Rehabilitation in Transverse Myelitis - Kennedy Krieger Institute

More documents

Recommendations

Info

have demonstrated the practical benefits of FES in individuals with sequelae of traumatic spinal cord injury (SCI). Some of those benefits include increased muscle mass, improved bone density, enhanced cardiovascular function, improved body composition (ratio of muscle to fat), improved bowel function, decreased spasticity, improved glucose metabolism, and reductions in bladder infection rate. In addition, electrical stimulation can be used in combination with other therapies to enhance functional recovery from SCI. One example is the use of FES to facilitate gait. 15 In a study of 70 patients, Solomonow and colleagues demonstrated that 14 weeks of FES walking (3 h/wk) improved total cholesterol, low-density lipoprotein levels, and hydroxyproline/creatinine ratios and reduced spasticity in patients with paraplegia from SCI. 16,17 In another study, after 10 weeks of FES cycling (2 to 3 sessions/wk), 18 subjects with SCI showed increased lean muscle mass, improved American Spinal Injury Association motor and sensory scores, and reductions in serum levels of IL-6, tumor necrosis factor ", and C-reactive protein (markers for inflammation). Limited clinical data are available on the use of FES in demyelinating disorders such as TM and multiple sclerosis (MS). A pilot trial of 12 patients with MS who underwent FES cycling (3 sessions/wk for 2 weeks) demonstrated improved spasticity but failed to show improvement in strength and walking speed. 18 Longterm FES bracing (3 to 12 months) for footdrop has been shown to increase strength and walking speed, suggesting that it strengthens activation of motor cortical areas and their residual descending connections in patients with MS. 19 A randomized trial of 44 subjects with MS and footdrop who received FES bracing or exercise for 18 weeks demonstrated that exercise may provide a greater training effect on walking speed and endurance than FES, although the FES group performed to a significantly higher level with FES than without for the same outcome measures. Therefore, the authors recommended studying the combined therapeutic effects of FES and exercise for this patient group. 20 In a recent pilot trial, patients with MS showed improvement on a broad array of functional and neurologic outcome measures including gait, upper extremity dexterity, and quality of life. Furthermore, analysis of CSF before FES and 3 months after initiating FES cycling revealed an enhanced neural repair program (increased CSF transforming growth factor $3) and a reduced inflammatory environment within the CNS (decreased interferon-,, IL-7, and IL-8). 21 Functional electrical stimulation characteristics in transverse myelitis. Successful implementation of FES to result in muscle contractions requires an intact lower motor neuron. Traditionally, the FES technology was used to generate purposeful contractions of paralyzed muscles. Newer FES technology, however, is based on applying low-level electrical currents that activate the ascending nerve fibers. Signals enter the spinal cord and are switched either directly or via interneurons to the lower motor neuron, which causes the muscle to contract. The use of FES is related not only to direct and visible muscle contraction but also to the effect of neural activation in the ascending sensory pathways and the effect of electrical current on the histology and biochemical characteristics of the muscle fibers. 22,23 In TM, the lower motor neuron is generally affected at the level of the inflammation. For that reason, muscle contractions in response KEY POINT h Functional electrical stimulation has shown proven benefits in individuals with sequelae of traumatic spinal cord injury, including increased muscle mass, improved bone density, enhanced cardiovascular function, improved body composition, improved bowel function, decreased spasticity, improved glucose metabolism, and reductions in bladder infection rate. Continuum Lifelong Learning Neurol 2011;17(4):816–830 www.aan.com/continuum Copyright @ 201 1 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 821
KEY POINT h Functional electrical stimulation does not always produce visible activation of muscles in transverse myelitis because of lower motor neuron involvement. In those cases, use of different current characteristics (ie, longer pulse width, bidirectional/rectangular, or even direct current) can prevent muscle atrophy and its sequelae. Rehabilitation to FES from levels at the injury site are usually limited or absent. This may be a transient phenomenon related to the acute inflammation. In most patients, some of the lower motor neuron function returns weeks to months following the injury. During that period, it is important to try to avoid muscle atrophy and its sequelae at that level. This may be attempted by using other electrical stimulation devices that utilize an unusually long duration (ie, 200 6s) and unusually shaped (bidirectional, rectangular) current impulse or by activating the muscle from a different spinal level in addition to using traditional rehabilitation approaches (eg, bracing, taping, splinting). Sensory Stimulation Sensory stimulation can be used to activate afferent pathways with the goal of providing information that can subsequentlybeusedtoperformamotortask with the direct effect being improved motor and sensory function. 24,25 An exampleofthisissensorystimulationthat enhances excitatory inflow from muscle spindles to the motor neuron pools and depresses the inhibitory effect of the Golgi tendon organ. Focal sensory activation or stimulation and nonfocal activation (eg, epidural stimulation or intrathecal delivery of neurotrophin-3 or brain-derived neurotrophic factor) can also produce complex lower limb cyclinglike movements. In a doubleblind, randomized controlled clinical trial using whole-body vibration in patients with MS, Schuhfried and colleagues demonstrated improved postural control and walking speed. 26 PEDIATRIC CONSIDERATIONS Approximately 20% of patients with acute transverse myelitis (ATM) are younger than 18 years of age. 27 Pidcock and colleagues 4 analyzed the largest cohort of pediatric patients with ATM ever published using standardized functional measures. According to the study, ATM may have a bimodal distribution of age, with approximately 40% of patients being younger than 3 years of age (compared to 10% reported in previous studies) and another peak in incidence occurring between the ages of 5 and 17 years. Most patients had the greatest impairment during the acute illness period and reached their functional nadir 2 days after the onset of symptoms. Eighty-nine percent of children had acute muscle weakness, were limited to bed or a wheelchair for mobility, or required ventilatory assistance during this stage. Of the patients who were nonambulatory, 52% were able to walk at least 30 feet with or without the help of a walker, while only 39% of the patients who initially needed ventilator assistance were able to do so at the time of follow-up. In the acute phase, 82% of the patients experienced bladder dysfunction requiring catheterization, and 50% of the patients still required catheterization at follow-up. Regarding functional outcome, most patients were independent in the skill areas measured by the Functional Independence Measure (FIM) and WeeFIM (FIM for children) systems: self-care, communication, social cognition, transfers, and locomotion. However, 33% required minimal to total assistance for ambulation or using the wheelchair for more than 160 feet. More than half (54%) of children required minimal to total assistance for sphincter control, while 36% required assistance for mobility with transfers and 27% required assistance for self-care needs. According to this study, even though most patients recover adequate muscle strength and motor control for ambulation, significant impairments remain within important functional domains such as transfers, self-care needs, and sphincter control. 822 www.aan.com/continuum August 2011 Copyright @ 201 1 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Page 1 and 2: Address correspondence to Dr Cristi
Page 3 and 4: KEY POINTS h Some muscle tightness
Page 5: KEY POINTS h Activity-based restora
Page 9 and 10: Rehabilitation Case 6-1 A 6-year, 8
Page 11 and 12: Rehabilitation they may be delayed
Page 13 and 14: KEY POINT h Applying conceptually s
Page 15: Rehabilitation unique complication

Rehabilitation in Transverse Myelitis - Kennedy Krieger Institute

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?