SPINAL CORD DISABILITIES

By Misty Hooper

Overview Definition Epidemiology Clinical Aspects Treatment Functional Assessment Effect on Exercise Effect of Medication on Exercise Exercise Testing Exercise Prescription Summary and Conclusion

Spinal Cord Disabilities are damage or trauma to the spinal cord that results in a loss or impaired function causing reduced mobility or feeling.

What are Spinal Cord Disabilities?

What are Spinal Cord Disabilities?

What are the types of Spinal Cord Disabilities?

Paraplegia is an impairment or sensory function of the lower extremities. (arms are not affected)

Tetraplegia, also known as quadriplegia, is paralysis caused by illness or injury that results in the partial or total loss of use of all the limbs and torso.

Epidemiology: Incidence & Prevalence

According to the CDC, about 200,000 people are currently living with Spinal Cord Injuries in the United States. 12,000 to 20,000 new cases are estimated to occur annually.

A regional study conducted in 2005 found that most new Spinal Cord Injury cases occur in persons younger than 30 years old, and an estimated 50-70% occur in those aged 15-35 years old.

Epidemiology: Incidence & Prevalence

Causes of Spinal Cord Injuries: Motor Vehicle Accidents-46%

According to the CDC, use of a seatbelt can reduce the odds of a spinal cord injury by 60%. Use of a seatbelt and airbag combined can reduce the odds of injury by 80%.

Falls-22% Violence-16% Sports-12%

Clinical Aspects

Symptoms Symptoms of spinal cord injury after an accident may include: Extreme back pain or pressure in the

neck, head or back Weakness, incoordination or paralysis

in any part of the body Numbness, tingling or loss of sensation

in hands, fingers, feet or toes Loss of bladder or bowel control Difficulty with balance or walking Impaired breathing after injury Oddly positioned or twisted neck or

back

Clinical Aspects

Laboratory Testing, Diagnosis & Evaluation

Conducted by a healthcare professional Clinic, lab, hospital, doctor’s office

Orthopedic Examination Evaluation of Airway, Breathing,

Circulation Level of consciousness Inspection beginning from the top of the

head until the bottom of the toes. Palpation of the spine from the skull to

the coccyx for areas of localized tenderness.

Clinical Aspects

Laboratory Testing, Diagnosis & Evaluation

Neurological Evaluation Neurological status must be

evaluated until the spinal shock period is absent which occurs 48 hours after injury. Testing includes sensation of pain and or light touch, strength of upper and lower extremity, deep tendon reflexes, plantar reflexes, pathologic reflexes.

Clinical Aspects

Laboratory Testing, Diagnosis & Evaluation

Emergency Diagnostic Tests X-Rays

X-rays reveal vertebral problems, tumors, fractures, or degenerative changes in the spine.

Computerized Tomography (CT) scan Uses computers to form a series of cross-

sectional images that can define bone, disk, and other problems.

Magnetic Resonance Imaging (MRI) Helpful for looking at the spinal cord and

identifying herniated disks, blood clots or other masses that may be compressing the spinal cord.

Myelography A special dye is injected into your spinal cord

to look for herniated disks or other lesions.

Clinical Aspects

Complications

Severity of Spinal Cord Injuries can lead to complications or can result it: Decubitus ulcers Osteoporosis Fractures Restriction in respiratory function

which can lead to pneumonia, atelectasis (collapse of a lung), aspiration

Spasticity Autonomic dysreflexia (at or above

T6 level) Deep Vein Thrombosis Cardiovascular disease

Treatment: Quadriplegia and Paraplegia Trauma Care• Immobilization to prevent further injury• Stabilization of heart rate, blood pressure, and condition• Possible intubation to assist breathing • Imaging tests to determine extent of injury • Surgery may be needed to relieve pressure on the spine from

bone fragments or foreign objects. No form of surgery can repair the damaged nerves of the spinal cord.

• Nerve damage caused by initial injury has a tendency to spread. Reasons for the spreading are not completely understood but it is related to spreading inflammation as blood circulation decreases and blood pressure drops. Inflammation causes nerve cells not directly in the injured area to die. A powerful corticosteroid can help prevent the spread of this damage if given within eight hours of the original injury.

Treatment: Quadriplegia Rehabilitation

Consists of training to learn to deal with new limitations Functional neuromuscular stimulation (FNS) stimulates

the intact peripheral nerves so that the paralyzed muscles will contract. This allows patients to ride a stationary bicycle to improve muscle and function to prevent the muscles from atrophying.

Tendon transfer is a surgery that transfers a nonessential muscle with nerve function to the shoulder or arm to help restore function.

Implantable FNS system to help regain use of hands. The shoulder’s position controls the stimulation to the hand’s nerves, allowing the individual to pick up objects at will.

Functional Assessment Functional assessment is a

method for describing abilities and activities in order to measure an individual’s use of the variety of skills included in performing the tasks necessary to daily living, vocational pursuits, social interaction, leisure activities, and other required behaviors.

Functional Assessment Functional Independence

Measure Self Care Sphincter Control Transfers Locomotion Communication Social Cognition

Barthel Index Feeding Bladder Bathing Toilet Transfer Grooming Transfers-Chair, Bed Dressing Ambulation Bowels Stair Climbing

Functional Assessment Funcional Status Index Gross Mobility Hand activities Personal care Home chores Social/Role Activities

Functional Status Index Assistance 1 – Independent 2 – Uses Devices 3 – Uses Human Assistance 4 – Uses Devices and Human Assistance 5 – Unable or unsafe to do the activity Pain 1 – No Pain 2 – Mild Pain 3 – Moderate Pain 4 – Severe Pain Difficulty 1 – No Difficulty 2 – Mild Difficulty 3 – Moderate Difficulty 4 – Severe Difficulty

Activity Assistance Pain Difficulty Mobility Walking Outside ________ _____ ________ Climbing up Stairs ________ _____ ________ Rising from Chair ________ _____ ________ Personal Care Put on Pants ________ _____ ________ Button Shirt/Blouse ________ _____ ________ Wash Whole Body ________ _____ ________ Put on Shirt/Blouse ________ _____ ________ Home Chores Vacuum Rug ________ _____ ________ Reach Low Cupboard ________ _____ ________ Do Laundry ________ _____ ________ Do Yardwork ________ _____ ________ Hand Activities Writing ________ _____ ________ Open Container ________ _____ ________ Dial Phone ________ _____ ________ Social Activities Perform your job ________ ______ __________ Drive a Car ________ ______ __________ Attend meetings ________ ______ __________ Visit Friends/Family ________ ______ __________

Effects of Spinal Cord Injury on Exercise

In paraplegia, the upper body must be used for all voluntary activities of daily living and exercise. Methods such as arm cranking, ambulation with orthotic devices and crutches, and wheelchair propulsion are used.

Smaller upper body mass restricts peak values of power output, oxygen consumption, and cardiac output to one-half of the normal values for those without spinal cord injury.

Effects of Spinal Cord Injury on Exercise

In tetraplegia, upper body power output, oxygen consumption, and cardiac output are reduced to one-half to one-third of the levels seen in individuals with paraplegia.

Strenuous exercise can produce dizziness, nausea, and other symptoms due to exercise hypotension.

Peak heart rates typically do not exceed 120 beats per minute.

Paralyzed Utah County woman to race in Boston Marathon

http://www.ksl.com/?sid=14917457&nid=148

•Ditropan (oxybutynin chloride)• Induces hypotension

•Dibenzyline (phenoxybenzamine hydrochloride) • Management of neuropathic bladder

•Alcohol, Diuretics • Diuresis

Effects of Medication on Exercise

Effect of Exercise

Improved glycemic control

Reduced postprandial lipemia (excess of lipids in the blood post meal)

Reduced serum lipids

Improved cholesterol ratios as peak oxygen consumption increased

Increase maximum oxygen consumption

Decrease heart rate Increase grip strength Increase arm work capacity Increased feelings of well-

being (depression and feelings of

isolation are common in SCI)

Acute Chronic

Exercise TestingMethod Measures Endpoints CommentsAEROBIC

•Arm ergometer•Wheelchair ergometer•Wheelchair treadmill•Wheeling on track or treadmill

•Peak HR, METS or VO2 peak

•BP

•RPE (6-20)

•Serious dysrhythmia•>2 mm ST-segment depression/elevation•Ischemic threshold •T-wave inversion with significant ST change •SBP >250 mmHg or DBP >115 mmHg

•Adjust incremental power levels to subject’s capacity. •Peak HR will be low (110-130 bpm) in tetraplegia due to sympathetic impairment •Persons with tetraplegia will need gloves or hand wrappings•Give rest periods between stages (stop exercise)•Watch for hypertension from autonomic dysreflexia or hypotension caused by orthostasis and exertion. •Indicates basic exercise tolerance and effort

FLEXIBILITY

•Goniometry•Stretching tests

•Flexibility of shoulders, elbow, wrist, hip, and knee

•Helpful in preventing contractures and injury

Exercise PrescriptionGOALS:

-AerobicIncrease active muscle mass and strengthMaximize overall strength for functional independence Improve efficiency of manual wheelchair propulsion

-Strength Increase active muscle mass and strengthMaximize overall strength for functional independenceImprove efficiency of manual wheelchair propulsion

-Flexibility Avoid joint contracture

-Psychological Enhance sense of well-being

Exercise PrescriptionAEROBIC:

-Arm ergometer, wheelchair ergometer, wheelchair treadmill, free wheeling, arm cycling, seated aerobics, swimming, wheelchair sports, electrically stimulated leg cycle ergometry with/without arm ergometry

40-90% VO2R 3-5 days/week20-60 min/session4-6 months to goal

STRENGTH-Weight machines or dumbbells, wrist weights

2-3 sets of 8-12 reps 2-4 days/week

4-6 months to goal

FLEXIBILITY-Stretching

Before aerobic or strength activities 4-6 months to goal

Summary & Conclusion There are many causes that can

effect the development of Spinal Cord Injury

When the spinal cord is injured the brain cannot properly communicate with it and so sensation and movement are impaired.

Serious complications can result if quadriplegia or paraplegia are not managed carefully.

Exercise is a great way for most individuals with spinal cord injury to improve their overall health and ability to do every day activities.

References American Spinal Injury Association, Autonomic Standards Form, Retrieved from

http://www.asia- spinalinjury.org/presentations/presentation.php#. Retrieved March 16, 2011.

Brain and Spinal Cord.org, Quadriplegia Treatment, Retrieved from http://www.brainandspinalcord.org/spinal-cord-injury-types/quadriplegia/index.html. Retrieved March 16, 2011. Centers for Disease Control, Spinal Cord Injury Fact Sheet, Retrieved from

http://www.cdc.gov/TraumaticBrainInjury/scifacts.html. Retrieved March 16,2011. Collins, E.(2010). Energy Cost of Physical Activities in Persons with Spinal Cord Injury.

Medicine and Science in Sports and Exercise, 42(4), 691-700. Durstine, J. L., et al. Spinal Cord Disabilities ACSM’s Exercise Management for Person with

Chronic Diseases and Disabilities. 3rd edition. ACSM, USA; 2009. Figoni, S. (1993).Exercise responses and quadriplegia. Medicine and Science in Sports and

Exercise, 25 (4), 433-441. Hicks, A. (2005). Exercise Research Issues in the Spinal Cord Injured Population. Exercise

and Sport Sciences Reviews, 33(1), 49-53 Hopman, M.(1997). Spinal Cord Injury and Exercise In The Heat. Sports Science Exchange,

10, 1551-1557. Howley, E. T., Franks, B. D. Nutrition. Fitness Professional’s Handbook. 5th edition. Human

Kinetics, USA; 2007. Mahan, K. L., Escott-Stump, S. Medical Nutrition Therapy for Quadriplegia. Krause’s Food

& Nutrition Therapy. 12th edition. Saunders Elsevier, USA; 2007. Mackie, J. W. (1989). Fitness and Spinal Cord Injuries. Canada Family Physician, 35, 1663-

1666. Mayo Clinic, Tests and Diagnosis, Retrieved from http://www.mayoclinic.com/health/spinal-

cord- injury/DS00460/DSECTION=tests-and-diagnosis. Retrieved March 16, 2011. National Spinal Cord Injury Association, Exercise. Retrieved from

http://www.spinalcord.org/resources/index.php?link=E&list=28. Retrieved March 16, 2011. Simpson, S. (2005).Conditioning in Injured and Disabled Populations. National Strength

and Conditioning Association, 27(6), 84-86.

SPINAL CORD DISABILITY TESTING

Arm ErgometerStage Workload

(W)Workload (kpm)

Time (min) O2 uptake (ml/kg/min)

0 10W 60kpm 2 (6.1)Rest 41 20W 120kpm 6 (12.2)Rest 82 40W 240kpm 10 (14.1)Rest 123 60W 360kpm 14 (19.4)Rest 164 80W 480kpm 18 (24.7)Rest 205 100W 600kpm 22 (30.0)Rest 246 120W 720kpm 26 (35.3)

Reference Values

Calculate VO2:

VO2= 3 * work rate/ body mass +3.5