Activity and Chronic SCI: Rebecca Martin & Beth Myers, Kennedy Krieger

The cord after injury . . ugh, yeah. Five major issues, all of which need attention. You have to block the molecules that are inhibiting axons from growing. You need some cells for remyelinating or regeneration. You need either a bridge or a scaffold — something to go around or through the injury site. That’s the big picture.

BUT you also need therapy. Activity promotes remyelination of surviving axons; if you have some axons without myelin, activity can help get them insulated again. The cord also has the capacity to learn (because it’s part of the brain), and activity is the way that happens. (Showing a video of a woman on a stim-bike; her arms are visibly firing in sync with the movement of her legs . . . as if she’s swinging them).

She has data about a group of their patients, all chronic. The transition probability is what they call the likelihood that a particular patient will go from one ASIA class to another; theirs isn’t huge, but it’s much better than that of traditional post-injury activity. And their patients are less likely to develop osteoparosis.

“We’re weird.” Okay, ten years ago we used to be weird, because ten years ago nobody thought it made sense to stand a person up, or to exercise the muscles below the level of the injury. Now they’re asking us what we’re doing.

We’re doing Activity-based restorative therapy. ABRT.

That means:

  • We want to activate the nervous system above and below the injury
  • High intensity practice for 2 – 5 hours per day
  • Non patterned and patterned movements
  • Restores lost function
  • Minimizes or eliminates compensatory devices

There are 5 key components to ABRT, learned painfully and slowly over the last 10 years:

  • FES, which is functional electrical stimulation. It can prevent or reverse disuse atrophy, substitute for orthotics . . .
  • Weight-bearing, which means loading weight on any joint. It promotes alignment, lessens bone stress, and normalizes input. It improves all kinds of things in your autonomic system (bowel and bladder, e.g.)
  • Locomotor training, which involves moving the legs and feet in an approximation of normal walking rhythm. It improves sensory, motor and autonomic function. It provides near normal sensory cues and comes with many benefits . . .
  • Massed practice, which is an intervention in which repeating a motion over and over is the primary factor. There’s a video of a man’s hand picking up ball after ball and dropping them into a plastic bucket. It promotes cortical reorganization; you have to do it multiple times for multiple hours and days.  In traditional rehab, the average duration was 36 minutes long — NOT enough. Not even close to what we ask of animals. Could high repetition training be done? They did 289 repetitions in each 47 minute session.
  • Task-specific practice is the last one; you’re train the task and not the impairment . . . video of a young man on a pt mat turning from back to side without help.

Aquatic therapy (pools!) can be a very effective way to work on all five. Most people don’t have access to fancy gyms or pools & therefore have to do home rehab programs. Best to have an FES unit, a standing frame of some kind, and an FES bike. That set of equipment would

Q: Is activity-based therapy now standard?

A: There are more of us, but . . .

Q: Are there hospitals using it for inpatients? What if I were somewhere else?

A: What we’re trying to do is incorporate the 5 principles WHILE training the self-care that has to be taught anyway. Transfer with no sliding board is one example.

Q: Something that scares all of us is the idea of becoming MORE impaired. Are there interventions that can prevent this?

A: Maintaining activity is how your body knows what to do, and that’s true for everybody, not just people in chairs. Your health literally depends on activity.

Q: What about the importance of nutrition and diet?

A: We have the luxury of having a nutritionist whom we can call in to address that — you’re correct that it’s vital. We’ve been looking at the correlation between BMI and skin scores . . . people who are slightly overweight seem to have some protection against skin breakdown.

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