technology and spinal cord injury (sci): how could technology further help the sci patient?
DESCRIPTION
Dr. Josh Geering, PT, DPT, from the Dallas VA Medical Center's Spinal Cord Injury & Disorders Center presents at the UT Arlington Research Institute's Symposium on Biomedical Technologies.TRANSCRIPT
TECHNOLOGY AND SPINAL CORD INJURY (SCI):How could technology further help the SCI patient
Presented by
Josh Geering, PT, DPT
Dallas VA Medical Center
Spinal Cord Injury and Disorders Center
Dallas VA Physical Medicine/Rehab PM&R Outpatient Section
Electromyography (EMG) and Nerve Conduction Study (NCS) Spine Section Physical Therapy (PT)/Kinesiotherapy (KT) Occupational Therapy (OT) Driver Rehabilitation Preservation, Amputation, Care and Treatment (P.A.C.T.) Comprehensive Integrated Inpatient Rehabilitation Program
(CIIRP) Polytrauma Network Site
Dallas VA Spinal Cord Injury Unit The Spinal Cord Injury (SCI) Center has provided inpatient and
outpatient services to Veterans with SCI, dysfunction or multiple sclerosis since August 1996. The center contains a comprehensive array of facilities and disciplines that SCI patients ordinarily require.
The SCI Center is a 65,000 square-foot complex that includes: 30-bed inpatient unit outpatient clinic rehabilitation therapy areas transitional living apartment internet cafe recreation therapy areas swimming pool gymnasium pharmacy
Objectives for today
Educate on a few of the challenges that a patient with SCI may face.
Provide information on what technology is available at the Dallas VA to help the patient with SCI.
Give some possible ideas for bridging the gaps in our treatment through technology.
Spinal Cord Injury (SCI): Who are we caring for? Majority are male patients Median age is around 55 years old Active duty and discharged veterans Causes of injury
Non-traumatic○ Stenosis/arthritis○ Cancer○ Other infections
Traumatic○ Accidents○ Gun shot○ Falls
Co-morbidities usually are present Previous surgeries Diabetes Cancer (not SCI Fractures Age
Spinal Cord Injury (SCI): Current Challenges Pressure, pressure, pressure… Lack of strength for function Mobility and locomotion (walking)
SCI Current Challenges: Pressure
Pressure ulcers “an area of localized soft tissue ischemic
necrosis caused by prolonged pressure higher than the capillary pressure with or without shear, related to posture which usually occurs over a bony prominence”.
Karoon Agrawal and Neha Chauhan Indian J Plast Surg. 2012 May-Aug; 45(2): 244–254. Pressure ulcers: Back to the basics
SCI Current Challenges: Pressure Wounds cost money
Nineteen patients with stage IV pressure ulcers (11 hospital-acquired and 8 community-acquired) were identified and their charts reviewed. The average hospital treatment cost associated with stage IV pressure ulcers and related complications was $129,248 for hospital-acquired ulcers during one admission, and $124,327 for community-acquired ulcers over an average of 4 admissions. Am J Surg Oct 2010:200(4): 473-477 High Cost of Stage IV Pressure Ulcers
Wounds can kill Ueda et al, 1990 reported 68.8% mortality amongst elderly
patients with NPUAP stage 3 and 4 pressure ulcers, because of secondary systemic complications.
These data indicate that presence of pressure ulcer hampers quality of life and prevention of pressure ulcer is an important goal
SCI Current Challenges: PressurePressure Ulcer Causes: Shear
Gravity and friction are involvedBlood vessels stretch and occludeChange the shape of the tissue, undermine
FrictionOccurs when 2 surfaces move across one another
Microclimate and MoistureAlters resiliency of the epidermisBoth friction and shear increase with mild mosture
SCI Current Challenges: Pressure
How we mitigate pressure now: Surfaces
CushionsMattresses
Positioning
SCI Current Challenges: Pressure
SCI Current Challenges: Pressure
Pressure mapping – How we measure Sensors and software Portability Mattresses and cushion assessments
SCI Current Challenges: Pressure
How we manage pressure Pressure = Force/Area
Increase the amount of areaRedistributing the force over this areaControlling microclimate
So where is the gap?
SCI Current Challenges: Pressure
How could technology help? Patient managing their own pressure
Pressure mapping visible to the patientReminding them to do their pressure reliefsGiving them the power to adjust pressure
wirelessly Adjustability of surfaces
A true turning mattress – so caregivers don’t have to do all of the work
SCI Current Challenges: Strengthening and Function
Patients with SCI usually gain weight Diabetes
Lack of movement Diet control
OsteoporosisLack of weight bearingNo pull of muscle on the bone
Previous behaviors and attitudes toward exercise.
SCI Current Challenges: Strengthening and Weight Gain
Exercise has been shown to decrease the risk for many of the secondary conditions associated with SCI, including osteoporosis, cardiovascular disease, pressure ulcers, urinary tract infections, diabetes and arthritis, yet this population is rarely a target for health promotion efforts.
Non-exercisers identified barriers to exercise, including a perceived low return on physical investment, lack of accessible facilities, unaffordable equipment, no personal assistance and fear of injury. M Kehn, T Kroll - BMC Public Health, 2009 - biomedcentral.com
SCI Current Challenges: Strengthening
The BMI of people with spinal cord injuries gradually increases during and after inpatient rehabilitation, with significant increases in the first year after discharge. It is recommended that emphasis is placed on weight-management protocols (diet and exercise) to encourage a healthy lifestyle. de Groot, Sonja; Post, Marcel W. M.; Postma, Karin; Sluis, Tebbe A.; van der Woude, Lucas H. V. Journal
of Rehabilitation Medicine, Volume 42, Number 10, November 2010, pp. 922-928(7)
SCI Current Challenges: Strengthening
Current Technology
Functional Electrical Stimulation (FES) FES Bike ES Elliptical FES Step and Stand
http://www.restorative-therapies.com/rt300leg
SCI Current Challenges: Strengthening and Function
Current Technology -- FES Legs – Bioness and Bioness L300 Plus
http://www.bioness.com/L300_Plus_For_Thigh_Weakness/How_Does_It_Work.php
SCI Current Challenges: Strengthening and Function
Current Technology – FES Walkaide -
https://www.youtube.com/watch?v=dB5xkPnR0oo&feature=player_detailpage
SCI Current Challenges: Strengthening and Function
Current Technology – FES Hands – Bioness H200 http://
www.bioness.com/H200_for_Hand_Paralysis/How_Does_It_Work.php
SCI Current Challenges: Strengthening and Function
How could technology improve SCI strengthening? More strengthening devices that improve
cardiac output and weight loss. Twice-weekly evoked resistive training (RT) to the paralyzed lower extremities resulted in significant skeletal muscle hypertrophy that was associated with reduction in VAT, visceral adipose tissue/subcutaneous adipose tissue ratio, and percent intermuscular fat. Significant improvements in insulin profile and lipid metabolism were
noted in the RT + diet when compared with diet alone. Med Sci Sports Exerc. 2012 Jan;44(1):165-74. doi: 10.1249/MSS.0b013e31822672aa. Effects of resistance
training on adiposity and metabolism after spinal cord injury.
SCI Current Challenges: Strengthening and Function Portability of the FES devices. More
streamlineWearable therapy http://www.axiobionics.com//Include FES training on all devices.
Smaller exercise devices that are portable and easily used
Wireless charging of devices so can you can use the device longer.
Cost effective. Cost is a barrier (maybe not to the VA but to others with a SCI)
SCI Current Challenges: Ambulation
Patient goals in spinal cord injury rehab typically start with walking“When Can I Walk?”
Ambulation has its benefits:Weight bearing to prevent osteoporosisMuscle control and movementBowel managementCardiorespiratory functionDecreased pain and spasticityQuality of life
SCI Current Challenges: Ambulation
Compensation for deficits to activity-dependent neural adaptation and training Physical Therapy October 2006 vol. 86 no. 10 1406-1425
We are trying to use what plasticity is available in the spinal cord to get outcomes.
Strengthen the muscles and have them ready.
SCI Current Challenges: Ambulation
Gait training with body weight-supported overground training is comparable to treadmill training for improving locomotion in people with traumatic incomplete tetraplegia.
Clin Rehabil. 2014 Jun 25. pii: 0269215514538068. Comparison of body weight-supported treadmill training versus body weight-supported overground training in people with incomplete tetraplegia: a pilot randomized trial.Senthilvelkumar T1, Magimairaj H2, Fletcher J3, Tharion G2, George J2.
SCI Current Challenges: Ambulation
Evidence on the effectiveness of locomotor therapy is limited. All approaches show some potential for improvement of ambulatory function without superiority of 1 approach over another. Arch Phys Med Rehabil. 2013 Nov;94(11):2297-308. doi:
10.1016/j.apmr.2013.06.023. Epub 2013 Jul 9. Effects of locomotor training after incomplete spinal cord injury: a systematic review. Morawietz C1, Moffat F.
SCI Current Challenges: Ambulation
Current technology Body Weight Support Treadmill Training
BWSTT Body Weight Support Treadmill Training
with Robotic assistLokomat
Robotic Exoskeletons Ekso BionicsRewalk
SCI Current Challenges: Ambulation
Body Weight Support Treadmill Training The improvements achieved by treadmill training are not
significantly different from other techniques such as over ground training and functional electrical stimulation. The most effective way of restoring locomotion is through complete repair; however, regeneration techniques are still
being developed. Labor intensive for therapy staff but effective – https://
www.youtube.com/watch?v=AWj9O-oMFyo&feature=player_detailpage
SCI Current Challenges: Ambulation
Body Weight Support Treadmill Training with Robotic assistLokomathttp
://www.hocoma.com/products/lokomat/lokomatpro/
SCI Current Challenges: Ambulation ReWalk
https://www.youtube.com/watch?v=cBzwbbTPJg0&feature=player_profilepage 5’3”-6’3” tall, weight 220lbs max Unit weights 49lbs Available for home use Not available for steps in the US Used at the Bronx VA
Speeds up to .06 m/sLimited community ambulators
SCI Current Challenges: Ambulation Ekso Bionics
https://www.youtube.com/watch?feature=player_detailpage&v=D5bgZ1mO97M Cervical level 7 (C7) or lower complete injury
(no sensation or motor below the level of injury
5'2" - 6'2" tall, weigh no more than 220 lbs Unit weighs around 50lbs (floor supports
weight of the device) Not yet approved for home use
SCI Current Challenges: Ambulation
What we need next… FES integrated training into bionics
FES training with activity base training is effective in motor recovery (hammons et al 2014).
In those with complete injuries, FES can be used in the lower limbs to promote muscular endurance and also improve cardiovascular fitness. FES can also be used to augment function and strengthen partially innervated muscles (Pouran, Garstang & Kida, 2009).
SCI Current Challenges: Ambulation
What we need next… More portable system
Can it be done?Will it fit in a car?
Do you wear it to work?Restroom or no restroom?
Can FES be added? More to come…
WE SERVE THOSE WHO SERVED
National Veteran Wheelchair Games
Coming to Dallas, June 2015http://www.va.gov/opa/speceven/wcg/index.asp#
References1. http://www.medetec.co.uk/slide%20scans/pressure-ulcer-images-a/index.html
2. Karoon Agrawal and Neha Chauhan Indian J Plast Surg. 2012 May-Aug; 45(2): 244–254. Pressure ulcers: Back to the basics
3. Am J Surg Oct 2010:200(4): 473-477 High Cost of Stage IV Pressure Ulcers4. Bliss MR. Acute pressure area care: Sir James Paget's legacy. Lancet. 1992;339:221–3.[PubMed]
5. Curry K, Casady L. The relationship between extended periods of immobility and decubitus ulcer formation in acutely spinal-cord injured individuals. J Neurosci Nurs. 1992;24:185–9.
6. Linares HA, Mawson AR, Saurez E, Biundo JJ. Association between pressure sores and immobilization in the immediate post-injury period. Orthopedics. 1987;10:571–3.
7. Mawsun AR, Biundo JJ Jr, Neville P, Linares HA, Winchester Y, Lopez A. Risk factors for early occurring pressure ulcers following spinal cord injury. Am J Phys Med Rehabil. 1988;67:123–7
8. Colen SR. Pressure sores. In: McCarthy JG, May JW, Littler JW, editors. Plastic surgery. Philadelphia: WB Saunders; 1990. pp. 3797–898.
9. Leigh IH, Bennet G. Pressure ulcers: Prevalence, etiology and treatment modalities. A review. Am J Surg. 1994;167:25S–30.
10. Med Sci Sports Exerc. 2012 Jan;44(1):165-74. doi: 10.1249/MSS.0b013e31822672aa.Effects of resistance training on adiposity and metabolism after spinal cord injury.
11. M Kehn, T Kroll - BMC Public Health, 2009 - biomedcentral.com
12. de Groot, Sonja; Post, Marcel W. M.; Postma, Karin; Sluis, Tebbe A.; van der Woude, Lucas H. V. Journal of Rehabilitation Medicine, Volume 42, Number 10, November 2010, pp. 922-928(7)
13. Physical Therapy October 2006 vol. 86 no. 10 1406-1425
14. Arch Phys Med Rehabil. 2013 Nov;94(11):2297-308. doi: 10.1016/j.apmr.2013.06.023. Epub 2013 Jul 9. Effects of locomotor training after incomplete spinal cord injury: a systematic review. Morawietz C1, Moffat F.
15. J Spinal Cord Med. 2014 Jun 29. [Epub ahead of print]Functional electrical stimulation as a component of activity-based restorative therapy may preserve function in persons with multiple sclerosis.Hammond ER, Recio AC, Sadowsky CL, Becker D.