Changes of tibia bone properties after spinal cord injury: effects of early intervention.

date: 02/01/1999
author: De Bruin ED, Frey-Rindova P, Herzog RE, Dietz V, Dambacher MA, Stussi E.
publication: Arch Physical Medicine Rehabilitation. 1999 Feb;80(2):214-20.
pubmed_ID: 10025500

OBJECTIVE: To evaluate the effectiveness of an early intervention program for attenuating bone mineral density loss after acute spinal cord injury (SCI) and to estimate the usefulness of a multimodality approach in diagnosing osteoporosis in SCI. DESIGN: A single-case, experimental, multiple-baseline design. SETTING: An SCI center in a university hospital. METHODS: Early loading intervention with weight-bearing by standing and treadmill walking. PATIENTS: Nineteen patients with acute SCI. OUTCOME MEASURES: (1) Bone density by peripheral computed tomography and (2) flexural wave propagation velocity with a biomechanical testing method. RESULTS: Analysis of the bone density data revealed a marked decrease of trabecular bone in the nonintervention subjects, whereas early mobilized subjects showed no or insignificant loss of trabecular bone. A significant change was observed in 3 of 10 subjects for maximal and minimal area moment of inertia. Measurements in 19 subjects 5 weeks postinjury revealed a significant correlation between the calculated bending stiffness of the tibia and the maximal and minimal area moment of inertia, respectively. CONCLUSION: A controlled, single-case, experimental design can contribute to an efficient tracing of the natural history of bone mineral density and can provide relevant information concerning the efficacy of early loading intervention in SCI. The combination of bone density and structural analysis could, in the long term, provide improved fracture risk prediction in patients with SCI and a refined understanding of the bone remodeling processes during initial immobilization after injury.

Effects of a dynamic versus a static prone stander on bone material density and behavior in four children with severe cerebral palsy.

date: 03/01/2002
author: Gudjonsdottir, Bjorg MS/PT, Vicki Stemmons Mercer, PhD, PT
publication: Pediatric Physical Therapy 2002;14:38-46.
pubmed_ID: 17053680

PURPOSE: in this case series, we examined how two types of prone standers affected bone material density and behavioral variables in four children of preschool age with severe cerebral palsy. METHODS: In phase one, four children of preschool age participated in an eight-week standing program, standing for 30 minutes a day, five days a week. Two children stood in a conventional stander, and two stood in a new type of motorized (dynamic) stander that provides intermittent weight bearing. Measurements of bone material density before and after the program revealed increases in bone material density in both children who used a dynamic stander and one child who used a static stander. In phase two, all four subjects stood in both types of stander during three separate test sessions. RESULT: Measures of behavioral variables, including behavioral state, reactivity, goal directedness, and attention span, indicated little or no effect of type of stander on behavior. CONCLUSIONS: These results suggest there is potential value in additional research concerning the effects of static and dynamic standers on bone material density and behavior in children with cerebral palsy.

Follow-up assessment of standing mobility device users.

date: 10/01/1998
author: Dunn RB, Walter JS, Lucero Y, Weaver F, Langbein E, Fehr L, Johnson P, Riedy L.
publication: Assistive Technology. 1998;10(2):84-93.
pubmed_ID: 10339284

The use of standing devices by spinal cord-injured subjects was investigated through a national survey of a sample of individuals who returned their manufacturer’s warranty card to two companies. We obtained a 32% response rate (99/310). The majority of respondents were male (87%) with a median age between 41 and 50 years. Seventy-seven percent were paraplegic and 21% were quadriplegic. Forty percent had between 1 and 5 years experience with their device, and 84% of those responding were currently using their standing device. Forty-one percent used their standing device one to six times a week; two-thirds stood between 30 minutes and 1 hour for each use. Less than 10% of subjects experienced any side effects, such as nausea or headaches, from standing. Twenty-one percent of subjects reported being able to empty their bladder more completely. There was also a favorable response by some individuals on the effects of the standing devices on bowel regularity, reduction of urinary tract infections, leg spasticity, and number of bedsores. Finally, 79% of subjects highly recommended use of standing devices to other people with spinal cord injury. The positive responses of individuals using standing devices is a strong recommendation for the assistive technology community to make these devices more available to individuals with spinal cord injury.

Technical note–a patient propelled variable-inclination prone stander.

date: 12/01/1983
author: Motloch WM, Brearley MN.
publication: Prosthet Orthot Int. 1983 Dec;7(3):176-7.
pubmed_ID: 6647014

A self-propelled mobile standing device is described with the facility of patient-operated inclination of the support platform, enabling objects on the floor to be reached. The device is provided with a removable tray at the level of the occupant’s chest.

Evaluation of the effects of muscle stretch and weight load in patients with spastic paraplegia.

date: 01/01/1981
author: Odeen I, Knutsson E.
publication: Scand J Rehabilitation Medicine. 1981;13(4):117-21.
pubmed_ID: 7347432
Clinical observations on patients with spastic paraplegia have indicated that a training regime including weight load on the lower limbs may reduce the muscular hypertonus. Due to the spontaneous fluctuations and great variability in muscle tone it is difficult to judge from clinical findings how the effects may be related to muscle stretch and weight load. Therefore, quantitative determination of the effects on muscle tone by stretch and loading was made in 9 paraplegic patients. Muscle tone was measured before and after 30 min of stretch or weight load in 8 sessions on 4 consecutive days. Stretch was obtained by bracing the foot in maximal dorsal flexion with patient in supine position. For weight load on the lower limbs, the patient stood on a tilt-table at an angle of 85 degrees with feet in 15 degrees dorsal or plantar flexion. Resistance to passive movements was determined during a series of sinusoidal ankle joint movements at three different speeds. After weight load in standing with the feet in dorsal or plantar flexion, the average reduction was 32 and 26%, respectively. After stretch in supine, the average reduction was 17%. Thus, the three procedures tested all resulted in reduction of muscle tone. The largest reductions were obtained by weight load with stretch imposed upon the calf muscles.

Nonoperative treatment of osteogenesis imperfecta: orthotic and mobility management.

date: 09/01/1981
author: Bleck EE.
publication: Clin Orthop Relat Res. 1981 Sep;(159):111-22.
pubmed_ID: 7285447

The problem of osteoporosis superimposed on the basic collagen defect of osteogenesis imperfecta has been approached by the use of plastic containment orthoses for the lower limbs, in addition to developmentally staged mobility devices that assist early standing and walking. The purpose of forcing early weight-bearing is to provide stress to the lower limb bones in order to minimize osteoporosis, prevent refracture and deformity, and curb subsequent immobilization osteoporosis, thus breaking a vicious cycle. Management goals are based upon adult needs for independence: efficiency in daily living activities and in mobility. These goals were reached in most of our patients via use of plastic orthoses, early weight-bearing, and electrically powered wheelchairs. Manual osteoclasis of the tibia followed by plastic orthoses utilizing principles of fluid compression to support fractured or structurally weak bones appeared successful at the time of follow-up. Intramedullary rodding of the femur was necessary in most of the 12 children with osteogenesis imperfecta congenita. Supplementary plastic orthoses have reduced the refracture rate in both the tibia and the femur. Social integration of the children was reflected by the fact that among the 12 OI congenita cases, ten were attending regular educational institutions. Twelve OI tarda children fared well, all attaining complete independence in daily living, mobility and ambulation. Seven of this group were treated with intramedullary rodding of the femur or tibia and with plastic orthoses. Five patients required no treatment.

Reliability and comparison of weight-bearing ability during standing tasks for individuals with chronic stroke.

date: 08/01/2002
author: Eng JJ, Chu KS.
publication: Arch Phys Med Rehabilitation. 2002 Aug;83(8):1138-44.
pubmed_ID: 12161837

OBJECTIVES: To determine the test-retest reliability over 2 separate days for weight-bearing ability during standing tasks in individuals with chronic stroke and to compare the weight-bearing ability among 5 standing tasks for the paretic and nonparetic limbs. DESIGN: Prospective study using a convenient sample. SETTING: Free-standing tertiary rehabilitation center. PARTICIPANTS: Fifteen community-dwelling stroke individuals with moderate motor deficits; volunteer sample. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Weight-bearing ability as measured by the vertical ground reaction force during 5 standing tasks (rising from a chair, quiet standing, weight-shifting forward, backward, laterally). RESULTS: The weight-bearing ability was less for the paretic limb compared with the nonparetic limb, but the intraclass correlation coefficients were high (.95-.99) for both limbs between the 2 sessions for all 5 tasks. The forward weight-shifting ability was particularly low in magnitude on the paretic side compared with the other weight-shifting tasks. In addition, the forward weight-shift ability of the nonparetic limb was also impaired but to a lesser extent. Large asymmetry was evident when rising from a chair, with the paretic limb bearing a mean 296N and the nonparetic side bearing a mean 458N. The weight-bearing ability during all 5 tasks correlated with one another (r range,.56-.94). CONCLUSIONS: Weight-bearing ability can be reliably measured and may serve as a useful outcome measure in individuals with stroke. We suggest that impairments of the hemiparetic side during forward weight shifting and sit-to-stand tasks presents a challenge to the motor systems of individuals with stroke, which may account for the poor balance that is often observed in these individuals. Copyright 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation.

Contractures secondary to immobility: is the restriction articular or muscular? An experimental longitudinal study in the rat knee.

date: 01/01/2000
author: Trudel G, Uhthoff HK.
publication: Arch Phys Med Rehabilitation. 2000 Jan;81(1):6-13.
pubmed_ID: 10638868

OBJECTIVES: To measure articular structures’ contribution to the limitation of range of motion after joint immobility. STUDY DESIGN: Experimental, controlled study involving 40 adult rats that had one knee joint immobilized in flexion for durations of 2, 4, 8, 16, and 32 weeks; 20 rats underwent a sham procedure. The angular displacement was measured both in flexion and extension at three different torques. Myotomy of transarticular muscles allowed isolation of the arthrogenic component of the contracture. RESULTS: A contracture developed in all immobilized knees. The articular structures were incrementally responsible for the limitation in range of motion (from 12.6 degrees +/-6.7 degrees at 2 weeks to 51.4 degrees +/-5.4 degrees at 32 weeks). The myogenic restriction proportionately decreased over time (from 20.1 degrees +/-8.4 degrees at 2 weeks to only 0.8 degrees +/-7.2 degrees at 32 weeks). The increase in the arthrogenic component of contracture was predominant in extension. CONCLUSION: This study quantified the increasing role of arthrogenic changes in limiting the range of motion of joints after immobility, especially as the period of immobility extended past 2 weeks. These data provide a better understanding of joint contracture development and can be used to guide therapeutic approaches.

Effects of prolonged muscle stretch on reflex and voluntary muscle activations in children with spastic cerebral palsy.

date: 01/01/1990
author: Tremblay F, Malouin F, Richards CL, Dumas F.
publication: Scand J Rehabilitation Medicine. 1990;22(4):171-80.
pubmed_ID: 2263918

We studied the short term effects of a single session of prolonged muscle stretch (PMS) on reflex and voluntary muscle activations in 22 children with spastic cerebral palsy (CP) assigned to an experimental (n = 12) and a control group (n = 10). Children of the experimental group underwent PMS of the triceps surae (TS) by standing with the feet dorsiflexed on a tilt-table for 30 min, whereas children of the control group were kept at rest. The effects were determined by measuring the associated changes in torque and in electromyographic (EMG) activity of the TS and tibialis anterior (TA) muscles during both passive ankle movements and maximal static voluntary contractions. The results indicate that PMS led to reduced spasticity in ankle muscles as demonstrated by the significant reductions (p less than 0.05) of the neuromuscular responses (torque and EMG) to passive movement. These inhibitory effects lasted up to 35 min after cessation of PMS. In addition, the capacity to voluntarily activate the plantar flexors was significantly (p less than 0.05) increased post-PMS, but the capacity to activate the dorsiflexors was apparently not affected. These findings suggest that repeated sessions of PMS may have beneficial effects in the management of spasticity in children with CP.

Considerations related to weight-bearing programs in children with developmental disabilities.

date: 01/01/1992
author: Stuberg WA.
publication: Phys Ther. 1992 Jan;72(1):35-40.
pubmed_ID: 1728047

Standing is a common modality used in the management of children with developmental disabilities. The purpose of this article is to examine the scientific basis for standing programs, with specific emphasis on the known effects of weight bearing on bone development. Guidelines for the use of standing programs are presented, and the supporting rationale is discussed.