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Stand and Deliver

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Vol. 16 •Issue 10 • Page 31
On Mobility

Stand and Deliver

Standing and gait therapy can be a winning combination for SCI patients.

Since World War II, life expectancy after a spinal cord injury (SCI) has increased sharply. More responsive emergency care, coupled with modern rehab techniques, has ensured many patients a long and promising future.

Yet reimbursement remains a constant challenge. Acute rehab for patients following SCI is limited, and therapy often focuses on achieving basic living needs only. But the goal of skilled rehab should be to prevent complications, promote independence and mobilize patients.1

From the first day of an injury, SCI changes a life. Volitional muscle control is reduced or lost, homeostasis is altered, and autonomic dysfunction and inefficient temperature control limit a person's ability to participate in functional and recreational activities, sports and therapeutic exercise.

Evidence suggests that exercise improves the physical and emotional well-being of patients after SCI, despite this multi-system decline. Active standing—using a standing frame with a glider component to replicate walking—can enhance overall health and decrease the accelerated aging and complications many patients experience.

ACTIVE STANDING'S ROLE

Using an active standing frame or glider during an acute rehab stay helps accomplish goals by combining the proven benefits of a standard standing program with those of a reciprocating movement. An active standing frame also gives patients a self-directed, activity-based home program after discharge.

Patients can experience the following key benefits:

  • Eye-level interaction. Standing devices provide the opportunity to stand and interact with peers and family at eye level. This equipment allows the patient to participate in mild or vigorous activity while enjoying the emotional benefits of being in an upright standing position.

  • Trunk control. By modifying the amount and location of support, therapists can challenge the patient's trunk control and balance. This carries across a patient's therapeutic goals to improve mat mobility, activities of daily living, wheelchair management and transfer skills.

  • Contracture management and cardiovascular training. A gliding program helps prevent contractures at the hips, knees and ankles, secondary to weight bearing and mobility. Standing with a glider frame offers the patient a unique opportunity to control lower extremity movement through assistance from the upper extremities. Because the patient controls the assistance of the upper extremities, he also controls the progression of cardiovascular training.

  • Bone mineral density. Disuse and neural changes lead to a loss of bone mineral density (BMD) after a spinal injury. This loss can be rapid–one study showed a 7.5 percent and 5.3 percent loss of bone mass in the calcaneus and proximal tibia respectively, within 6 weeks of injury.2

    Research shows mixed results regarding the ability of standing to counteract this loss. Because many studies suggest that BMD loss is greatest within the first 2 years post-injury, a load-imposing intervention may have a greater effect sooner rather than later.3,4

    In one study, patients involved in early loading exercises (either a standing program or a body weight-supported gait training program) lost almost no bone mineral content after participating in the program 5 days per week for 6 months. By contrast, immobilized patients lost 6.9 percent to 9.4 percent of trabecular bone during the same time frame.4

    Furthermore, if a patient has an incomplete SCI, and maintains the ability to voluntarily contract lower extremity muscles with the active stander, then BMD loss may be prevented secondary to muscle pulling on the bone.

    During acute rehab, an injury initially diagnosed as complete may eventually become incomplete, since the ASIA classification hasn't been stabilized. A glider lets you place these patients in a supported, weight-bearing position. As a result, patients can contract their lower extremity muscles with assistance from the arms, even though they're not strong enough to move the limb independently.

    When combined with functional neuromuscular electrical stimulation (NMES), a standing program can encourage muscle contractions similar to a normally innervated limb.

    NMES applied to the lower extremity muscles during standing activities may help a patient modulate physiological responses to demonstrate improved upright tolerance.

    Programming the stimulation to provide a muscle pump at the gastrocnemius, tibialis anterior, quadriceps and hamstring muscles may assist the patient to achieve an upright position and be a more active participant in rehab.5 The gliding motion may also assist the muscle pump to maintain physiological responses to upright positioning.

    If the patient can't independently initiate the gliding motion, he can try grip-assist gloves, or therapists can assist.

    COMBINING GAIT AND NEURAL COUPLING

    Recent studies have indicated that gait therapy after a neurological injury should incorporate simultaneous upper and lower extremity rhythmic movement to take advantage of neural coupling.6

    Researchers have found that during locomotor tasks, neural connections between upper and lower extremities coordinate muscle activation patterns. Walking, crawling and swimming all involve upper and lower extremity rhythmic movements that preserve the basic coordination pattern between the limbs.

    A glider can help patients achieve this pattern by letting the patient control the assistance of the arms to move the legs. This actively engages the patient in the activity, thereby maximizing activity-dependent plasticity and promoting motor learning and recovery.

    During gliding activity, patients with cervical incomplete lesions demonstrate remarkable muscle activation, due to this neural coupling.7 Results are different with clinically complete spinal cord injury, as the imposed upper limb movement has no effect on lower limb muscle activation.

    However, because injury classification can change over time, therapists should consider this treatment approach for all SCI patients in acute rehab. Furthermore, rhythmic upper body movement appears to increase lower limb muscle recruitment proportional to upper limb muscle activation.8

    Although randomized clinical trials haven't examined the benefits of gliders in rehab, clinical case studies encourage investigating the ability of simultaneous rhythmic upper and lower limb activity to promote neural plasticity in locomotor neural networks. You can incorporate this activity into a therapy program without much additional cost or labor.

    There are specific differences between walking and the gliding motion achieved within the gliding standing frame. However, this doesn't necessarily negate its potential for therapeutic benefits. For example, the bottom of the patient's foot remains in constant contact with the footplate throughout the gliding cycle, unlike the swing phase of walking.

    Also, the degrees of range of motion throughout the gliding cycle and gait cycle differ at the hips and knees. While the gliding cycle isn't identical to the gait cycle, the system is set up to allow a patient to transfer into the device easily and maintain gliding with minimal therapist intervention. Frequency is the key—performing a stepping task that's only 50 percent similar to walking every day may be more beneficial than performing a stepping task that's 95 percent similar to walking once per week.8

    EASING A DIFFICULT PERIOD

    A stay in acute rehab after SCI is filled with emotions for the patient and caregivers. Any modality that can lower stress, depression, anxiety or pain goes a long way toward easing this difficult time.

    Studies have evaluated the perceived effectiveness of prolonged standing programs (greater than 20 minutes per session). Patients report improved well-being, circulation, spasticity, bowel and bladder function, digestion, breathing, skin integrity, fatigue, pain, ability to perform self-care skills and ability to sleep. Patients reported these benefits as soon as 1 week within initiating a standing program.9,10

    Once a patient can physiologically tolerate upright positioning within a tilt table, and is medically cleared to participate in an active standing frame, you can initiate an active standing program. Be aware of the following precautions—shearing forces, physiologic vital signs, including autonomic responses, and cardiovascular and cardiopulmonary responses.

    Evaluate the patient's positioning in the standing device. Be sure the pelvis is aligned and the thorax is supported.

    Once a program is initiated in the rehab setting, these devices are appropriate for the home, after the family has been trained. At our facility, we often use an active standing frame with our acute rehab SCI patients. We incorporate NMES and therapeutic exercise as indicated to maximize effectiveness.

    But cost is the biggest barrier for patients to continue a gliding program at home. However, active standing is a relatively simple intervention that can potentially prevent costly complications. From a payer perspective, if these benefits prevent a single secondary complication for a patient with SCI, the cost of the frame is justified.

    An acute standing program can be a stepping stone to the patient's home program after discharge. Patients and families appreciate the ability to participate in this empowering, and therapeutically beneficial, mode of therapy.

    For a list of references, go to www.advanceweb.com/rehab and click on the references toolbar.

    Amy Warfield, PT, DPT, NCS, is a senior physical therapist at the International Center for Spinal Cord Injury at Kennedy Krieger Institute in Baltimore. She can be reached at warfielda@kennedykrieger.org




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