.15 FES for LE: Intro Mechanisms of FES - Has multiple impact on CNS to improve signaling from brain to periphery - Along w/ functional movement, it guides: - Neuroplasticity - Reactivates damaged neural pathways - Activate central pattern generators - E-Stim complements & enhances voluntary movement - OR replaces absent signals from the brain - FES relies on intact peripheral nerve to stimulate muscle activation - UMN/Mixed Presentation - Will likely have intact peripheral nerve - LMN Presentation - Injury in cauda equina - Nerves usually severed or damaged significantly, may not respond to FES FES Triggers - External Triggers - Commercial devices use external - Examples: Buttons, Heel Switches, Combo of gyroscopes & accelerometers - Internal Triggers - Possible w/ electromyography - EMG triggered FES - Only applied in full when muscle activity is noted - EMG controlled FES - Allows for fine tuning of muscle response by triggering only amount of E-Stim needed FES Parameters to Tibialis Anterior - Typically target Tib Ant due to its role in forwarding advancement during gait - Can also stimulate the fibular or perineal nerve - Parameters to think about - Stimulation frequency - Wave Form - Pulse Width - Purpose or Function - Use asymmetric bipolar waveform Trigger Use - To address foot drop, use external triggers for FES - EX: Heel Switches, handheld triggers - Trigger can be used manually by therapist or patient, to time muscle activation w/ swing - Heel Switch Trigger FES to Quadriceps - Can activate during STS - Can activate during gait from loading response through mid stance FES to Glute Max - Used less often, targets hip extensors only - Used to facilitate STS & during gait (Loading response - mid stance) - Should require or be more beneficial to have symmetric bipolar waveform - Due to large muscle belly - Equal amounts of charge gathered under each electrode General Parameters - Pulse Wave: Biphasic - Symmetric vs. Asymmetric varies on size of muscle being targeted - Pulse Width - 500-1000 us - (less muscle fatigue w/ low frequency) - Endurance - 50-100 us - (Recruit more muscle fibers, generate larger joint torque) - Strength - Frequency Ranges - 20-50 Hz - Lower frequency prevents muscle fatigue, generates lower forces - Amplitude - 0-100 mA - Will rely on the muscle response FES - Has open door to target any muscle that requires activity during patient targeted goal - Can be creative in use of POC to induce neuroplasticity 9.16 FES for LE Electrical Stimulation for AFO - Use of E-Stim & movement sensors used in variety of brands to address foot drop - Purpose is to target perineal nerve or target muscles to counter foot drop - Typically worn like a cuff around proximal tibia - E-Stim is triggered by accelerometer or gyroscopes - Combo of these can be programmed to sense degree of tilt of the tibia or angular motion as gait happens - Does not provide any increase stability during stance phases FES Rowing - Allows for multi muscle timed stimulation for bilateral leg movements in repeated motions - Can be used for patients w/ SCI or other pathologies - Expands exercise possibilities for people w/ disabilities - Look at long video in the lecture FES Cycling: Stationary - Has become more available to patients w/ SCI - Options - Patients in supine - A seated step machine or cycling version - All allow for stimulation of hamstrings, quads, glutes, tib ant, gastroc FES Cycling - Berkel Bike - Allows for community mobility - Increases potential activity & participation - Gives blood supply and allows muscles to be worked FES Gait - Can be combined w/ exoskeleton or robotic device if needed - Can increase neuroplasticity & motor strength - Lokomat - IDK WHY THE PHOTO IS FADED - Demonstrated on video in lecture (15 min) FES in Stroke Rehabilitation - 2020 Systematic review & meta-analysis of 7 randomized controlled trials of FES cycling - 273 stroke patients - FES cycling demonstrates significant effects on walking, sitting, & work produced by paretic leg - Comparable to conventional training - 2019 systemic review & meta-analysis of 14 trials of FES cycling - Positive benefits on gait speed, endurance, balance - Shown to improve aerobic capacity & participation - Demonstrates capacity to help people recover post-stroke - Can also address health promotion & wellness FES in MS Rehabilitation - 2020 systemic review & meta analysis included 9 trials on FES cycling - May reduce risks of cardiovascular disease & spasticity - Need more impactful conclusions - 2020 4 small trials on FES cycling - Holds promising benefits on cognition, pain, & fatigue FES on SCI Rehabilitation - Review in 2021 including 92 studies on FES cycling - Most were level 3 or 4 evidence - Moderate to high certainty of positive impact on muscle health - Low certainty of positive impact on power output & aerobic fitness - FES Rowing - 24 studies for improved cardiovascular performance by changes in peak Vo2 & reduced bone density loss - Functional mobility (Level 4 evidence) - FES improves walking distance or velocity - Level 1b evidence for combo of FES & treadmill training Exam 25 , 6, 9, 10(vestib only)