Debunking Misconceptions of SCISara Galante, SPT

Division of Physical Therapy

Objectives

1. Review clinically relevant information on SCI

2. Understand the importance of white matter sparing for neuroplasticity in SCI

3. Apply research regarding prognosis when educating patients

4. Identify causes of shoulder pain in patients with SCI

5. Implement use of FES for cardiovascular, respiratory and spasticity management

6. Choose appropriate sitting balance outcome measures to justify acute rehabilitation as a discharge location

But first…

1.Get out your cell phone or laptop

2.Go to kahoot.it

3.Type in the Game PIN

4.Choose your nickname

5.Answer fast!

Does this mean I will never walk

again?

Misconception: Individuals with SCI will never be able to move

their legs again.

Patients who’s injuries were initially classified as:1

At 1 year post injury were classified as:

AIS A 69.8% - still AIS A17.3% - AIS B5.8% - AIS C7.2% - AIS D0% - AIS E

AIS B 10.0% - AIS A22.5% - still AIS B35.0% - AIS C32.5% - AIS D0% - E

AIS C 4.3% - AIS A0% - AIS B10.9% - still AIS C84.8% - AIS D0% - AIS E

AIS D 0% - AIS A1.7% - AIS B0% - AIS C89.8% - still AIS D8.5% - AIS E

Physiological Justification for Neuroplasticity2,3

After SCI, amount of white matter in cord is decreased

White matter loss is major pathological process that leads to functional disorder

Spared and regenerated white matter found 1 day post injury indicates greater motor functional recovery

Spinal shock masks potential recovery- AIS exams are

completed ASAP after injury BEFORE white matter has

regenerated

Pinprick sensation is

a large indicator of

whether motor

function will return4

Pinprick Sensation

Distal Limb Motor

Six Month Prediction5

⬇ SCIM Score

Medical Complications

Tetraplegia > Paraplegia

Delay of rehab Delay of

community reintegration

⬆ Risk of chronic occurrences

Complete Injuries (AIS A)

Higher BMI Paraplegia > Tetraplegia

Limits functional UE use

Shorter acute care length of stay and transfer to inpatient facility optimizes

long-term functional recovery

I’ll just wait until I get to rehab to do

therapy

Misconception: Initial acute PT

sessions don’t matter as much as rehab PT

sessions5

TIMING MATTERS

DOSE MATTERS• Significant gains multiple times over 120 sessions• Walking and balance gains highest >60 sessions• $82,232 cost savings/year by extending dose and

preventing rehospitalization in 4 patients

YOUR CHOICES MATTER• Average length of stay for a patient with SCI in

acute rehab is 38 days• Less time in rehab, more readmissions• Prime time for neuroplasticity in hospital

I’ve had shoulder pain since my injury

happened, what could be causing it?

Misconception: Shoulder pain

in patients with SCI is from

propelling a manual WC

81%

Tetraplegia6

VS.

Paraplegia

58%

Jain et al:

Correlation between Assistive Device and Shoulder Pain

35.4% 47.6% 33.3%46.7%

�Largely unknown�Pain is most intense with ADLs that

require force through hand (WC propulsion, transfers)6

�Theorized that subacromial impingement is large contributor to rotator cuff pathology and pain8

�Ball and socket joint implies biomechanics of shoulder was meant for multidimensional mobility, not weightbearing9

Mechanism of Injury

What could e-stim do for me?

Abdominal FES can:13

• Produce immediate cough• Improve unassisted

respiratory function• Decrease vent and trach

time• Decrease respiratory

complications

FES or TENS can have anti-spasticity effects that:9,14

• Last up to 4 hours• Can help control spasticity-

related pain• Gives incentive for patients

refusing therapy

Misconception: The only benefit of using NMES after SCI is to prevent muscle atrophy

FES 3x/wk for 2 mon increases:10,11,12

• Musculoskeletal fitness• Oxidative potential of

muscle• Exercise tolerance• Cardiovascular fitness

Sitting Balance Measures for SCI15

Function in Sitting Test (FIST)

Sitting Balance Measure (SBM)

Functional Reach (FR)

Modified Functional Reach (mFRT)

Trunk Control Test

Bibliography

1. Spiess MR, Miller RM, Rupp R et al. Conversion in AISA impairment scale during the first year after traumatic spinal cord injury. J Neurotrauma. 2009;26:2027-2036.

2. Song W, Song G, Zhao C, et al. Testing Pathological Variation of White Matter Tract in Adult Rats after Severe Spinal Cord Injury with MRI. Biomed Res. Int. 2018;2018:4068156. doi:10.1155/2018/4068156. Basso DM

3. D. M. Basso, M. S. Beattie, and J. C. Bresnahan, “Gradedhistological and locomotor outcomes after spinal cord contusion using the NYU weight-drop device versus transection,” Experimental Neurology,vol.139,no.2,pp.244–256,1996.

4. Jacobs PL, Nash MS. Exercise recommendations for individuals with spinal cord injury. Sports Med. 2004;34(11):727-751. doi:10.2165/00007256-200434110-00003.

5. Denis AR-, Feldman D, Thompson C, Mac-Thiong J-M. Prediction of functional recovery six months following traumatic spinal cord injury during acute care hospitalization. J Spinal Cord Med 2018;41(3):309-317. doi:10.1080/10790268.2017.1279818.

6. McCasland LD, Budiman-Mak E, Weaver FM, Adams E, Miskevics S. Shoulder pain in the traumatically injured spinal cord patient: evaluation of risk factors and function. J Clin Rheumatol 2006;12 (4):179-86.

7. Jain NB, Higgins LD, Katz JN, Garshick E. Association of shoulder pain with the use of mobility devices in persons with chronic spinal cord injury. Pm R 2010;2(10):896-900.

8. Morrow MM, Van Straaten MG, Murthy NS, Braman JP, Zanella E, Zhao KD. Detailed shoulder MRI findings in manual wheelchair users with shoulder pain. Biomed Res Int 2014;2014:769649.

9. Sisto SA, Druin E, Sliwinski MM. Spinal Cord Injuries: Management and Rehabilitation. St.Louis, MO: Mosby Elsevier; 2009.10. Berry HR, Kakebeeke TH, Donaldson N, Perret C, Hunt KJ. Energetics of paraplegic cycling: adaptation to 12 months of high

volume training. Technology and Health Care 2012; 20: 73-84.11. Crameri RM, Cooper P, Sinclair PJ, Bryant G, Weston A. Effect of load during electrical stimulation training in spinal cord

injury. Muscle Nerve 2004; 29: 104-11. 38. 12. Hjeltnes N, Aksnes AK, Birkeland KI, Johansen J, Lannem A, Wallberg-Henriksson H. Improved body composition after 8 wk

of electrically stimulated leg cycling in tetraplegic patients. Am J Physiol 1997; 273: R1072-9 13. McCaughey EJ, Butler JE, McBain RA, et al. Abdominal functional electrical stimulation to augment respiratory function in

spinal cord injury. Top. Spinal Cord Inj. Rehabil. 2019;25(2):105-111. doi:10.1310/sci2502-105. 14. Sivaramakrishnan A, Solomon JM, Manikandan N. Comparison of transcutaneous electrical nerve stimulation (TENS) and

functional electrical stimulation (FES) for spasticity in spinal cord injury - A pilot randomized cross-over trial. J Spinal Cord Med 2018;41(4):397-406. doi:10.1080/10790268.2017.1390930.

15. Abou L, de Freitas GR, Palandi J, Ilha J. Clinical Instruments for Measuring Unsupported Sitting Balance in Subjects with Spinal Cord Injury: A Systematic Review. Top. Spinal Cord Inj. Rehabil. 2018;24(2):177-193. doi:10.1310/sci17-00027.

Questions?

Debunking Misconceptions of SCISara Galante, SPT

Division of Physical Therapy