Terms in this set (120)

In the case of a flaccid bladder, loss of detrusor muscle tone prevents bladder emptying and leads to bladder wall damage from over-filling, urine reflux and an increase in infection risk due to stasis. The sphincter tone also tends to be flaccid (at least the external sphincter) causing incontinence, especially with maneuvers that increase intraabdominal pressure (so-called "Valsalva" maneuvers) including straining during transfers, coughing and sneezing. Internal sphincter tone may be intact due to the higher origin of sympathetic innervation, thus complete emptying, even with externally applied suprapubic pressure, may be difficult.

Compared to DESD, patients with detrusor areflexia comprise a much smaller proportion of the SCI population and there is very little literature examining the effectiveness of interventions for this patient subpopulation (patients with detrusor areflexia).

Detrusor areflexia is seen most commonly in cauda equina lesions where the sacral reflex is disrupted. It can occasionally occur at other levels of spinal lesions. The clinical manifestation of this results in an inability for the bladder to empty completely or at all, leading to overdistension and stasis. Additionally, there is frequently incontinence due to lack of external sphincter tone, most often due to increased abdominal pressure on the bladder (i.e. stress incontinence). This can be especially problematic in persons with paraplegia that may require high valsalva forces for activities such as transferring from wheelchairs.

In general, the goal is either: 1) stopping leakage and improving storage with medications and intermittent catheterization, or 2) improving emptying, either voluntarily in the incomplete injury, and/or into condom drainage in the person with more severe neurogenic bladder impairments.
Intermittent Catheterization NS Prevention of UTIs
•Sterile and clean approaches to intermittent catheterization seem equally effective in minimizing UTIs in inpatient rehabilitation.
•Similar rates of UTI may be seen with intermittent catheterization as conducted by the patients themselves or by a specialized team during inpatient rehabilitation.
•Similar rates of UTI may be seen with intermittent catheterization, whether conducted in the short-term during inpatient rehabilitation or in the long-term while living in the community.
•UTIs were not associated with differences in residual urine volumes after intermittent catheterization.

Intermittent Catheterization using Specially Coated Catheters for Preventing UTIs
•A reduced incidence of UTIs or reduced antibiotic treatment of symptomatic UTIs have been associated with pre-lubricated or hydrophilic catheters as compared to standard non-hydrophilic catheters.

Other Issues Associated with Bladder Management and UTI Prevention
•Intermittent catheterization is associated with a lower rate of UTI as compared to use of indwelling or suprapubic catheter.
•The Statlock device to secure indwelling and suprapubic catheters may lead to a lower rate of UTI.
•Removal of external condom drainage collection systems at night or for 24 hours/day may reduce perineal, urethral or rectal bacterial levels but has no effect on bacteriuria.
•The presence of vesicoureteral reflux likely has a greater impact on development of significant infections than the choice of bladder management.
There is growing evidence that Body Weight Supported Treadmill Training (BWSTT) can improve indicators of cardiovascular health in individuals with complete and incomplete tetraplegia and paraplegia.
Tetraplegics and paraplegics can improve their cardiovascular fitness and physical work capacity through aerobic arm cycling exercise training which are of moderate intensity, performed 20-60 min day, at least three times per week for a minimum of six to eight weeks. Resistance training at a moderate intensity at least two days per week also appears to be appropriate for the rehabilitation of persons with SCI. It remains to be determined the optimal exercise intervention for improving cardiovascular fitness.
Interventions that involve Functional Electrical Stimulation (FES) training a minimum of 3 days per week for 2 months may improve muscular endurance, oxidative metabolism, exercise tolerance, and cardiovascular fitness.
Aerobic and FES exercise training may lead to clinically significant improvements in glucose homeostasis in persons with SCI. Preliminary evidence indicates that a minimum of 30 min of moderate intensity training on 3 days per week is required to achieve and/or maintain the benefits from exercise training.
Aerobic and FES exercise training may lead to improvements in lipid lipoprotein profile that are clinically relevant for the at risk SCI population. The optimal training program for changes in lipid lipoprotein profile remains to be determined. However, a minimal aerobic exercise intensity of 70% of heart rate reserve on most days of the week appears to be a good general recommendation for improving lipid lipoprotein profile in persons with SCI.
The mechanism underlying heterotopic ossification following spinal cord injury is not fully understood but it appears to be initiated by mesenchymal cells into bone precursor cells (Schuetz et al. 2005). Pape et al. (2004) has noted that mesenchymal stem cells can differentiate into osteogenic cells given the right stimuli within the right environment, even soft tissues (Chalmers et al. 1975). These mesenchymal stem cells can generate cartilage, bone, muscles, tendons, ligaments or fat (Williams et al. 1999) and are thought to play a pivotal role in the development of HO (Pape et al. 2004). HO then forms through a typical process beginning with the formation of a protein mixture created by bone cells (osteoid) that eventually calcifies within a matter of weeks (Pape et al. 2001). Over the next few months, the calcified osteoid remodels and matures into well-organized trabecular bone (Pape et al. 2001). Months following the initial trauma patients develop bone formation in muscle and soft tissues adjacent to a joint (paraarticular) with resultant restriction in range of motion, pain and ankylosis (Banovac & Gonzalez 1997, Garland et al. 1980). The bony lesion has a high metabolic rate, adding new bone at more than three times the rate of normal bone. Osteoclastic (bone removal cell) density is more than twice that found in healthy bone (Puzas et al. 1987). It is suspected there may be a neurogenic factor contributing to HO but the mechanism is poorly understood (Hurvitz et al. 1992, Pape et al. 2001, Pape et al. 2004).
In many cases, discharge from hospital is delayed for SCI patients due to lack of accessible housing, which leads to unnecessary increase of cost of care.
Independent Living Centres (ILCs) that have relationships with hospital Medical Rehabilitation Programs (MRPs) serve more clients than those without, and the most frequently serviced individuals are those with SCI who attend for peer counseling, skills training, and discharge planning.
Living with a spouse and/or children, living alone, or living with unrelated persons are more desirable arrangements than living with parents and spouse/children together, living with distant family (i.e., grandparents), or living with parents and siblings.
Marital status, transportation barriers, education level, medical supervision requirements, economic disincentives, services received, and severity of disability are predictors of independent living.
Choice and control are important when planning living situations and setting goals with clients with SCI because they are directly related to residential and life satisfaction.
Individuals with SCI have lower perceived life satisfaction, locus of control, and satisfaction with certain aspects of housing than normative samples.
Accommodation options for a person with a disability are limited. The preferred accommodation is a private house or apartment.
Living with someone prior to SCI, having insurance or private funding for equipment, and being younger decrease the risk of being discharged to an extended care facility following SCI rehabilitation.
Individuals with SCI have a need for assistance with fire safety to increase their perception of home safety.
Individuals with SCI move multiple times after injury. In most cases they start living with their parents and/or in an institution before moving into their own homes.
The transition process from rehabilitation setting to community is difficult because of the lack of resources mainly in terms of adaptation, accommodation and equipment.
A majority of caregivers indicated to be overwhelmed with their caregiving responsibilities.
Most informal caregivers are female spouses of individuals with SCI who require assistance in fulfilling and maintaining services.
There is general satisfaction with informal attendant services.
The most significant predictors of Personal Care Assistance (PCA) use are motor function, days spent in rehabilitation, and length of stay in a nursing home.
Personal attendant turnover is positively correlated with higher injury level and increased need for assistance in exercise and transfers.
Goal-directed occupational therapy can achieve gains in role performance and improvements in life satisfaction.
Re-hospitalization might be reduced after participation in an educational intervention involving a workshop, a collaborative home visit, and access to follow-up.
Counselling on proper technique and hygiene for at least one session might reduce the risk of urinary tract infections (UTIs) to below-threshold for individuals at risk for UTIs.
Workshops for attendants and consumers can increase knowledge about SCI.
Directing, training, and financing one’s personal attendant care may lead to financial savings, better health outcomes, and increased life satisfaction.
PES programs are beneficial in preventing and restoring lower limb muscle atrophy as well as improving lower limb muscle strength and endurance.
FES-assisted exercise programs are beneficial in preventing and restoring lower limb muscle atrophy as well as improving lower limb muscle strength and endurance in motor complete SCI.
For patients less than 12 months post-SCI, body weight supported treadmill training has equivalent effects on gait outcomes to conventional rehabilitation consisting of overground mobility practice.
Body weight-support gait training strategies can improve gait outcomes in chronic, incomplete SCI, but no body weight-support strategy (overground, treadmill, with FES) is more effective.
There is limited evidence for the benefits of combining the use of certain pharmacological agents with gait training on ambulation in individuals with SCI.
FES-assisted walking can enable walking or enhance walking speed in incomplete SCI or complete (T4-T11) SCI. Regular use of FES in gait training or activities of daily living can lead to improvement in walking even when the stimulator is not in use.
There is limited evidence that bracing alone does not enable significant gains in functional ambulation for people with complete SCI. The advantages of bracing appear largely restricted to the general health and well-being benefits related to practice of standing and the ability to ambulate short-distances in the home or indoor settings. The benefits of bracing-alone on functional ambulation are primarily with people with incomplete spinal lesions.
There is limited evidence that a combined approach of bracing and FES results in additional benefit to functional ambulation in paraplegic patients with complete SCI.
Locomotor training programs are beneficial in improving lower limb muscle strength although in acute SCI similar strength increases may be obtained with conventional rehabilitation. The real benefit of locomotor training on muscle strength may be realized when it is combined with conventional therapy. This should be further explored in acute, incomplete SCI where better functional outcomes may be realized with the combination of therapies.
Individuals with complete tetraplegia have higher rates of altered glucose metabolism.
Impaired gallbladder emptying is seen in diabetic and obese SCI individuals.
A combined diet and exercise program can help patients reduce weight following SCI without compromising total lean mass and overall health.
Participation in a holistic wellness program is positively associated with improved eating and weight-related behaviours in persons with SCI.
A combined nutrition, exercise and behaviour modification program can help persons with SCI increase metabolically active lean tissue, work efficiency, resting oxygen uptake and strength.
Dietary counseling results in improved lipid profile; consultation with a registered dietitian should be obtained, because individualized diets may enhance compliance.
Blood concentrations of DHA and EPA increased as the result of n-3 fatty acid supplementation; however, no significant changes in lipid profile were identified.Â
Omega-3 fatty acid supplementation increases upper body strength and endurance in persons with SCI.
Individuals with SCI should be screened for vitamin D deficiency and, if needed, replacement therapy should be initiated.
Clinicians should conduct early screening for and treatment of vitamin B12 deficiency.
Creatine supplementation does not result in improvements in muscle strength, endurance or function in weak upper limb muscles.
Creatine supplementation enhances exercise capacity in persons with complete tetraplegia and may promote greater exercise training benefits.
Consumption of a standard liquid meal does not change blood pressure, heart rate or noradrenalin levels in tetraplegics with postural hypotension.
The consumption of a whey protein plus carbohydrate supplement following fatiguing ambulation improves subsequent ambulation by increasing distance, time to fatigue and caloric expenditure in persons with incomplete SCI.
Meal-induced thermogenesis is not decreased in tetraplegic individuals with low sympathoadrenal activity and efferent sympathoadrenal stimulation from the brain is not necessary for nutrient-induced thermogenesis.
Impairment of sympathetic control of the kidney secondary to SCI resulting in tetraplegia does not impact renal sodium conservation in response to dietary salt restriction.
More research is needed to evaluate the role of nutrition in the management of post-acute SCI to provide the evidence base required for optimal clinical decisions.
•There is limited evidence that BWSTT can improve indicators of cardiovascular health in individuals with complete and incomplete SCI.
•Tetraplegics and paraplegics can improve their cardiovascular fitness and physical work capacity through aerobic exercise training of moderate intensity, performed 20-60 min day, at least three times per week for a minimum of six to eight weeks. Resistance training at a moderate intensity at least two days per week also appears to be appropriate for the rehabilitation of persons with SCI. It remains to be determined the optimal exercise intervention for improving cardiovascular fitness.
•Interventions that involve FES training a minimum of 3 days per week for 2 months can improve muscular endurance, oxidative metabolism, exercise tolerance, and cardiovascular fitness.
•Aerobic and FES exercise training may lead to clinically significant improvements in glucose homeostasis in persons with SCI. Preliminary evidence indicates that a minimum of 30 min of moderate intensity training on 3 days per week is required to achieve and/or maintain the benefits from exercise training.
•Aerobic and FES exercise training may lead to improvements in lipid lipoprotein profile that are clinically relevant for the at risk SCI population. The optimal training program for changes in lipid lipoprotein profile remains to be determined. However, a minimal aerobic exercise intensity of 70% of heart rate reserve on most days of the week appears to be a good general recommendation for improving lipid lipoprotein profile in persons with SCI.
Although it has been suggested by some that repetitive movements are deemed necessary for obtaining a clinical effect (Rosche et al. 1997), there have been several reports of reduced spasticity associated with regular periods of passive standing (Odeen & Knutsson 1981; Bohannon 1993; Kunkel et al. 1993; Dunn et al. 1998; Eng et al. 2001; Shields & Dudley-Javoroski 2005). The majority of these are individual case reports (Bohannon 1993; Kunkel et al. 1993; Shields & Dudley-Javoroski 2005) or user satisfaction surveys (Dunn et al. 1998; Eng et al. 2001) and have not been included in Table 21.1 (i.e., other than Odeen & Knutsson, 1981) which outlines the specific investigations of effectiveness of these "passive" approaches. The individuals examined in all 3 case reports reported reductions in lower limb spasticity associated with passive standing despite the fact that different procedures and devices were used across the reports including a tilt table (Bohannon 1993), a standing frame (Kunkel et al. 1993) and a stand-up wheelchair (Shields & Dudley-Javoroski 2005). In addition, a significant number of people have indicated they receive benefit with respect to reduced spasticity in response to surveys about prolonged standing programs. Specifically, Eng et al. (2001) and Dunn et al. (1998) reported that 24% and 42%, respectively, of individuals engaged in this activity find it beneficial in reducing spasticity. However, it should be noted that in each of these studies some individuals also reported an increase in spasticity with this activity (13% and 3% respectively).
Neuromuscular stimulation-assisted exercise following a spinal cord injury is effective in improving muscle strength, preventing injury and increasing independence in all phases of rehabilitation.
Augmented feedback does not improve motor function of the upper extremity in SCI rehabilitation patients.
Intrathecal baclofen may be an effective intervention for upper extremity hypertonia of spinal cord origin.
Afferent inputs in the form of sensory stimulation associated with repetitive movement and peripheral nerve stimulation may induce beneficial cortical neuroplasticity.
Restorative therapy interventions need to be associated with meaningful change in functional motor performance and incorporate technology that is available in the clinic and at home.
The use of concomitant auricular and electrical acupuncture therapies when implemented early in acute spinal cord injured persons may contribute to neurologic and functional recoveries in spinal cord injured individuals with AIS A and B.
There is clinical and intuitive support for the use of splinting for the prevention of joint problems and promotion of function for the tetraplegic hand; however, there is very little research evidence to validate its overall effectiveness.
Shoulder exercise and stretching protocol reduces post SCI shoulder pain intensity.
Acupuncture and Trager therapy may reduce post-SCI upper limb pain.
Prevention of upper limb injury and subsequent pain is critical.
Reconstructive surgery appears to improve pinch, grip and elbow extension functions that improve both ADL performance and quality of life in tetraplegia.
The use of neuroprostheses appears to have a positive impact on pinch and grip strength and ADL functions in C5-C6 complete tetraplegia; however, access to the devices is limited and they continue to be expensive.
The IST-12 neuroprosthesis, a second generation, myoelectrically controlled implantable device appears to have a positive effect on pinch and grasp functions which result in increased independence with activities of daily living.
Non-modifiable personal characteristics such as being male and Caucasian, younger at injury, with a longer duration of injury (20-30 years) with a higher pre-injury education, less severely injured, and being employed at injury in a low-intensity job increase the likelihood of employment post-SCI.
Modifiable personal characteristics such as being married, highly educated, limiting the occurrence of health complications with a higher level of independence (including wheelchair skills), valuing work increase the likelihood of employment post-SCI.
Environmental barriers to employment are social or physical and include financial disincentives, discrimination associated with negative attitudes toward people with disabilities and difficulties with physical access to workplace.
Environmental facilitators include having access to various assistive devices, using transportation independently and having the possibilities of work adaptation including reduced work hours.
A single environmental factor can be perceived either as a barrier or a facilitator to employment based on its presence/absence in one’s environment and its impact on effective returning to work.
People with SCI may benefit from vocational rehabilitation in the process of job placement and work reintegration.
There is a dearth of high quality research in vocational (re) training. Consequently, conclusions are based on evidence from observational studies or case studies.
Continuous support to the employee and employer before and after vocational placement might lead to a successful return to work and job retention.
Individuals with complete C1-C4 (high) tetraplegia have little or no movement of upper and lower extremity muscles. They have movement of the head and neck, as well as, possibly, shoulder elevation (shrug). Persons with an injury at the C4 level have innervation of the diaphragm (the primary muscle for respiratory inspiration). They should not need long-term ventilatory assistance, although it is not uncommon to receive ventilation initially after injury.

Patients with C1-C3 injuries are likely to require long-term mechanical ventilatory support because of the loss of innervation to the diaphragm. These individuals may be candidates for FES of the phrenic nerve (or diaphragm) to reduce their need for mechanical ventilation, if their lower motor innervation to the diaphragm remains intact.[10] Swallowing and phonation functions are preserved.

Individuals with injuries at the C1-C4 level will likely depend on others for help with almost all of their mobility and self-care needs, although they may be able to use a power wheelchair with chin or pneumatic (sip and puff) controls. If their elbow flexion and shoulder movement are suboptimal (muscle grade 2 or 3), a balanced forearm orthosis (BFO) or mobile arm support (MAS) may assist them with feeding and grooming activities. The use of a long bottle or straw can allow these individuals to drink independently.

Patients should be able to communicate with caregivers (and provide direction) about their mobility needs, as well as about self-care and bladder and/or bowel care. Assistive technologies, such as electronic aids to daily activities (EADLs, previously referred to as environmental control units), may be accessed by using a mouth stick or switch or by employing voice activation. Assistive devices transmit signals by means of radio waves, infrared light, or ultrasonographic waves to facilitate an individual's control of his/her environment. In this way, the person can accomplish such tasks as answering phones, adjusting bed height, and controlling computers, lights, and televisions.

Brain Control Interface (BCI) methods, using noninvasive electroencephalography (EEG), is being trialed in order to bridge the disconnection between the brain and muscle.[11, 12] With BCI, it is necessary to interpret brain activity and interface brain signals with a computer, and this may enable a person with tetraplegia to control a computer, operate devices such as an EADL, or control a power wheelchair. Individuals using BCI systems indicate it gives them an increased sense of independence and improves their quality of life. This technology needs further refinement before it can be clinically implemented.
Individuals with C6 tetraplegia have the added function of wrist extension. This permits tenodesis, or passive thumb adduction on the index finger during active wrist extension, which assists with grasp and release. A wrist-hand orthosis (tenodesis splint) can be used to facilitate these abilities. The patient should avoid overstretching the finger flexors, which limits the tenodesis action.

C6 is the highest level at which patients can have a complete injury and still function independently without the aid of an attendant, although this situation is not common. Individuals with injuries at this level can achieve functional independence in terms of feeding, grooming, bathing, and bed mobility by using assistive devices. They can dress their upper body and assist with lower-body dressing, as well as with the bladder and bowel program. With the use of a slide board, persons with C6 tetraplegia may become independent in performing transfers from a bed to a chair, although they usually require assistance with these. Intermittent catheterization for bladder care may be possible with set-up and assistive devices, although this is not common and is technically more difficult for women than for men.[14]

Manual wheelchairs with enhancement for gripping the wheel rims may be used for community mobility, although patients may prefer a power chair. Driving a vehicle with adaptations, such as a custom lift and hand controls, is an option. Patients with C6 injuries can be independent in using a phone, turning pages, and writing and typing (with assistive devices).
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