Frequency of Complications

In a study of patients transferred to a rehabilitation center within a mean of 10 days after a stroke, the incidence of serious medical complications found upon admission rose from 22 before to 48 the year after institution of DRGs.18 Many of these complications derived from altering or starting medications during the acute hospitalization, especially antihyper-tensives, antiarrhythmics, platelet antiaggre-gants, anticoagulants, steroids, hypoglycemics, antibiotics, anticonvulsants, analgesics,...

Sleep Disorders

Insomnia often accompanies anxiety and depression. From 12 to 25 of healthy people over age 65 years report chronic insomnia with the greatest disturbance in maintaining sleep. Hospitalization with its new noises and discomforts and impaired bed mobility from neurologic disease may add to this difficulty. Over the short run, both behavioral and pharma-cologic approaches, using temazepam for example, are significantly better than placebo management.263 Sleep apnea is reported in 4 of middle-aged...

Reduction Of Cardiovascular Risk

Risk factors for chronic disease can also be reduced by exercise. Several small group comparisons have suggested that persons with quadriplegia and paraplegia have significantly lower high-density lipoprotein (HDL) cholesterol levels than controls. In the first year after SCI, however, a prospective study of HDL levels in 100 patients found an increase of 26 in those with quadriplegia and 18 with paraplegia, but the levels are still low.164 A regimen of 8 weeks of wheelchair ergometer training...

Orthostatic Hypotension

Orthostatic hypotension (OH) occurs often enough in elderly patients, after stroke or SCI, after bed rest with deconditioning, from dehydration, and in relationship to drugs or diseases such as diabetes mellitus that block normal vasomotor and cardiac responses to standing that the condition may interfere with rehabilitation. The sometimes subtle effects of standing hypotension include exercise intolerance, fatigue, dizziness, confusion, a decline in mental functioning, and of course, syncope....

Medical Interventions

Early rehabilitation efforts include measures to prevent and manage medical complications. The third NASCIS study prospectively monitored medical complications for 6 weeks after SCI. The rates have been similar for over 1400 patients in NASCIS trials. Table 10-4 shows the frequencies of the most common complications. Complications may differ in a patient population that includes victims of firearms. The NASCIS complication rates stand in some contrast to the medical comorbidities during...

Chronic Pain

Pain after SCI arises from contractures, osteo-porotic fractures, extensor spasms, soft tissue injury, musculoligamentous strain, myofascial pain, and inflammation of tendons and bursas, especially from overuse of the upper extremities. Current pain is reported by up to 80 of people with SCI. Common locations include the back (60 ), hip and buttocks (60 ), and legs and feet (58 ).86 In a community survey, pain limited participation in ADLs and IADLs for 2 weeks out of the previous 3 months....

Clinical Trials

Even in subjects with PPS, in whom fatigue from overuse of muscles is a common complaint, leg ergometry with interval exercise training improved maximal oxygen uptake by 15 and increased knee extensor strength by 30 .46 In another study of patients with PPS, resistance exercise led to muscle strengthening by a combination of neural and muscular adaptations.47 A 12-week program of alternating daily isometric (3 sets of 4 contractions) and isokinetic (3 sets of 12 repetitions) strengthening...

Mechanisms Of Neuropathic Pain

The ascending and descending components of the pain transmission and modulation systems are complex in their connectivity, parallel pathways, use of neurotransmitters and peptides, and functional and structural plasticity. Evidence for activity-dependent neuronal plasticity that can cause hypersensitivity to pain has been found in peripheral nociceptors, spinal dorsal horns, the thalamus, and the cortex.77,78 The sensation of pain is processed along with the unpleasantness of pain and the...

Sensory Map Plasticity

Using a mapping technique with an array of microelectrodes over the cortical surface of monkeys, Merzenich and colleagues conducted a series of experiments that demonstrate the mutability of so-matosensory representations.388 Following the amputation of a digit in adult monkeys, the sensory representation of adjacent digits in cortical areas 3b and 1 enlarged topographically by approximately 1 mm to occupy the territory that had been filled by the sensory neurons associated with the lost...

Gene Expression For Repair

After an injury such as ischemia, neural tissue expresses genes in a general relationship to the time from onset, intensity, and duration of ischemia. After the upregulation of immediate-early gene messenger ribonucleic acids (mR-NAs) such as c-fos and junB,17 various regions within, surrounding, and remote from the injury may express new mRNAs or downregulate the expression of other genes. Over time, various signaling mechanisms lead to the expression of many of the genes found during stages...

Experimental Case Studies

Large Scale Anatomic Reorganization and Representational Plasticity Somatotopic reorganization can occur at the earliest stages of somatosensory processing. Stimulation of peripheral afferents extends a cell's receptive field beyond the boundaries usually found in electrophysiologic studies. For example, after a peripheral nerve lesion, reorganization in the somatotopic map was shown in the ventroposterior lateral nucleus of the thalamus in adult monkeys that was as complete as what was found...

Stimulate Axonal Regeneration

Inhibitory proteins in myelin and other matrix barriers, along with a lack of trophic factors and other molecules that signal genes and intracel-lular cascades for growth cone extension, must be managed if axons are to regenerate in the CNS. The patchwork of substances that attract, repel, and modulate axonal regeneration has grown so complex that the clinician may have difficulty seeing the whole fabric. The potential to manipulate some of these substances for neural repair, however, puts some...

Increase Axonal Regeneration

The major barriers to axonal regeneration include glial scar, molecules in the milieu that inhibit growth cones or are not available to attract growth cones, and a core of necrosis and dead space that cannot be traversed. Following a SCI in rodents, lesioned corticospinal tract axons from layer V pyramidal cells have regenerated into implants of neurotrophins, fetal tissue, peripheral nerve, and Schwann cell grafts, but tend not to extend beyond these stimuli into distal white matter. Olfactory...

Neuroimaging Techniques Positron Emission Tomography

Positron emission tomography and fMRI provide a view of the distributed functional and anatomical network engaged by a task. The ability of PET to reveal rCBF and metabolism was the first solid advance in functional imaging for understanding specific operations within the distributed neural systems for movement, language, attention, memory, perception, and other aspects of cognition.4,5 The technique allows quantification of absolute physiologic variables such as rCBF, oxygen extraction and...

Single Photon Emission Computerized Tomography

Single photon emission computerized tomography (SPECT) is performed with radiophar- maceuticals that are given intravenously or by inhalation. Radioisotopes that emit gamma rays include xenon-133, iodine-123, and tech-netium-99m. Single photon emission computerized tomography does not directly assess neuronal function. The procedure measures cerebral perfusion, blood volume, and the distribution of several receptors, which indirectly reflect metabolism and network activity.7 Early after stroke,...

Molecules For Attraction And Repulsion

Around a SCI contusion and cavity, axons retract less than 1 cm and then may sprout. Bres-nahan and colleagues found corticospinal tract sprouting between 3 weeks and 3 months after a moderate SCI in rodents.242 Collateral-ization and penetration of reticulospinal tracts into the matrix of the lesion started by 3 months. Thus, a modest percentage of injured axons may regenerate into the trabecular tissue that thinly bridges the cavity, as well as into residual gray and white matter around the...

Sensorimotor Impairment Scales

Strength is most commonly measured by the 5 grades of the British Medical Council Scale. This scale is least sensitive to change at grade 4, which describes movement against less than full resistance. This scale may be incorporated into other scales for a specific muscle group innervated by a particular root level, as in the American Spinal Injury Association Motor Score (see Chapter 10). Hand-held dynamom-etry can be performed at most muscles in a sensitive and reliable way,31,32 but limb...

Phenol

No well-designed clinical trials of phenol blocks to muscle or nerve have been reported214 and no functional gains are evident. Blocks with phenol as a 2 -10 solution and ethyl alcohol have been used for over 30 years.215 The nerve or motor point is most often located by percutaneous electrical stimulation via a hypodermic needle cathode, but an intraneural injection by an open procedure is also advocated.216 An initial injection of a long-acting local anesthetic such as bupivacaine helps...

Ventral Horn Neurons And Roots

Approximately 20 of traumatic SCIs occur at the level of the conus and cauda equina, producing a lower motor neuron injury. Traumatic and ischemic SCI invariably affect ventral and dorsal horn roots and neurons. Trauma often tears or avulses proximal nerve roots, which, if proximal enough to the cord, leads to mo-toneuron death. The motoneuron operates within both the CNS and PNS, so its regenerative ability to make a new axon depends on features of both environments. Although a variety of...

Transcranial Magnetic Stimulation

Magnetic scalp stimulation techniques apply a transient clockwise current from a stimulating coil placed on the scalp in an optimal position to induce a counterclockwise current in the brain (Fig. 3-2). The brief, intense electric field induced by magnetic coils shaped as a figure-of- Figure 3-2. Transcranial magnetic stimulation over primary motor cortex causes a twitch of the finger muscles. When the subject contracts the extensor propius indicis slightly, this muscle is preferentially...

Spinal Cord Stimulators

Placed over the dorsal spinal cord in the epidural space, electrical stimulation, initially preformed to reduce some types of central pain, may also lessen hypertonicity after SCI.29 Stimulation of the upper lumbar cord has also produced rhythmic leg movements in subjects with complete SCI.30 Stimulation with four dorsally placed lumbar electrodes reportedly improved the gait pattern of a patient with spastic quadriparesis. Walking speed and endurance increased beyond what had been accomplished...

Conventional Training

Pregait training often includes neurophysio-logic and neurodevelopmental techniques to elicit movements and develop sitting and standing balance (see Chapter 5). Mat activities include rolling or rotating at the hip to elicit flexion, as well as supine bridging, kneeling and half-kneeling. No data are available to determine whether or not this approach is worth the time and effort compared to immediately finding a technique that helps the patient stand and train in stepping. Most therapists...

Myasthenia Gravis

Myasthenia gravis is an antibody-mediated autoimmune disease, but 15 of patients with generalized myasthenia have no detectable antibodies to nicotinic acetylcholine receptors. Over the age of 50 years, and especially over age 70 years, myasthenia gravis may affect many more patients who decline functionally than is appreciated. Up to 25 of elderly patients do not have antibodies to the receptors and others show no decrement in the evoked responses to repetitive nerve simulation. The proper...

Interventions for Skilled Action

COMPENSATORY EXERCISE AND REEDUCATION Muscle reeducation evolved primarily for the management of polio, but these programs of exercise of muscle were considered less useful for rehabilitating patients with upper motor neuron syndromes. Traditional exercise programs emphasize repetitive passive and active joint-by-joint exercises and resistance exercises in anatomical planes to optimize strength and range of motion.19 The approach aims to prevent the complications of immobilization, such as...

Invasive Procedures

Neurostimulation techniques and surgical procedures, such as augmentation cystoplasty and other urinary diversions, are used mostly for people with myelopathies from SCI and MS who cannot maintain a low-pressure detrusor with intermittent catheterization. These patients run the risk of recurrent urinary infection, vesicoureteral reflux, and stone formation. Table 8-1. Pharmacologic Manipulation of Bladder Dysfunction Facilitate emptying internal sphincter dyssynergia Facilitate emptying due to...

Task Oriented Training

This approach includes muscle strengthening, strategies that meet the requirements of walking such as training on a treadmill, and practice under varied conditions on different surfaces and at greater walking speeds (see Chapter 5). Task-specific therapy for gait, including treadmill training, shows promise for improving the quality and speed of overground ambulation and enhancing fitness and strength compared to conventional training.5,30-32 BODY WEIGHT-SUPPORTED TREADMILL TRAINING With the...

References

Observational gait analysis. In Scully R, Barnes M, eds. Physical Therapy. Philadelphia JB Lippincott, 1989 670-695. 2. Rancho Professional Staff Association. Normal and Pathological Gait Syllabus. Downey, CA Rancho Los Amigos Hospital, 1981. 3. Lehmann J, de Lateur B, Price R. Biomechanics of abnormal gait. Phys Med Rehabil Clin N Am 1992 3 125-138. 4. Krebs D, Edelstein J, Fishman S. Reliability of observational kinematic gait analysis. Phys Ther 1985 65 1027-1034. 5. Richards C,...

The Primary Motor Cortex and Locomotion

Supraspinal motor regions are quite active in humans during locomotion.45,46 In electro-physiologic studies of the cat, motoneurons in M1 discharge modestly during locomotion over a flat surface under constant sensory conditions. The cells increase their discharges when a task requires more accurate foot placement, e.g., for walking along a horizontally positioned ladder, compared to overground or treadmill locomotion. Changing the trajectory of the limbs to step over obstacles also increases...

Memory Disorders

Patients are called upon to encode and retrieve new information during rehabilitation. Memory disturbances may have a proportionately negative influence on the compensatory learn ing that underlies much of the rehabilitation process. The incidence and risk factors for memory loss and for dementia caused by one or more strokes have become increasingly appreci-ated.378'381,384-386 Up to 30 of all stroke survivors have a disturbance in memory. In a population study, dementia was 9 times greater in...

Body Weight Supported Treadmill Training

As an adjunct to traditional physical therapies, the suspension of a patient over a treadmill belt to control the level of weight bearing and cadence of stepping may serve as a safety measure to prevent falls and allow therapists to more easily assess and correct gait deviations. Ideally, BWSTT allows mass practice that is task-oriented (Chapter 6). With BWSTT for patients with SCI, up to 50 of body weight is suspended in a climbing harness connected to an overhead hydraulic lift (Fig. 10-3)....

Bowel And Bladder

Neurogenic bowel and bladder dysfunction rank among the most life-limiting problems of people with SCI. No more than 15 regain normal control.25 Fecal incontinence, constipation, and impaction affect most SCI patients until a practical bowel program is attained.67 Digital stimulation with a lubricated and gloved finger in a gentle, circular motion will induce reflex peristalsis in patients with an intact conus medullaris. Glycerine suppositories and contact irritants, stool softeners, colonic...

Assistive Devices

Assistive devices include a wide variety of braces, canes, and walkers. Randomized trials of the utility of common assistive devices or Table 6-7. Rationales for and Against Body Weight-Supported Treadmill Training Initiates step training and upright posture as early as possible after onset of disability Therapists can readily optimize kinematics, kinetics, and temporal parameters of walking Allows practice at normal walking velocities Encourages exercise to increase fitness, prevent disuse leg...

Limit Glial Scar

Immediately after a spinal cord contusion, pe-techial hemorrhages and tissue damage spread and enlarge in centripetal and rostrocaudal directions for up to several days. Resident and activated inflammatory cells infiltrate an increasingly necrotic cavity. Neutrophils, mi-croglia, and proinflammatory chemokines and cytokines initiate macrophage phagocytosis. Within a week, T-lymphocytes and circulating monocytes enter the region of injury. These cells move throughout the perilesional area for...

Eight Potential Pitfalls of Animal Models

What is the study population In animal research, vendors provide healthy, highly inbred rats and mice. The rodents are the same species and strain, same age, weight, and gender. Males tend to be used most often to avoid the hormonal fluxes of the estrous cycle. The experiments are usually carried out on neonates and young adults, approximately 3-6 months old (an old rat is 2 years old). The CNS of a neonate may still be developing, allowing for far greater opportunity for morphologic...

Functional Electrical Stimulation

Among all the neurologic disabilities, the most scientific attention to the limitations and benefits of fitness training and testing has been given to paraplegia and tetraplegia.172 After SCI, cardiovascular conditioning can be limited by exercising only the upper body's small muscle mass, by pooling of blood in the leg muscles that reduces cardiac preloading, and by impaired cardiovascular reflexes. Functional electrical stimulation-induced leg cycle er-gometry can improve both peripheral...

Neurostimulators and Neuroprostheses

Functional Neuromuscular Stimulation Nerve Cuffs Neuroaugmentation Spinal Cord Stimulators Brain-Machine Interfaces Sensory Prostheses ROBOTIC AIDS Upper Extremity Lower Extremity TELETHERAPY SUMMARY Along with the generation of axons and neurons to aid neurorecovery, the first quarter of the 21st century will see the creation of interfaces that allow neurons to drive or be driven by computers and micromachines (Table 4-1). Such human-machine interfaces may reduce impairments and disabilities....

Adjuvant Pharmacotherapy

Attempts to develop pharmacotherapy for neu-rorehabilitation are drawn from animal and human studies of drug-induced enhancement of learning and neuroplasticity (see Chapter 1)288-291 gome drug interventions are drawn from biologic responses in rats and applied to humans after a focal brain or spinal cord injury, which is a precarious leap (see Chapter 2). Neurotransmitters and neuromodulators given in pharmacologic dosages may augment the activation of a network during a specific task, but...

Interventions for Personal Independence

For neurologic rehabilitation, theories about assessment and intervention by the occupational therapist have evolved over the past 10 years in parallel to those of physical therapy.101,102 The approaches of OT rely on behavioral and educational techniques that combine skills training, compensation, and environmental adaptation. Therapists demonstrated in a randomized trial of outpatients with schizophrenia that a program of training in independent living skills and psychosocial functioning...