Shoulder Preservation And Locomotor Training After SCI Flashcards
(34 cards)
Incidence and rationale behind shoulder pain in SCI
- 70% by 20 years post injury
- weight-bearing joint now for transfers, pressure relief, wheelchair mobility
- partial innervation
- inability to rest
- reaching overhead
Risk factors for shoulder pain post SCI
- Increased time since injury
- Older age
- Higher level of injury
Specific structures involved with subacromial impingement
- supraspinatus
- long head of biceps
- bursae
Poor scapular stability/RTC strength leading to subacromial impingement
Muscle imbalances between overactivation of upper trap and decreased activation of serratus anterior
Anatomical abnormalities contributing to subacromial impingement
- flat vs curved vs hooked acromion (cannot change)
- posterior capsule and pec minor tightness
Abnormal kinematics contributing to subacromial impingement
- Excess scapular anterior tipping, downward rotation and internal rotation -> focus on opposite; external rotation, upward rotation and posterior tipping of scapula
- GH internal rotation
STOMPS stretching exercises
Pec
Posterior capsule
Upper traps
STOMPS hypertrophy (more weight less reps) and endurance exercises (less weight more reps)
- Retraction
- External rotation
-Serratus anterior/lats - Abduction
Modifications to seating system to ensure good postural alignment
- “Dump” the chair for improved trunk stability (moving back of w/c posterior)
- Solid foot plate/rigid frame
STOMPS trial results
- Strength gains
- Reduction in shoulder pain
- Improved QOL
Educations for shoulder preservation
- teach/modify transfer techniques and wheelchair propulsion to maximize shoulder health
- prescribe stretching and strengthening exercises to optimize scapular and GH kinematics and muscle activation
- when scapula is not fully innervated; modify program
- if pain persists and not remediated through intervention, recommend patient consider power mobility
Functional ambulation requires
- Adequate muscle strength
- Postural alignment
- Range of motion
- Cardiovascular endurance
Walking outcome measures
- walking index for SCI
- spinal cord independence measure
Pin prick intact indicates
Better chance of walking again bc ALS tract closer to motor tract in spinal cord vs light touch (DCML)
- Especially for AIS B if intact
CPR for indoor walking
- sensation at S1 (pin prick or light touch)
- motor innervation at L3 (any)
- younger than 65 years old
Have better chance at walking
Big predictor of outdoor walking
- big toe motor innervation L5
- L3 motor innervation
- S1 sensation
A single dermatome CPR for independent walking 1 year after SCI; indoor and outdoor
S1 lateral malleolus
Central pattern generators
- Intrinsic circuits that can produce rhythmic motor patterns without descending inputs
Ie. Breathing, walking in other animals; flying , swimming
It is the intrinsic capacity of the spinal cord to respond to sensory input with a motor output
- more of a reflexive pattern (does not need to go back to the brain)
Sensory input for triggering of central pattern generators
- Hip extension angle (stretch); important in the initiation of swing, muscle spindle response to hip flexor stretch
- Ankle plantarflexion load; amplitude of extensor muscle activation directly related to weight bearing, GTOs sense load -> increase extensor activation in stance phase for push-off
Locomotor training using recovery approach
- Treadmill training with BWS and manual facilitation
- Transition to over ground training
- Community reintegration; uses sensory experience of walking to guide walking recovery
Note: treadmill not the dominant critical component but provides consisted and controlled environment, task specific, ability for intense practice
The four principles to locomotor training
- Provide maximal WB through LE; minimize UE WB, use harness to provide body weight assistance but only what is required to maintain upright position
- Provide sensory cues consistent w/ task of walking; flexors during swing (hand on hamstring), extensors during stance (hand on patellar tendon)
- Optimal kinematics; head, trunk, pelvis, LE alignment, ensure adequate hip extension at terminal stance
- Minimize compensatory strategies for movement; goal is to recover pre-injury movmt patterns, reduce bracing and UE support
Translation from locomotor training to overground training
- critical!!
- challenge new skills
- reinforce new patterns
- informative for goal setting
Intensity for locomotor training
- Moderate to high recommended; 60-85% age predicted HR max, RPE >15, hit target intensities to promote neuroplasticity
- Technique and kinematics less important
- Minimize therapist support or body weight assistance overtime
- If person can walk independently, do not provide assistance *
Task specificity and gait training
- if you want to get better at walking… walk
- high reps, high speed
- VR in conjunction with walking has benefits
- strength training can be considered to improve walking speed or distance
- LE strength correlated with walking ability
- Activity dependent neuroplasticity in spinal cord exists *
