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Sep 07
0

Abdominal Binders

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Author: Sharon Jang | Reviewer: Cathy Nevens | Published: 7 September 2019 | Updated: ~

Abdominal binders are simple pieces of equipment that are used to support the abdomen. This page outlines what abdominal binders are and how they are used after spinal cord injury (SCI).

Key Points

  • Abdominal binders are devices which apply pressure to the abdomen to help improve breathing and circulation in upright postures.
  • These may be elastic or non-elastic devices that wrap around the lower torso to apply pressure and mimic the function of the abdominal muscles.
  • Abdominal binders are considered safe with a minimal number of risks when used appropriately.
  • Research suggests that abdominal binders can help to reduce changes in blood pressure (orthostatic hypotension) when moving from a lying to standing position and may help to improve breathing after SCI.

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What are abdominal binders?

A man in a wheelchair with an abdominal binder over his shirt

Abdominal binders wrap around to support the abdomen when the abdominal muscles are weak or paralyzed. They are normally worn under the shirt.1

An abdominal binder is an elastic piece of material that is placed normally placed around the lower torso to apply pressure to the abdomen. Abdominal binders should fit snugly around the torso and be tight enough to provide support, but should not be uncomfortable. Abdominal binders are typically worn under the shirt and are mainly used to improve circulation and breathing when in an upright position. They are also sometimes used to help maintain balance and stability of the trunk and to support sagging of the abdomen (sometimes called “quad belly”) that can happen when the abdominal muscles are weak.

What types of abdominal binders are there?

There are two main types of abdominal binders: elastic and non-elastic binders. Each of these types will have a number of different models or designs available that may be used. Talk to your health providers about what type are most appropriate for you.

Elastic abdominal binders

The most common type of abdominal binder used by people with SCI is made from a stretchy elastic fabric that is placed around the abdomen and closed with Velcro. The material mimics the nature of the abdominal muscles by providing some pressure but also allowing the abdomen to expand and recoil while breathing. Some elastic abdominal binders have additional supports built into them that may be used to assist with balance and stability.

Non-elastic abdominal binders

Non-elastic abdominal binders include pieces of equipment such as a corset, girdle, straps or mechanical device to support the abdomen. These are made from a non-stretchy material that provides greater support. Non-elastic abdominal binders are not used as often after SCI because they have greater potential to injure the skin and may also restrict the abdomen while breathing, which may contribute to an abnormal breathing pattern.

Why are abdominal binders used?

Breathing and cough function

Cartoon lungsPeople with cervical and thoracic SCI may experience breathing problems because of a loss of nerve control to the diaphragm and other breathing muscles (including the abdominal muscles). This causes the diaphragm to sit too low in the abdomen so it cannot work optimally.

Abdominal binders are thought to mimic some of the function of the abdominal muscles to help support breathing. The binder compresses the abdomen, which increases pressure and may help to raise the diaphragm into a better position for breathing.

There is evidence that abdominal binding in people with tetraplegia can improve respiratory function. Studies have shown that the use of abdominal binders can improve an individual’s ability to inhale and exhale. Overtime, the use of an abdominal binder can strengthen the muscles that are used to inhale. The design of the abdominal binder may also influence its effectiveness. For example, one (weak evidence) study found that a custom girdle may cause individuals to perceive breathing as easier.

More research is required to find out how using an abdominal binder strengthens the diaphragm and whether this leads to easier breathing. Abdominal binding for people with SCI should be introduced gradually due to potential adverse effects on one’s ability to breathe.

Refer to our article on Respiratory Changes After SCI for more information!

Blood pressure and circulation

Cartoon electrocardiogram signal underneath a heartMany people with SCI experience a drop in blood pressure when moving from a lying or sitting position to an upright position. This is known as orthostatic hypotension. This condition happens because a loss of nerve function can impair the body’s ability to tighten (constrict) the blood vessels and change heart rate, which is an important part of maintaining blood pressure in different positions.

Because abdominal binders wrap around and compress the abdomen, they may help to increase pressure in the abdominal area. This may help to prevent blood pooling in the blood vessels in the abdomen when upright, which may help maintain blood pressure and allow better circulation.

There is conflicting evidence based on limited research that abdominal binders have any effect on cardiovascular responses in people with SCI. One study found that abdominal binders do not have any effect on average blood pressure or other cardiovascular responses. However, other studies suggest that abdominal binders in combination with leg stockings may have an effect on cardiovascular responses during lower intensity arm exercise.

Refer to our article on Orthostatic Hypotension for more information!

Speech

Cartoon sound waves coming out of a person's mouthThere is some weak evidence for the use of an abdominal binder to improve speech. One study found that participants with difficulty speaking due to cervical level injuries were able to produce more natural sounding speech, were able to speak louder, and improved overall voice quality with the use of an abdominal binder. Meanwhile, another study has shown that using an abdominal binder can extend the length that sound is produced for.

Balance, stability, and appearance

A profile of a man on a wheelchair with a protruded belly on the left. A profile of a man on a wheelchair with a flattened belly wearing an abdominal binder on the right.

Abdominal binders may be used to support the abdomen to reduce the appearance of “quad belly”.5

Some individuals use an abdominal binder as they perceive it helps to support their trunk or assist with sitting balance. In addition, some individuals find that it helps them balance when performing two-handed exercises. However, no research has been done to support this. Some individuals may use a binder to reduce the appearance of the abdomen sagging forward, sometimes called “quad belly”.

Are abdominal binders safe to use?

Abdominal binders are considered safe for most people. In all cases, the skin under the binder should be regularly checked for pressure sores. However, there are situations in which abdominal binders may not be appropriate and carry possible risks. Please consult a health provider for detailed safety information.

Abdominal binders should be used with caution in the following situations:

  • Do not use directly over areas prone to pressure injuries or over current injuries, wounds, or sores
  • Caution is advised if a person has a stoma (colostomy or urostomy bag) on the front of their abdomen. There is the possibility of the binder causing irritation or interference to the stoma site. A customized binder may be required to ensure no irritation to the area.

Risks of using abdominal binders may include:

  • Pressure injuries, if the equipment is too tight and creates too much pressure or cuts into the skin.
  • If the abdominal binder is tightened too much, it can get in the way of the abdomen and lower ribs expanding, which may make breathing difficult.
  • Also, an overly tight abdominal binder could cause an increase in spasticity or trigger autonomic dysreflexia in some people.

Refer to our articles on Pressure Injuries, Spasticity, and Autonomic Dysreflexia for more information!

The bottom line

Abdominal binders are a physical treatment that supports the abdomen when the abdominal muscles are weak or paralyzed.

The support from the binder can improve cardiovascular and respiratory responses including blood pressure and breathing.

Some individuals may use a binder to help with balance and stabilizing the trunk but there is no research evidence to support this.

Some individuals may use a binder to reduce the appearance of abdominal muscles that bulge out following paralysis.

For a review of how we assess evidence at SCIRE Community and advice on making decisions, please see SCIRE Community Evidence.

Reference list

This page has been adapted from SCIRE Professional “Respiratory Management” and “Orthostatic Hypotension” Modules:

Sheel AW, Reid WD, Townson AF (2018). Respiratory Management Following Spinal Cord Injury. In: Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, Sproule S, Querée M, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 6.0. Vancouver: p. 1-72.
Available from: scireproject.com/evidence/respiratory-management/

Krassioukov A, Wecht JM, Teasell RW, Eng JJ (2014). Orthostatic Hypotension Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 5.0. Vancouver: p 1- 26.
Available from: scireproject.com/evidence/orthostatic-hypotension/non-pharmacological-management-of-oh/ 

Evidence for “Are abdominal binders safe to use?”

Cornwell, P., Ward, E., Lim, Y., & Wadsworth, B. (2014). Impact of an Abdominal Binder on Speech Outcomes in People With Tetraplegic Spinal Cord Injury: Perceptual and Acoustic Measures. Topics in Spinal Cord Injury Rehabilitation, 20(1), 48–57. https://doi.org/10.1310/sci2001-48

Wadsworth, B. M., Haines, T. P., Cornwell, P. L., Rodwell, L. T., & Paratz, J. D. (2012). Abdominal Binder Improves Lung Volumes and Voice in People With Tetraplegic Spinal Cord Injury. YAPMR, 93(12), 2189–2197. https://doi.org/10.1016/j.apmr.2012.06.010

Image credits:

  1. Image by SCIRE
  2. Lungs ©karina, CC BY 3.0 US
  3. Blood Pressure ©Ricardo Moreira, CC BY 3.0 US
  4. speak ©Gregor Cresnar, CC BY 3.0 US
  5. Image by SCIRE

 

Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication.

Mar 25
0

Exercise Guidelines for Adults With Spinal Cord Injury

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Download the Exercise Guidelines, currently available in 13 languages:

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Author: Dominik Zbogar | Reviewer: Kathleen Martin Ginis | Published: 25 March 2019 | Updated: 30 June 2023

Physical activity is an important consideration after spinal cord injury (SCI) and is a key factor in preventing lifestyle diseases. This page provides guidelines for physical activity following SCI.

Key Points

  • People with SCI face tremendous physical, psychosocial, and environmental barriers to physical activity. They are less active and physically deconditioned than the general population and people with other disabilities.
  • Overwhelming evidence suggests that people living with SCI can achieve health benefits from activity levels well below the generally recommended 150 min/week threshold.
  • The guidelines herein were created for adults aged 18-64 with chronic SCI (at least one year post-onset), with consideration given to the potential risks of SCI-specific adverse events including upper-body over-use injuries, skin breakdown, autonomic dysreflexia, and over-heating as well as consideration to the feasibility of these guidelines in the SCI population.

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How were the exercise guidelines developed?

A screen-capture of the first page of the journal article "Evidence-based scientific exercise guidelines for adults with SCI" from Martin-Ginis et al.A group led by Dr. Kathleen Martin Ginis at the University of British Columbia and Dr. Victoria Goosey-Tolfrey at Loughborough University, UK developed international guidelines on exercise after SCI. The process of developing these guidelines involved a systematic review of relevant literature, consensus meetings, stakeholder feedback, and a formal audit of the process.

The result was the publication of the journal article about the guidelines (available in the journal Spinal Cord via nature.com/articles/s41393-017-0017-3) and the actual guidelines titled, “Scientific Exercise Guidelines for Adults with Spinal Cord Injury” which are described next.­

What are the exercise guidelines for adults with SCI?

The exercise guidelines for adults with SCI.

For cardiorespiratory fitness and muscle strength benefits, adults with SCI should engage in:

  • At least 20 minutes of moderate to vigorous intensity aerobic exercise 2 times per week.
  • 3 sets of strength exercises for each major functioning muscle group, at a moderate to vigorous intensity, 2 times per week.

For cardiometabolic health benefits, adults with SCI are suggested to engage in:

  • At least 30 minutes of moderate to vigorous intensity aerobic exercise 3 times per week.

wheelchair sign image multiplied and stretched out

What are cardiometabolic health, cardiorespiratory fitness, and muscle strength?

Cardiometabolic health

Cardiometabolic health encompasses measures of body composition (e.g., fat mass, lean body mass) and risk factors for cardiovascular disease (e.g., high cholesterol and hypertension). Common measures to assess cardiometabolic health include a blood test to assess triglycerides and cholesterol, measuring blood pressure, and measuring height, weight, and waist circumference.

Cardiovascular fitness

Cardiovascular fitness refers to the ability of the heart and lungs to deliver oxygen to working muscles and can be assessed through a maximal graded exercise test which provides information such as peak oxygen uptake and peak power output.

Muscle strength

Muscle strength refers to the amount of force that a muscle can exert. It can be measured by lifting objects of specified weight or exerting force against a measurement tool such as a hand grip dynanometer.

The exercise guideline details

These exercise guidelines provide minimum thresholds for improving cardiorespiratory fitness and muscle strength and for improving cardiometabolic health.

orange speedometer set to lowIf you are not already exercising, it is okay to start with smaller amounts of exercise and gradually increase duration, frequency, and intensity, as a progression toward meeting the guidelines. Doing exercise below the recommended levels may or may not bring small changes in fitness or cardiometabolic health.

green speedometer set to highExceeding these exercise guidelines would be expected to yield additional cardiorespiratory fitness and muscle strength and cardiometabolic health benefits. However, there are insufficient data to comment on the risks associated with a person with SCI exceeding these guidelines.

The guidelines should be achieved above and beyond the incidental physical activity one might accumulate in the course of daily living. Adults are encouraged to participate routinely in exercise modalities and contexts that are sustainable, enjoyable, safe and reasonably achievable.

Refer to our article on Physical Activity for more information! 

These guidelines are appropriate for adults (aged 18-64) with chronic SCI (at least one year post-onset), neurological level of injury C3 and below, from traumatic or non-traumatic causes, including tetraplegia and paraplegia, irrespective of sex, race, ethnicity or socio-economic status.

The guidelines may be appropriate for individuals with a SCI less than one year post-onset, aged 65 years or older, or living with comorbid conditions. There is currently insufficient scientific evidence to draw firm conclusions about the risks and benefits of the guidelines for these individuals. These individuals should consult a health care provider prior to beginning an exercise programme.

The risks associated with these guidelines are minimal when managed in consultation with a health care professional who is knowledgeable in SCI. Individuals with a cervical or high thoracic injury should be aware of the signs and symptoms of autonomic dysreflexia during exercise.

Refer to our article on Autonomic Dysreflexia for more information! 

The bottom line

These guidelines were developed using transparent and rigorous steps that align with international best-practices for developing clinical practice guidelines. They represent an important step toward developing exercise policies and programs for people with SCI around the world.

References

Hicks, A. L., Martin Ginis, K. A., Pelletier, C. A., Ditor, D. S., Foulon, B., & Wolfe, D. L. (2011). The effects of exercise training on physical capacity, strength, body composition and functional performance among adults with spinal cord injury: a systematic review. Spinal Cord, 49(11), 1103–1127.

Martin Ginis, K. A., van der Scheer, J. W., Latimer-Cheung, A. E., Barrow, A., Bourne, C., Carruthers, P., … Goosey-Tolfrey, V. L. (2018). Evidence-based scientific exercise guidelines for adults with spinal cord injury: an update and a new guideline. Spinal Cord, 56(4), 308–321.

Hoekstra, F., McBride, C.B., Borisoff, J. et al. (2020). Translating the international scientific spinal cord injury exercise guidelines into community and clinical practice guidelines: a Canadian evidence-informed resource. Spinal Cord. https://doi.org/10.1038/s41393-019-0410-1

Images credits
  1. Flag of the Netherlands: ©Zscout370, CC BY 4.0
  2. Flag of the United Kingdom: ©Xaosflux, CC BY 4.0
  3. Flag of France: Public Domain
  4. Flag of Germany: ©Anomie, CC BY 4.0
  5. Flag of Greece: Public Domain
  6. Flag of Indonesia: Public Domain
  7. Flag of Italy: ©Anomie, CC BY 4.0
  8. Flag of Japan: Public Domain
  9. Calligraphic rendition of Farsi: By Jahongard – Own work based on: Farsi.jpg, CC BY-SA 3.0
  10. Flag of South Korea: Public Domain
  11. Flag of Spain: ©Vzb83, CC BY 4.0
  12. Flag of Sweden: ©Mr. Stradivarius, CC BY 4.0
  13. Flag of Thailand: ©Zscout370, Public Domain
  14. Modified from: Journal article screencap©Kathleen A. Martin Ginis, CC BY-NC 4.0
  15. Modified from: The scientific exercise guidelines for adults with spinal cord injury©Kathleen A. Martin Ginis, CC BY-NC 4.0
  16. Modified from: Pictogram of person in wheelchair©Kathleen A. Martin Ginis, CC BY-NC 4.0
  17. Modified from: Speedometer: ©designvector, CC BY-NC 4.0
  18. Modified from: Speedometer: ©designvector, CC BY-NC 4.0

 

Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication.
Apr 09
0
Illustration showing a person lying on a tilt table and secured with a band around the waist. There is an arrow showing that the tilt table is moving to an upright position.

Orthostatic Hypotension (Postural Hypotension)

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Author: SCIRE Community Team | Reviewer: Darryl Caves | Published: 9 April 2018 | Updated: ~

Changes to blood pressure control after spinal cord injury (SCI) may contribute to a condition called orthostatic hypotension. This page provides information about orthostatic hypotension after SCI.

Key Points

  • Orthostatic hypotension is a decrease in blood pressure when moving from a lying or sitting position to an upright position.
  • Orthostatic hypotension may be experienced as dizziness, light-headedness, fainting and weakness when getting upright.
  • Research suggests that the medication midodrine hydrochloride is effective for treating orthostatic hypotension after SCI.
  • A number of other medications and non-drug treatments are also used to treat orthostatic hypotension, including fluid and salt intake, compression garments, electrical stimulation and various forms of physical activity. Further research is needed to determine if these treatments are effective.

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What is orthostatic hypotension?

Orthostatic hypotension (also called postural hypotension) is a decrease in blood pressure when moving from a sitting or lying position to an upright position.

Orthostatic hypotension is common early after an SCI, but it can also be present long-term or following an illness or period of reduced mobility. Orthostatic hypotension may happen with or without symptoms.

Signs and symptoms of orthostatic hypotension:

Blurry image of a city in the night time.

Blurry vision is a common symptom of orthostatic hypotension.1

  • Dizziness
  • Light-headedness
  • Fainting
  • Temporary loss of consciousness (experiencing a ‘black out’)
  • Fatigue (tiredness)
  • Blurry vision
  • Muscle weakness

Orthostatic hypotension is more common early after injury. For some people, orthostatic hypotension gradually goes away as their body adapts to the changes after the injury. However, for others, orthostatic hypotension persists over time and may require treatment to manage their symptoms.

Who is at risk of experiencing orthostatic hypotension after SCI?

Orthostatic hypotension can happen to anyone after SCI; however certain factors are associated with developing orthostatic hypotension.

People with higher level injuries

Orthostatic hypotension is more common in people with higher levels of SCI, especially with injuries in the cervical and mid to upper thoracic spinal cord (injuries above T6).

People with traumatic injuries

People with traumatic SCI are more likely to develop orthostatic hypotension than those with a non-traumatic SCI.

Why does orthostatic hypotension happen?

Blood pressure changes in response to changes in body position.2

 

When the body moves into an upright position, the blood naturally flows downward because of gravity. If the body does not respond in any way to help push the blood back up, it pools in the blood vessels of the lower body, causing a drop in blood pressure in the upper body. If blood pressure is low, not enough blood can reach the heart and brain, which causes symptoms like dizziness, fainting and tiredness.

 

 

How is blood pressure controlled when the spinal cord is not injured?

Under normal circumstances, when we move upright, the body’s blood pressure control mechanisms kick in to maintain circulation. The main changes include:

  • The blood vessels narrow (called vasoconstriction), to prevent pooling and maintain blood pressure.
  • The heart works harder by pumping more quickly to help push blood through circulation.

The combined narrowing of blood vessels and increase in heart rate help maintain blood pressure against the force of gravity in standing. These changes are controlled by the autonomic nervous system.

Orthostatic hypotension is common after SCI, particularly in the early period after injury. There are several reasons that orthostatic hypotension happens after SCI.

Bed rest

During the early phase after injury, bed rest is often required for healing of injuries. However, long periods of bed rest and reduced movement can cause the heart and blood vessels to become less responsive to position changes and changes in blood pressure.

During bed rest, there is a shift in the distribution of fluids within the body which causes a loss of fluid through urination (called diuresis). This leads to reduced blood volume (the volume of blood in circulation), which affects the body’s ability to adapt to changes in blood pressure. This likely contributes to orthostatic hypotension in the early phase after SCI.

The body may also produce more of a chemical called nitric oxide as a result of bed rest following SCI, which causes widening (relaxing) of the blood vessels and further contribute to orthostatic hypotension.

Changes to the autonomic nervous system

The main reason that orthostatic hypotension happens after SCI is because of altered control of the autonomic nervous system.

The autonomic nervous system

The autonomic nervous system controls largely unconscious bodily processes such as blood pressure, heart rate, breathing rate, body temperature, digestion, bladder, bowel and sexual function. It has two divisions:

  • The sympathetic nervous system prepares the body for stressful or emergency situations. It is often called the ‘fight or flight’ system, because it prepares the body for action. For example, it increases heart rate and constricts blood vessels.
  • The parasympathetic nervous system prepares the body for normal, non-emergency situations. It is often called the ‘rest and digest’ system, because it allows the body to restore itself. For example, it slows heart rate and relaxes blood vessels.

The sympathetic and parasympathetic systems have different (and often opposite) effects on the organs and work together to control bodily functions according to the situation.

Cartoon images of the lungs, heart, digestive system, and urinary tract system.

The autonomic nervous system controls various body functions.3-6


Most of the nerves that control the sympathetic nervous system arise from the thoracic spinal cord. Because the sympathetic nerves are responsible for narrowing (constricting) the blood vessels and increasing heart rate when changing positions, SCI in these areas can affect blood pressure control. Without the sympathetic nervous system, the blood vessels and heart rate do not respond appropriately to changes in position and blood can pool in the legs and abdomen, leading to orthostatic hypotension.

Reduced muscle activity

Loss of muscle activity in the legs and trunk after SCI may also contribute to orthostatic hypotension. Normally, when the muscles tense, they act like small pumps that squeeze the blood vessels to help push blood back up to the heart. Muscle activity in the legs and abdomen helps to maintain blood pressure in standing. This is sometimes called the skeletal muscle pump.

If there is paralysis in the leg muscles, the muscles do not help to pump blood back up to the heart, which can lead to blood pooling and orthostatic hypotension. This is why sometimes just sitting for a long time after a position change to upright can lead to symptoms of orthostatic hypotension. The effects of the loss of muscle activity seem to have a greater impact earlier after injury, before the body develops strategies to compensate for blood pressure changes.

Cardiovascular deconditioning

Silhouette of a person lying in bed with the red cross emblem above.During the early phase after injury, bed rest is often required for healing of injuries. However, long periods of bed rest and reduced movement can cause the heart and blood vessels to become less responsive to position changes and changes in blood pressure. This likely contributes to orthostatic hypotension in the early phase after SCI.

The body may also produce more of a chemical called nitric oxide as a result of bed rest following SCI, which causes widening (relaxing) of the blood vessels and further contributes to orthostatic hypotension.

Low blood volume and salt levels in the blood

The body regulates blood volume (the amount of blood in circulation) through water and salt levels in the blood. Spinal cord injury can disrupt this balance and lead to low blood volume, low blood pressure and orthostatic hypotension. Low salt levels in the blood are also common after SCI, which can also contribute to orthostatic hypotension. A diet that is low in salt or fluids can also contribute to orthostatic hypotension.

Other factors that may contribute to orthostatic hypotension after SCI

Heat exposure

Warm environments can increase the likelihood of experiencing orthostatic hypotension. The body responds to heat by widening the blood vessels, which lowers blood pressure. Excessive sweating in warm environments may also lead to dehydration, which further contributes to orthostatic hypotension.

A pile of different pills and capsules.Medications

Many medications can trigger orthostatic hypotension. These include medications used to treat conditions such as high blood pressure, heart disease and erectile dysfunction.

Alcohol and caffeine

Consuming alcohol and caffeine can worsen orthostatic hypotension by affecting the constriction of blood vessels during position changes and contributing to dehydration.

After eating meals

After eating, more blood is sent to the intestines for digestion, which may lower blood pressure. Postprandial hypotension is a form of orthostatic hypotension experienced after eating large meals. It is more common among older people.

Exercise (in people with high levels of SCI)

People with complete cervical SCI may experience orthostatic hypotension during and after exercise, even if they are well-hydrated and have taken steps to avoid overheating. This happens because the heart and blood vessels do not respond adequately to compensate for the increased blood flow to the muscles. This can cause symptoms like dizziness or nausea while exercising. To adjust for this, individuals may start their exercise programs with a slow progression or may need to use other strategies to enable them to exercise safely.

How is orthostatic hypotension diagnosed?

Automatic blood pressure meter with blood pressure reading of 118/66 mmHg and heart rate reading of 72 beats per minute.

Blood pressure reading from a blood pressure monitor.9

To diagnose orthostatic hypotension, blood pressure is first measured while in a lying or sitting position and then again in an upright or standing position. The two blood pressure readings are compared to see if there is a drop in blood pressure. Other times, severe symptoms alone (such as fainting) may be used to diagnose orthostatic hypotension.

Since many people with SCI cannot stand, blood pressure can be assessed based on a lying then sitting position instead. A tilt table or other supportive device can be used to assist with getting upright.

 

How to interpret blood pressure readings

The heart contracts and relaxes as it pumps blood throughout the body. A blood pressure reading usually shows up with two numbers:

  • The systolic blood pressure is the blood pressure when the heart contracts. It is usually the first of the two numbers (i.e. ‘120’ when someone says ‘120 over 80’).
  • The diastolic blood pressure is the blood pressure when the heart relaxes. It is usually the second of the two numbers (i.e. ‘80’ when someone says ‘120 over 80’).

Orthostatic hypotension is diagnosed when there is a decrease of at least 20 mmHg in systolic blood pressure or a decrease of at least 10 mmHg in diastolic blood pressure after moving from lying or sitting to standing.

What medications are used to treat orthostatic hypotension?

Currently, midodrine hydrochloride (midodrine) is the only medication recommended for managing orthostatic hypotension after SCI. There is not enough evidence to support the use of other medications. However, medications intended to help treat orthostatic hypotension may also have other unwanted effects on blood pressure after SCI, so should be discussed in detail with your health team for more information.

A healthcare provider helping a person measure their blood pressure using an automatic blood pressure meter.

Monitoring blood pressure will help you determine if drug therapy is safe and effective.10

Midodrine hydrochloride (midrodrine, ProAmatine) is a medication that causes the blood vessels to tighten (constrict). When this occurs, more blood flow travels to the heart and blood pressure increases to prevent blood pressure from dropping in standing. Midodrine is taken by mouth in the form of tablets. Regular blood pressure monitoring done by you or your caregiver will be required to ensure the medication is working properly.

There is moderate evidence that midodrine is effective for treating orthostatic hypotension after SCI and may improve exercise performance by decreasing symptoms of low blood pressure.

There are a number of other medications that have been suggested for reducing orthostatic hypotension, but are ineffective or the evidence is inconclusive. These include:

  • Fludrocortisone
  • Dihydroergotamine or ergotamine
  • Ephedrine
  • Droxidopa or L-DOPS
  • Nitro-L-arginine methyl ester or L-NAME

What other treatment options are there?

Several other treatment options may be used to treat orthostatic hypotension. Although there is limited evidence to determine whether these treatments are effective, they may be used in addition to drug treatments to help manage orthostatic hypotension after SCI.

Fluids and salt

A cartoon glass of water on the left and a cartoon pepper shaker on the right.

Adequate fluid and salt intake may help to increase blood volume and maintain blood pressure. There is weak evidence that fluid and salt intake combined with medications may be effective for treating orthostatic hypotension after SCI. However, no research studies have been done using fluid and salt alone.

Compression garments

Blood pooling happens when gravity causes blood to collect in the abdomen and legs. This limits blood flow to other areas of the body and contributes to orthostatic hypotension. Compression garments are devices that apply pressure to these areas of the body to help blood circulate back up toward the heart. Compression garments used after SCI include:

  • Abdominal binders are devices that are placed around the lower torso to apply pressure to the abdomen. Most abdominal binders are elastic wraps with Velcro closures that are fitted around the waist.
  • Compression stockings are long socks that apply pressure to the calves.

Compression garments are commonly used for orthostatic hypotension after SCI because they are inexpensive and unlikely to cause side effects. However, there is conflicting evidence about whether they are effective to reduce orthostatic hypotension after SCI.

Click here to read more about Abdominal Binders.

Gradual progression toward moving upright

A silhouette of a person stretching their arms and dangling their legs on the side of the bed.

After a prolonged period of bed rest (such as very early after an SCI) it may take time for the body to adjust to getting upright. Health providers will usually gradually progress a person towards getting upright to help adjust the body to the new position slowly.

This may be done by dangling the legs on the edge of the bed for a period of time before slowly raising the head and getting into a wheelchair. It may also be done by gradually increasing the degree of incline of a tilt table while being mindful of symptoms.

Gradual progression towards moving upright is commonly used in the management of orthostatic hypotension, however, it has not been investigated in research studies.

Exercise

Regular exercise improves blood flow and may enhance the body’s ability to adapt to changes in posture. However, after an SCI, there are many different ways that the body responds to exercise, depending on the characteristics of the injury itself. People who have complete injuries in the cervical spinal cord can actually sometimes cause a drop in blood pressure (see above).

  • A person in a wheelchair ready to take a basketball shot.

    Exercise regimens should be tailored to each individual following SCI.14

    There is moderate evidence that arm exercise is not beneficial for reducing orthostatic hypotension in people with SCI.

  • There is weak evidence that body weight-supported treadmill training does not significantly improve orthostatic hypotension in people with SCI.
  • There is weak evidence suggesting that two hours of daily exercise twice a week for a period of at least two years may help reduce orthostatic hypotension in individuals with SCI.

Standing

Standing treatments, especially those that involve some type of stimulation to the leg muscles, are thought to stimulate the nervous system and potentially improve blood pressure responses to standing. There is weak evidence that standing with a harness and assistance from health providers may help to increase resting blood pressure and improve orthostatic hypotension in people with cervical SCI.

See our article on Supported Standing for more information!

A person walking between parallel bars with FES applied to their legs and two other people supporting the feet.

FES can be applied to the leg muscles during assisted walking.15

Functional electrical stimulation (FES)

Functional electrical stimulation (FES) is a treatment where electrical stimulation is applied to the nerves and muscles to cause muscle contractions during an activity. Functional electrical stimulation stimulates the nerves and produces muscular contractions, which may help pump blood back to the heart. There is moderate evidence that functional electrical stimulation can help stabilize blood pressure during changes in position and may be used to supplement other forms of orthostatic hypotension treatment after SCI.

See our article on FES for more information!

Vibration

Whole-body vibration is a primarily experimental treatment that involves exercising on a vibrating platform. This treatment is thought to cause muscle contractions which may help improve blood flow. There is strong evidence that whole-body vibration can increase blood pressure in people with SCI, but the direct effects of vibration on orthostatic hypotension after SCI has not been studied. Currently, whole-body vibration is not usually available outside of research settings.

The bottom line

Orthostatic hypotension is a common condition after SCI, in which blood pressure drops when moving from a lying or sitting position to an upright position. For some, orthostatic hypotension gradually goes away over time. For others, it may persist long-term and require medical treatment.

While research evidence supports the use of the medication midodrine for treating orthostatic hypotension following SCI, there is little evidence to support the use of other medications for this purpose.

Many non-drug treatments also exist that are commonly used. However, for the most part, there is a lack of research on whether these treatments are effective. Functional electrical stimulation may be effective in reducing orthostatic hypotension after SCI.

It is important to discuss these treatment options with your health providers to determine which ones are suitable options for you.

For a review of how we assess evidence at SCIRE Community and advice on making decisions, please see SCIRE Community Evidence.

Reference list

Parts of this page have been adapted from the SCIRE Professional “Orthostatic Hypotension” Module:

Krassioukov A, Wecht JM, Teasell RW, Eng JJ (2014). Orthostatic Hypotension Following Spinal Cord Injury. In: Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 5.0. Vancouver: p. 1-26.

Available from: scireproject.com/evidence/orthostatic-hypotension/

Evidence for “What medications are used to treat orthostatic hypotension?” is based on the following studies:

Midodrine:

[1] Nieshoff EC, Birk TJ, Birk CA, Hinderer SR, Yavuzer G. Double-blinded, placebo-controlled trial of midodrine for exercise performance enhancement in tetraplegia: a pilot study. J Spinal Cord Med 2004;27:219-225.

[2] Wecht JM, Rosado-Rivera D, Handrakis JP, Radulovic M, Bauman WA. Effects of midodrine hydrochloride on blood pressure and cerebral blood flow during orthostasis in persons with chronic tetraplegia. Arch Phys Med Rehabil 2010; 91: 1429-1435.

Other medications:

[1] Barber DB, Rogers SJ, Fredrickson MD, Able AC. Midodrine hydrochloride and the treatment of orthostatic hypotension in tetraplegia: two cases and a review of the literature. Spinal Cord 2000;38:109-111.

[2] Groomes TE, Huang CT. Orthostatic hypotension after spinal cord injury: treatment with fludrocortisone and ergotamine. Arch Phys Med Rehabil 1991;72:56-58.

[3] Frisbie JH, Steele DJ. Postural hypotension and abnormalities of salt and water metabolism in myelopathy patients. Spinal Cord 1997;35:303-307.

[4] Wecht JM, Rosado-Rivera D, Weir JP, Ivan A, Yen C, Bauman WA. Hemodynamic effects of L-Threo-3,4-dihydroxyphenylserine (droxidopa) in hypotensive individuals with spinal cord injury. Arch Phys Med Rehabil 2013; 94: 2006-2012.

[5] Muneta S, Iwata T, Hiwada K, Murakami E, Sato Y, Imamura Y. Effect of L-threo-3, 4-dihydroxyphenylserine on orthostatic hypotension in a patient with spinal cord injury. Jpn Circ J 1992;56:243-247.

[6] Wecht JM, Radulovic M, Rosado-Rivera D, Zhang RL, La Fountaine MF, Bauman WA. Orthostatic effects of midodrine versus L-NAME on cerebral blood flow and the renin-angiotensin-aldosterone system in tetraplegia. Arch Phys Med Rehabil 2011; 92: 1789-1795.

[7] Wecht JM, Weir JP, Goldstein DS, Krothe-Petroff A, Spungen AM, Holmes C, et al. Direct and reflexive effects of nitric oxide synthase inhibition on blood pressure. Am J Physiol Heart Circ Physiol 2008;294:H190-197.

[8] Wecht JM, Radulovic M, La Fountaine M, Rosado-Rivera D, Zhang RL, Bauman W. Orthostatic responses to nitric oxide synthase inhibition in persons with tetraplegia. Arch Phys Med Rehabil; 2009:1428-1434.

[9] Wecht JM, Weir JP, Krothe AH, Spungen AM, Bauman WA. Normalization of supine blood pressure after nitric oxide synthase inhibition in persons with tetraplegia. J Spinal Cord Med 2007; 30: 5-9.

Evidence for “What other treatment options are there?” is based on the following studies:

[1] Yarar-Fisher C, Pascoe DD, Gladden LB, Quindry JC, Hudson J, Sefton J. Acute physiological effects of whole body vibration (WBV) on central hemodynamics, muscle oxygenation and oxygen consumption in individuals with chronic spinal cord injury. Disabil Rehabil 2013; early online: 1-10.

[2] Faghri PD, Yount J. Electrically induced and voluntary activation of physiologic muscle pump: a comparison between spinal cord-injured and able-bodied individuals. Clin Rehabil 2002;16:878-885.

[3] Elokda AS, Nielsen DH, Shields RK. Effect of functional neuromuscular stimulation on postural related orthostatic stress in individuals with acute spinal cord injury. J Rehabil Res Dev 2000;37:535-542.

[4] Sampson EE, Burnham RS, Andrews BJ. Functional electrical stimulation effect on orthostatic hypotension after spinal cord injury. Arch Phys Med Rehabil 2000; 81: 139-143.

[5] Lopes P, Figoni SF, Perkash I. Upper limb exercise effect on tilt tolerance during orthostatic training of patients with spinal cord injury. Arch Phys Med Rehabil 1984;65:251-253.

[6] Ditor DS, Macdonald MJ, Kamath MV, Bugaresti J, Adams M, McCartney N, Hicks AL. The effects of body-weight supported treadmill training on cardiovascular regulation in individuals with motor-complete SCI. Spinal Cord 2005;43:664-673.

[7] Otsuka Y, Shima N, Moritani T, Okuda K, Yabe K. Orthostatic influence on heart rate and blood pressure variability in trained persons with tetraplegia. Eur J Appl Physiol 2008;104:75-78.

[8] Harkema SJ, Ferreira CK, van den Brand RJ, Krassioukov AV. Improvements in orthostatic instability with stand locomotor training in individuals with spinal cord injury. J Neurotrauma 2008;25:1467-1475.

Other references:

Claydon VE, Steeves JD, Krassioukov A. Orthostatic hypotension following spinal cord injury: understanding clinical pathophysiology. Spinal Cord 2006;44:341-351.

Hopman MT, Groothuis JT, Flendrie M, Gerrits KH, Houtman S. Increased vascular resistance in paralyzed legs after spinal cord injury is reversible by training. J Appl Physiol 2002;93:1966-1972.

McKinley WO, Jackson AB, Cardenas DD, DeVivo MJ. Long-term medical complications after traumatic spinal cord injury: a regional model systems analysis. Arch Phys Med Rehabil 1999;80:1402-1410.

Munakata M, Kameyama J, Kanazawa M, Nunokawa T, Moriai N, Yoshinaga K. Circadian blood pressure rhythm in patients with higher and lower spinal cord injury: simultaneous evaluation of autonomic nervous activity and physical activity. J Hypertens 1997;15:1745-1749.

Narkiewicz K, Cooley RL, Somers VK. Alcohol potentiates orthostatic hypotension: Implications for alcohol-related syncope. Circulation 2000; 101: 398-402.
Vaziri ND. Nitric oxide in microgravity-induced orthostatic intolerance: relevance to spinal cord injury. J Spinal Cord Med 2003;26:5-11.

Wecht JM, Bauman WA. Implication of altered autonomic control for orthostatic tolerance in SCI. Auton Neurosci. 2018 Jan;209:51-58.

Wecht JM, De Meersman RE, Weir JP, Spungen AM, Bauman WA. Cardiac autonomic responses to progressive head-up tilt in individuals with paraplegia. Clin Auton Res 2003; 13: 433-438.

 

Image credits:

  1. Blurry Downtown ©Dru Kelly, CC BY-ND 2.0
  2. Illustration by SCIRE Community Team
  3. Lung ©mungang kim, CC BY 3.0 US
  4. Heart ©Laymik, CC BY 3.0 US
  5. Digestive System ©Design Science, CC0 1.0
  6. Excretory system ©Olena Panasovska, CC BY 3.0 US
  7. Patient ©David, CC BY 3.0 US
  8. Assorted Medications ©NIAID, CC BY 2.0
  9. Blood pressure monitor robe materiel medical ©CHONION ANTOINE, CC BY-SA 4.0
  10. Multicare Pharmacist measuring Blood Pressure ©Woonjiawei, CC BY-SA 4.0
  11. Glass of water ©Maria Zamchy, CC BY 3.0 US
  12. Salt ©J Ray Rivera F, CC BY 3.0 US
  13. Stretch ©Claire Jones, CC BY 3.0 US
  14. Army Trials at Fort Bliss 160306-A-QR477-037 ©Adasia Ortiz, CC0 1.0
  15. Functional Electrical Stimulation Therapy for walking ©MilosRPopovic, CC BY-SA 4.0

 

Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication.
Jan 17
0

Supported Standing

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Author: SCIRE Community Team | Reviewer: Darryl Caves | Published: 17 January 2018 | Updated: ~

Standing with supportive equipment is a therapy option after spinal cord injury (SCI). This page outlines basic information about the use of supported standing after SCI.

Key Points

  • Passive standing using supportive equipment is a therapy option for people who do not stand as part of their everyday mobility.
  • Passive standing involves using equipment such as standing frames, tilt tables, orthoses or standing wheelchairs to support an upright position for a period of time.
  • Standing involves a change in posture that challenges the circulatory system, loads the legs, and provides different sensory stimulation.
  • Research evidence suggests that standing may improve blood pressure control and spasticity management. There is conflicting evidence about whether passive standing helps with bone density or bowel and bladder health.
  • Further research is needed to better understand the benefits of standing after SCI and how long standing should be done for to achieve those benefits.

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Why is standing used as a therapy?

Running shoes

Standing is a therapy option following SCI.1

Standing is an important part of functional movement in humans. Standing is needed for walking, and also provides a challenge to the circulatory system, bones, and muscles in ways that cannot be achieved in sitting or lying.

Passive standing (standing with support instead of by muscle activation) may have treatment benefits after SCI, even when the recovery of walking and standing abilities is unlikely. Standing may have benefits in treating health conditions associated with SCI, such as conditions involving the musculoskeletal, circulatory, breathing, bowel and bladder systems. It remains a key treatment tool used in rehabilitation.

What types of equipment are used for standing?

Supported standing involves the use of special equipment to support an upright posture. The type of equipment used depends on the person’s unique characteristics and abilities (such as the amount of muscle control in the arms, legs and trunk), the equipment that is available, and other medical concerns like joint contractures, spasticity and osteoporosis. Equipment used for standing may include a wide range of different devices such as:

Tilt tables

Illustration showing a person lying on a tilt table and secured with a band around the waist. There is an arrow showing that the tilt table is moving to an upright position.

Tilt tables can be moved from a horizontal to a vertical position.2

Tilt tables are flat surfaces that can be tilted from a horizontal position into a vertical standing position. The person is strapped securely to the table while in a horizontal lying position and the table can be tilted vertically. Tilt tables are typically the first devices that are used to work towards standing because the table can be gradually increased by degrees. This is often needed because it may take some time to tolerate being upright and maintaining a safe blood pressure. It is also a good device to test a person’s physical tolerance and safety for standing.

Standing frames

Standing frames are simple frames that have padding at the joints to support a standing position. There are many different types of standing frames. The frame needs to be fitted to the person’s unique physical abilities and body type and minimize areas of excess pressure.

Standing wheelchairs

Photograph of a person using a standing frame with cushions behind and in front of the legs to help align them. The person is resting their arms on a small desk that is attached to the frame.

Standing using a standing frame.3

Standing wheelchairs are wheelchairs that can extend from a sitting position into standing. There are many different types of standing wheelchairs, from manual devices to motorized systems. However, standing wheelchairs are expensive and not commonly available.

Body weight-supported treadmill training

Suspension body weight support systems involve a harness system that is suspended from above to support a percentage of body weight while standing. These systems are typically used while walking on a treadmill (body weight-supported treadmill training) or sometimes while walking over ground. This type of system is usually used for people with incomplete injuries that may work towards standing or stepping independently.

See our article on Body Weight Supported Treadmill Training.

Robotic exoskeletons

Robotic exoskeletons are a relatively new and emerging technology that is typically used for walking and walking training, but may also have benefits related to standing. However, this equipment is costly and not available in most settings.

Walkers, crutches or canes may be used by people with incomplete SCI and good strength in the arms who need only minimal support in standing.

Orthoses

Orthoses and braces may be used to brace the hip, knee and/or ankle joints to keep them from bending. This can help to support the person in an upright standing posture with training and rehabilitation. Orthoses and braces are typically custom-made and usually used by people with paraplegia who have good upper body strength and hip flexibility. Orthoses and braces used for standing may include:

  • Knee Ankle Foot Orthoses (KAFOs) provide support at the knee, ankle and foot.
  • Reciprocating Gait Orthoses (RGOs) are more complex orthoses that are made of a left and right KAFO that are linked together with a rigid brace at the pelvis or abdomen. The brace has hip joints that are built with an alternating stepping mechanism. When one leg is extended, the other flexes forward, providing assistance for stepping. Although normally used for walking, reciprocating gait orthoses can also be used to help support a standing position.

     

    Functional electrical stimulation

    A person walking between parallel bars with FES applied to their legs and two other people supporting the feet.

    FES can be applied to the leg muscles during assisted walking.4

    Functional electrical stimulation (FES) involves the use of electrical stimulation to activate muscles that are weak or paralyzed after an SCI during a purposeful activity. FES over the trunk or leg muscles may be used while standing with equipment for added benefits.

     

     

    See our article on Functional Electrical Stimulation (FES) for more information.

     

    Standing equipment may be expensive and sometimes requires repeated visits to healthcare facilities, which can sometimes be a barrier to regular standing. It is important for the individual to work with their health providers to find appropriate equipment that is safe and suitable.

How is standing done?

Once appropriate equipment and strategies for standing are selected with assistance from a health provider, standing is gradually introduced over time. The amount of time spent standing, the amount of load that is taken through the legs, and the final standing position will be adjusted until a suitable standing position can be maintained. During these first several sessions, health providers will monitor for any adverse effects related to the treatment.

A person walking between parallel bars with his wheelchair behind him. A heathcare provider on the side watches him.

Standing and stepping activities may be combined to optimize therapy.5

Current research findings are unable to tell us how long or how often standing should be done to have benefits. Studies have used standing for 20 to 60 minutes, three to four times per week to study the effects of this treatment. It will be different for everyone. The standing prescription will be based on the person’s unique situation.

Depending on the treatment goals, standing may also involve:

  • Adding extra weight while standing
  • Using standing together with functional electrical stimulation (FES) to activate the muscles of the legs and/or trunk
  • Weight-shifting, balance or stepping activities

Is supported standing safe?

Supported standing is considered to be a relatively safe treatment for use after SCI. However, there are some situations in which standing may not be appropriate and some possible risks. This is not a complete list; please consult a health provider for further safety information.

Standing should not be used in the following situations:

  • By people with recent broken bones (fractures) or a high risk of fractures (such as people with severe osteoporosis)
    Diagram comparing bone with normal bone mineral density to bone with osteoporosis.

    People with osteoporosis have weaker bones which can pose a risk during supported standing.6

  • Where the standing equipment places excess pressure on areas where there are injuries, sores, and wounds; or areas of skin prone to pressure injuries
  • By individuals whose limbs cannot be brought into a good standing position due to other conditions like joint contractures, spasticity, or heterotopic ossification
  • By people with medical conditions where heart rate or blood pressure are uncontrolled, such as those who are unable to stay upright without a major drop in blood pressure (severe orthostatic hypotension)
  • By people with muscle or joint injuries or other conditions that may be worsened by standing

Risks of standing may include:

  • Pressure injuries if the position and equipment used for standing creates too much pressure or shear while standing – it is essential that the equipment used for standing is appropriately fitted to prevent skin damage
  • Blood pooling in the legs may lead to feelings of light-headedness, dizziness or fainting (orthostatic hypotension)
  • Broken bones (fractures) are possible in weight-bearing positions in people with osteoporosis
  • Increased spasticity or autonomic dysreflexia in some people
  • Pain in the standing position

For more information on these topics, see our articles on Pressure Injuries, Orthrostatic Hypotension, Osteoporosis, Spasticity, and Autonomic Dysreflexia

If using electrical stimulation, the safety precautions and risks associated with use of functional electrical stimulation (FES) also apply.

Does supported standing work?

Bone health

It is not clear if standing helps to maintain or increase bone density in the legs after SCI. Current research evidence is inconclusive and further studies are needed.

Blood pressure and circulationA person taking a blood pressure reading of another person wearing a blood pressure cuff

Another proposed use of standing after SCI is to help with blood pressure control. One study provides weak evidence that standing with a harness and assistance from health providers helps to increase resting blood pressure and reduce drops in blood pressure when standing (orthostatic hypotension) in people with cervical SCI.

Spasticity

There is weak evidence that standing may help to reduce spasticity short term in people with SCI. There are also surveys that report that many people with SCI report that regular standing helped to reduce their spasticity.

Bowel problems

There is not enough evidence to determine whether standing can also improve bowel function. Further research in this area is needed.

The bottom line

Supported standing serves as a therapy option for people such as individuals with SCI as they do not normally stand as part of their everyday mobility. This therapy involves equipment such as standing frames, tilt tables, orthoses, or standing wheelchairs to support an upright position for a designated period of time. While there is research supporting the benefits of supported standing, conflicting evidence is still apparent. Further research is needed to better understand the benefits of supported standing after SCI.

For a review of how we assess evidence at SCIRE Community and advice on making decisions, please see SCIRE Community Evidence.

Reference list

Parts of this page have been adapted from the SCIRE Project “Bone Health”, “Orthostatic Hypotension”, “Spasticity”, and “Bowel Dysfunction and Management”  Chapters:

Craven C, Lynch CL, Eng JJ (2014). Bone Health Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 5.0. Vancouver: p 1- 37.

Available from: http://scireproject.com/evidence/rehabilitation-evidence/bone-health/

Krassioukov A, Wecht JM, Teasell RW, Eng JJ (2014). Orthostatic Hypotension Following Spinal Cord Injury. In: Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 5.0. Vancouver: p. 1-26.

Available from: https://scireproject.com/evidence/rehabilitation-evidence/orthostatic-hypotension/

Hsieh JTC, Connolly SJ, McIntyre A, Townson AF, Short C, Mills P, Vu V, Benton B, Wolfe DL (2016). Spasticity Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Curt A, Mehta S, Sakakibara BM, editors. Spinal Cord Injury Rehabilitation Evidence. Version 6.0.

Available from: http://scireproject.com/evidence/rehabilitation-evidence/spasticity/

Coggrave M, Mills P, Willms R, Eng JJ, (2014). Bowel Dysfunction and Management Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 5.0. Vancouver: p 1- 48.

Available from: https://scireproject.com/evidence/rehabilitation-evidence/bowel-dysfunction-and-management/

 

Evidence for “Does standing work for treating the symptoms of SCI?” is based on the following studies:

Bone health

[1] Dudley-Javoroski S, Saha PK, Liang G, Li C, Gao Z, and Shields RK. High dose compressive loads attenuate bone mineral loss in humans with spinal cord injury. Osteoporos Int 2012; 23:2335-2346.

[2] Goktepe A, Tugco I, Alaca, R, Gunduz S, Nikent M. Does standing protect bone density in patients with chronic spinal cord injury? JSCM 2008;31:197-201.

[3] Needham-Shropshire BM, Broton JG, Klose KJ, Lebwohl N, Guest RS, Jacobs PL. Evaluation of a training program for persons with SCI paraplegia using the Parastep 1 ambulation system: part 3. Lack of effect on bone mineral density.  Arch Phys Med Rehabil 1997;78:799-803.

[4] Kunkel CF, Scremin AM, Eisenberg B, Garcia JF, Roberts S, Martinez S. Effect of “standing” on spasticity, contracture, and osteoporosis in paralyzed males. Arch Phys Med Rehabil 1993;74:73-78.

[5] Kaplan PE, Roden W, Gilbert E, Richards L, Goldschmidt JW. Reduction of hypercalciuria in tetraplegia after weight-bearing and strengthening exercises. Paraplegia 1981;19:289-293.

[6] Ben M, Harvey L, Denis S, et al.  Does 12 weeks of regular standing prevent loss of ankle mobility and bone mineral density in people with recent spinal cord injuries? Aust J Physiother. 2005;51:251-256.

[7] de Bruin ED, Frey-Rindova P, Herzog RE, Dietz V, Dambacher MA, Stussi E. Changes of tibia bone properties after spinal cord injury: effects of early intervention. Arch Phys Med Rehabil 1999;80:214-220.

[8] Dudley-Javoroski S, and Shields RK. Active-resisted stance modulates regional bone mineral density in humans with spinal cord injury. Journal of Spinal Cord Medicine 2013; 36: 191-199.

Blood Pressure and Circulation

[1] Harkema SJ, Ferreira CK, van den Brand RJ, Krassioukov AV. Improvements in orthostatic instability with stand locomotor training in individuals with spinal cord injury. J Neurotrauma 2008;25:1467-1475.

Spasticity

[1] Odeen I, Knutsson E. Evaluation of the effects of muscle stretch and weight load in patients with spastic paraplegia. Scand J Rehabil Med 1981;13:117-21.

[2] Bohannon R. Tilt table standing for reducing spasticity after spinal cord injury. Arch Phys Med Rehabil 1993;74:1121-2.

[3] Kunkel C, Scremin A, Eisenberg B, Garcia J, Roberts S, Martinez S. Effect of “standing” on spasticity, contracture, and osteoporosis in paralyzed males. Arch Phys Med Rehabil 1993;74:73-8.

[4] Dunn R, Walter J, Lucero Y, Weaver F, Langbein E, Fehr L, et al. Follow-up assessment of standing mobility device users. Assist Technol 1998;10:84-93.

[5] Eng JJ, Levins S, Townson A, Mah-Jones D, Bremner J, Huston G. Use of prolonged standing for individuals with spinal cord injuries. Phys Ther 2001;81:1392-9.

[6] Shields R & Dudley-Javoroski S. Monitoring standing wheelchair use after spinal cord injury: a case report. Disabil Rehabil 2005;27:142-6.

Bowel problems

[1] Hoenig H, Murphy T, Galbraith J, Zolkewitz M. Case study to evaluate a standing table for managing constipation. SCI Nursing 2001;18:74-7.

Other references

Dunn RB, Walter JS, Lucero Y, Weaver F, Langbein E, Fehr L, Johnson P, Riedy L. Follow-up assessment of standing mobility device users. Assist Technol. 1998;10(2):84-93.

Glickman LB, Geigle PR, Paleg GS. A systematic review of supported standing programs. J Pediatr Rehabil Med. 2010; 3(3),197-213.

Sadeghi M, McLvor J, Finlayson H, Sawatzky B. Static standing, dynamic standing and spasticity in individuals with spinal cord injury. Spinal Cord 2016;54:376-82.

Spinal Cord Injury Centre Physiotherapy Lead Clinicians. Clinical guideline for standing adults following spinal cord injury. 2013 Apr. Available from: https://www.mascip.co.uk/wp-content/uploads/2015/05/Clinical-Guidelines-for-Standing-Adults-Following-Spinal-Cord-Injury.pdf. Accessed Dec 1, 2017.

Image credits

  1. 58/365 ©John Lustig, CC BY 2.0
  2. Image by SCIRE Community Team
  3. Standing frame ©Memasa, CC BY-SA 3.0
  4. Functional Electrical Stimulation Therapy for walking ©MilosRPopovic, CC BY-SA 4.0
  5. Image by SCIRE Community Team
  6. Modified from: oesteoporosis_eng ©go elsewhere…, CC BY-NC 2.0
  7. KRT LIFE HEALTH-BLOOD-PRESSURE PG ©Fort George G. Meade Public Affairs Office, CC BY 2.0

 

Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication.
Nov 29
0

Body Weight Supported Treadmill Training

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Author: SCIRE Community Team | Reviewers: Tania Lam, Shannon Sproule | Published: 29 November 2017 | Updated: ~

Body weight supported treadmill training is a therapy that can be used to support walking training after spinal cord injury (SCI). This page outlines basic information about the use of body weight supported treadmill training after SCI.

Key Points

  • Body weight supported treadmill training is a therapy modality in which part of a person’s body weight is supported while walking on a treadmill.
  • It is usually used to work on walking ability, walking speed, and fitness in people with some control of movement in their legs after SCI (usually people with incomplete SCI).
  • Research evidence supports that body weight supported treadmill training is effective to help improve walking in people with incomplete SCI. It may also have benefits for fitness, reducing spasticity, and overall wellness.
  • The relationship between body weight supported treadmill training and stepping movements after complete SCI is not well understood. Further research is needed to understand whether body weight supported treadmill training has potential treatment benefits on walking (locomotor) function for people with complete injuries.

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What is body weight supported treadmill training?

Body weight supported treadmill training is a therapy modality in which part of a person’s body weight is supported while walking on a treadmill. It is usually done using an overhead suspension system attached to a harness that supports part of a person’s body weight over a treadmill. While supported, the person walks with or without assistance from health providers on a treadmill.

Man supported with harness walks on a treadmill with a female clinician standing beside him

Man engages in body weight supported treadmill training.

Body weight supported treadmill training is usually used to work on walking in people with some control of movement in their legs after SCI (usually people with incomplete SCI).

The goals of treatment with body weight supported treadmill training may include:

To practice walking and standing

Body weight supported treadmill training is usually used to work on walking and standing skills after incomplete SCI. Because the body weight is partially supported, walking can be practiced even when a person cannot stand or walk independently. This may also allow for walking training to begin earlier after injury.

To work on walking quality and speed

Body weight supported treadmill training may be used to practice better walking patterns and prevent unwanted movement compensations that can happen during unsupported walking. It may also allow a person to safely practice walking at faster speeds. This may provide important feedback to the nervous system to help with learning.

To train fitness and health

Standing upright and walking may have benefits for cardiovascular fitness and overall health. It may also have other benefits, such as improving spasticity and feelings of wellness.

How is body weight supported treadmill training done?

Body weight supported treadmill training usually involves the use of an overhead harness and suspension system that supports the person in standing over a treadmill. There are other forms of body weight support training, such as underwater treadmills, anti-gravity treadmills and robotic assisted systems, although these are less common in standard clinical settings.

The amount of body weight that is supported will be different for each person depending on the characteristics of their SCI (such as the level of injury), the level of support provided by the health providers, and the person’s experience with the training.

Equipment

Photograph of a treadmill with handrails and equipment at the back of the treadmill supporting a harness that is placed above the treadmill.

Equipment for a suspension type system includes a treadmill, overhead suspension system, and harness1

Body weight supported treadmill training may involve the use of several different pieces of equipment, depending on the type of support provided. The most common type of harness and suspension system may involve a variety of pieces of equipment such as:

  • A harness
  • Groin and abdominal straps and padding
  • An overhead suspension system
  • A treadmill with adjustable speeds
  • A ramp up to the treadmill
  • Additional tubing or strapping
  • Parallel bars
  • Braces and orthoses

Some body weight supported treadmill training systems may also involve the use of computer systems which control the training and/or robotic systems which guide movement of the legs.

Procedures

The exact procedures depend on the type of equipment used and the person’s physical abilities. General procedures for use of a standard harness and overhead suspension system may include the following steps:

Female clinician adjusting the harness on a man sitting up out of his wheelchair

Female clinician adjusting the harness, preparing a man for the treadmill.

  • In order to ensure this treatment is safe for you, your health providers will measure your heart rate, blood pressure, and assess your risk of fractures before beginning this treatment.
  • Your health providers with help you put the harness and groin straps on in a lying or standing position. The harness is then tightened so it does not slide up when weight is supported.
  • The harness is then securely connected to the overhead suspension over the treadmill and you are lifted up using a mechanical lift to support some weight. There are usually bars on the side to hold on to for balance.
  • Once you are standing upright, your health provider will then turn on the treadmill and gradually increase the speed of the treadmill. Depending on your needs and abilities, hands-on assistance or braces may be used to help move the legs or control the trunk and pelvis.

Training usually begins with maximum body weight support at a slow speed. The amount of support is usually between 35% and 50% of body weight, but depends on your ability to stand on one leg without it buckling. As you get used to the training, the amount of support provided is reduced and the speed or time spent on the treadmill can be increased. It is important to maintain a good quality walking pattern to practice normal movement patterns.

Illustration showing a person walking on a treadmill supported by a harness around their pelvis and waist attached to an overhead suspension system. Suspension system is behind the treadmill and on the other side has an off-weighting system and a height adjustable winch. There is a healthcare provider supporting the movement of the person's legs while seated next to the treadmill.

Body weight supported treadmill training is usually done using an overhead suspension system and harness that supports the body over a treadmill. Hands-on assistance or braces may be used to help move the legs or control the trunk and pelvis.

Amount of training

Your health provider will determine how long the training will last, depending on you and your training goals, as well as the availability of equipment and staff. Body weight supported treadmill training is often done for 15 to 30 minutes two to five times per week. However, we do not know what the optimal amount of training is.

 

Additional therapies

Body weight supported treadmill training is just one of many different walking therapies for people with SCI. It is often accompanied by other forms of walking training such as:

  • Walking overground (off the treadmill) with or without an assistive device, such as a walker. This may be used to help reinforce walking after treadmill training in a form that is more realistic to everyday movement.
    A leg with two electrodes on the thigh for functional electrical stimulation execise therapy

    FES training can also strengthen muscles used for walking

  • Functional electrical stimulation (FES) can be applied to the muscles of the legs and trunk during treadmill training to stimulate muscle activity. This may help to create stronger muscle contractions in weakened muscles when walking. Special FES systems (such as foot control systems that raise the toes up with each step) may be used to help with coordination when stepping.

It is important to speak with a health provider about body weight supported treadmill training to make sure it is safe and suitable for you and to learn how to use the equipment correctly.

Refer to our article on Functional Electrical Stimulation (FES) for more information!

Are there restrictions or precautions for body weight supported treadmill training?

There are some situations in which body weight supported treadmill training may be unsafe to use. This not a complete list, speak to a health provider about whether this treatment is safe and appropriate for you.

Body weight supported treadmill training should not be used in the following situations:

  • By people with medical conditions where heart rate, blood pressure, or seizures are uncontrolled
  • By individuals who are unable to stay upright for 5-10 minutes without a major drop in blood pressure
  • By people at risk of broken bones (fractures), such as people with severe osteoporosis or recent fractures
  • By people with joint limitations (such as contractures) which limit walking, weight-bearing, or standing
  • In areas where the harness may put pressure on open wounds or areas at risk of pressure sores
  • By people using mechanical ventilation

Body weight supported treadmill training should be used with caution in the following situations:

  • When there are tubes or lines attached to the body, such as a feeding tube or indwelling catheter
  • By people with severe and uncontrolled spasticity
  • By people with blood clots or a history of blood clots
  • By people with other major medical conditions or injuries
  • By people prone to autonomic dysreflexia

What are the risks and side effects of body weight supported treadmill training?

There are some risks and side effects that should be discussed before participating in body weight supported treadmill training. This is not a complete list; ask your health providers for more detail.

Risks and side effects of body weight supported treadmill training may include:

  • Groin discomfort or pain around the harness
  • Skin irritation near where skin or clothes are shearing against the harness
  • Abdominal discomfort or difficulty breathing if the harness is too tight
  • Broken bones (fractures)
  • Muscle strain, soreness, or injuries
  • Worsening of muscle spasms
  • Autonomic dysreflexia
  • Changes in blood pressure that may cause light-headedness and dizziness

Are there other limitations to using this treatment?

In addition to the risks and side effects of body weight supported treadmill training, there are also practical limitations its use, including:

  • It is challenging to use and sometimes requires assistance from up to four people
  • The equipment and staff time needed for body weight supported treadmill training can be very costly
  • Many facilities do not have the staff or equipment to use body weight supported treadmill training in their day to day programs

Does body weight supported treadmill training improve walking after incomplete SCI?

Walking

Research studies have found that body weight supported treadmill training may help to:

  • Improve walking ability in people with chronic incomplete SCI (weak evidence)
  • Improve walking to a similar degree as walking off the treadmill at a similar intensity in people with recent incomplete SCI (moderate evidence)
  • Improve functional walking in people with incomplete SCI when used together with functional electrical stimulation (FES) of the leg muscles (moderate evidence)

Man walking while holding parallel bars

However, the benefits for walking do not appear to be unique to this type of training. Most walking strategies which involve weight-bearing (including walking overground, treadmill walking, and walking with FES) appear to be equally effective at improving walking after incomplete SCI.

Cardiovascular fitness

Several studies have looked at the effects of body weight supported treadmill training on different aspects of cardiovascular fitness after SCI. Taken altogether, these studies provide early evidence that body weight supported treadmill training helps to improve many aspects of cardiovascular fitness and health in people with complete and incomplete tetraplegia and paraplegia.

Other effects

In addition to benefits for walking and fitness, body weight supported treadmill training may also have other effects after SCI.

  • Body weight supported treadmill training may help to improve spasticity (weak evidence)
  • Body weight supported treadmill training may lead to greater life satisfaction and well-being (weak evidence)
  • Body weight supported treadmill training has been thought to improve bone density after SCI, however, early research suggests that it may not help to prevent bone loss after SCI (weak evidence).

Can body weight supported treadmill training cause stepping after complete SCI?

Although we tend to think about walking as being entirely voluntary, the ability to step and walk is actually related to both conscious and unconscious (automatic) processes. Some of the automatic walking processes are thought to be controlled within the spinal cord by networks of nerve cells known as central pattern generators or CPGs.

What are central pattern generators (CPGs)?

Central pattern generators (CPGs or spinal pattern generators) are networks of nerve cells in the spinal cord that generate rhythmic movement patterns. These networks do not require signals from the brain or sensation to keep going once they are activated.

CPGs were discovered when researchers found that animals with complete SCI demonstrated stepping movements when they were supported over a treadmill. These animals could not start the movement themselves, but once it was triggered (typically by electrical stimulation, application of certain drugs, or sensory stimulation to an area between the pubic bone and sacrum called the perineum), the stepping movements continued in a rhythmic pattern which resembled walking.

These networks of nerve connections are thought to be located within the spinal cord itself and exist to allow repetitive movements to continue without the need to think about each step.

Evidence for central pattern generators in humans with complete SCI

A diagram showing how the pathway of locomotor CPG is cut short by a complete SCI

Generation of rhythmic movement through the CPG is debatable in people with SCI2

Researchers are still unsure about whether central pattern generators can be activated after complete SCI in humans. Researchers have suggested several observations that may show evidence of central pattern generators after complete SCI in humans, including:

  • Spontaneous rhythmic movements below the level of injury;
  • Stepping-like movements when electrical stimulation is applied through an electrode implanted over the spinal cord (epidural stimulation); and
  • Rhythmic muscle contractions that can be induced through treatment with certain drugs.

However, there is debate among researchers about whether these findings really show evidence of central pattern generators or not. It is also not clear if central pattern generators are activated during body weight supported treadmill training after SCI.

Refer to our article on Epidural Stimulation for more information!

Automatic stepping is not walking

It is also important to consider that automatic stepping is not walking. Walking is much more complex, involving many other components, such as strength to support the body weight, balance to stay upright and shift weight, and sensation and voluntary control to adapt to the environment and situation. For these reasons, even if central pattern generators are activated after complete SCI, we do not know whether this will help a person regain walking ability or have any other benefits for functional walking.

Further research is needed to better understand central pattern generators after complete SCI. At this time, body weight supported treadmill training continues to be used clinically as a treatment for people with incomplete SCI who retain some movement in the legs.

The bottom line

Overall, the research evidence suggests that body weight supported treadmill training has positive effects on walking after incomplete SCI that are similar to other forms of walking training. It may also have benefits for fitness, spasticity, and wellness after SCI, although more high quality research is needed to confirm.

Body weight supported treadmill training appears to be relatively safe when used appropriately, however the equipment and support needed for this treatment may not be commonly available for regular use. If you are interested in this treatment, discuss your options with your health providers to find out if it is suitable to you.

For a review of how we assess evidence at SCIRE Community and advice on making decisions, please see SCIRE Community Evidence.

Reference list


Parts of this page have been adapted from the SCIRE Professional “Lower Limb and Walking”, “Cardiovascular Health and Exercise”, “Bone Health”, “Mental Health” and “Spasticity” modules:

 

Lam T, Wolfe DL, Domingo A, Eng JJ, Sproule S (2014). Lower Limb Rehabilitation Following Spinal Cord Injury. In: Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 5.0. Vancouver: p 1-74.
Available from: https://scireproject.com/evidence/lower-limb-and-walking/

Warburton DER, Krassioukov A, Sproule S, Eng JJ (2014). Cardiovascular Health and Exercise Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 5.0. Vancouver: p 1-48.
Available from: https://scireproject.com/evidence/cardiovascular-health-and-exercise/

Craven C, Lynch CL, Eng JJ (2014). Bone Health Following Spinal Cord Injury, In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 5.0. Vancouver: p 1-37.
Available from: https://scireproject.com/evidence/bone-health/

Orenczuk S, Mehta S, Slivinski J, Teasell RW (20140). Depression Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 5.0. Vancouver: p 1-35.
Available from: https://scireproject.com/evidence/mental-health/depression/

Hsieh JTC, Connolly SJ, McIntyre A, Townson AF, Short C, Mills P, Vu V, Benton B, Wolfe DL (2016). Spasticity Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Curt A, Mehta S, Sakakibara BM, editors. Spinal Cord Injury Rehabilitation Evidence. Version 6.0.
Available from: https://scireproject.com/evidence/spasticity/

Evidence for “Does body weight supported treadmill training improve walking after incomplete SCI?” is based on the following studies:

Walking

[1] Behrman AL, Ardolino E, VanHiel LR, Kern M, Atkinson D, Lorenz DJ, Harkema SJ. Assessment of functional improvement without compensation reduces variability of outcome measures after human spinal cord injury. Arch Phys Med Rehabil 2012;93:1518-29.

[2] Buehner JJ, Forrest GF, Schmidt-Read M, White S, Tansey K, Basso DM. Relationship between ASIA examination and functional outcomes in the NeuroRecovery Network Locomotor Training Program. Arch Phys Med Rehabil 2012;93:1530-40.

[3] Lorenz DJ, Datta S, and Harkema SJ. Longitudinal patterns of functional recovery in patients with incomplete spinal cord injury receiving activity-based rehabilitation. Arch Phys Med Rehabil 2012;93:1541-52.

[4] Winchester P, Smith P, Foreman N, Mosby J, Pacheco F, Querry R, and Tansey K. A prediction model for determining over ground walking speed after locomotor training in persons with motor incomplete spinal cord injury. J of Spinal Cord Med 2009;32:63-71.

[5] Hicks AL, Adams MM, Martin Ginis K, Giangregorio L, Latimer A, Phillips SM, and McCartney N. Long-term body-weight-supported treadmill training and subsequent follow-up in persons with chronic SCI: effects on functional walking ability and measures of subjective well-being. Spinal Cord 2005;43:291-298.

[6] Wirz M, Zemon DH, Rupp R, Scheel A, Colombo G, Dietz V, and Hornby TG. Effectiveness of automated locomotor training in patients with chronic incomplete spinal cord injury: A multicenter trial. Arch Phys Med Rehabil 2005;86:672-680.

[7] Thomas SL, Gorassini MA. Increases in corticospinal tract function by treadmill training after incomplete spinal cord injury. J Neurophysiol 2005;94:2844-2855.

[8] Protas EJ, Holmes SA, Qureshy H, Johnson A, Lee D, and Sherwood AM. Supported treadmill ambulation training after spinal cord injury: a pilot study. Arch Phys Med Rehabil 2001;82:825-831.

[9] Wernig A, Nanassy A, and Muller S. Maintenance of locomotor abilities following Laufband (treadmill) therapy in para- and tetraplegic persons: follow-up studies. Spinal Cord 1998;36:744-749.

[10] Field-Fote EC, Roach KE. Influence of a locomotor training approach on walking speed and distance in people with chronic spinal cord injury: A randomized clinical trial. Physical Therapy 2011;91:48-60.

[11] Dobkin B, Apple D, Barbeau H, Basso M, Behrman A, Deforge D, Ditunno J, Dudley G, Elashoff R, Fugate L, Harkema S, Saulino M, and Scott M. Weight-supported treadmill vs over-ground training for walking after acute incomplete SCI. Neurology 2006;66:484-493.

[12] Hitzig SL, Craven BC, Panjwani A, Kapadia N, Giangregorio LM, Richards K, Masani K, and Popovic MR. Randomized trial of functional electrical stimulation therapy for walking in incomplete spinal cord injury: effects on quality of life and community participation. Top Spinal Cord Inj Rehabil 2013;19(4):245-58.

[13] Field-Fote EC, Lindley SD, and Sherman AL. Locomotor training approaches for individuals with spinal cord injury: a preliminary report of walking-related outcomes. J Neurol Phys Ther 2005;29:127-137.

[14] Field-Fote EC, Tepavac D. Improved intralimb coordination in people with incomplete spinal cord injury following training with body weight support and electrical stimulation. Phys Ther 2002;82:707-715.

[15] Field-Fote EC. Combined use of body weight support, functional electric stimulation, and treadmill training to improve walking ability in individuals with chronic incomplete spinal cord injury. Arch Phys Med Rehabil 2001;82:818-824.

[16] Hesse S, Werner C, and Bardeleben A. Electromechanical gait training with functional electrical stimulation: case studies in spinal cord injury. Spinal Cord 2004;42:346-352.

Cardiovascular fitness

[1] Miller PJ, Rakobowchuk M, Adams MM, Hicks AL, McCartney N, Macdonald MJ. Effects of short-term training on heart rate dynamics in individuals with spinal cord injury. Auton Neurosci 2009;150(1-2):116-21.

[2] Jack LP, Allan DB, Hunt KJ. Cardiopulmonary exercise testing during body weight supported treadmill exercise in incomplete spinal cord injury: a feasibility study. Technol Health Care 2009; 17(1):13-23.

[3] Soyupek F, Savas S, Ozturk O, Ilgun E, Bircan A, Akkaya A.E ffects of body weight supported treadmill training on cardiac and pulmonary functions in the patients with incomplete spinal cord injury. J Back Musculoskelet Rehabil 2009; 22(4):213-8.

[4] Ditor DS, Macdonald MJ, Kamath MV, Bugaresti J, Adams M, McCartney N, et al. The effects of body-weight supported treadmill training on cardiovascular regulation in individuals with motor-complete SCI. Spinal Cord 2005b;43(11):664-73.

Other effects

[1] Giangregorio LM, Hicks AL, Webber CE, Phillips SM, Craven BC, Bugaresti JM, et al. Body weight supported treadmill training in acute spinal cord injury: impact on muscle and bone. Spinal Cord 2005;43:649-657.

[2] Hicks AL, Adams MM, Martin GK, Giangregorio L, Latimer A, Phillips SM, McCartney N. Long-term body-weight-supported treadmill training and subsequent follow-up in persons with chronic SCI: Effects on functional walking ability and measures of subjective well-being. Spinal Cord 2005;43:291-8.

[3] Adams M, Hicks A. Comparison of the effects of body-weight-supported treadmill training and tilt-table standing on spasticity in individuals with chronic spinal cord injury. J Spinal Cord Med 2011;34:488-94.

Evidence for “Can body weight supported treadmill training cause stepping after complete SCI?” is based on the following studies:

[1] Minassian K, Hofstoetter US, Dzeladini F, Guertin PA, Ijspeert A. The Human Central Pattern Generator for Locomotion. Neuroscientist. 2017 Mar 1:1073858417699790. doi: 10.1177/1073858417699790. [Epub ahead of print]
[2] Kern H, McKay WB, Dimitrijevic MM, Dimitrijevic MR. Motor control in the human spinal cord and the repair of cord function. Curr Pharm Des. 2005;11:1429-1439.

[3] Dietz V, Muller R, Colombo G. Locomotor activity in spinal man: significance of afferent input from joint and load receptors. Brain. 2002;125:2626-2634.

[4] Guertin PA. Central pattern generator for locomotion: anatomical, physiological, and pathophysiological considerations. Front Neurol. 2013 Feb 8;3:183.

[5] Yang JF, Gorassini M. Spinal and brain control of human walking: implications for retraining of walking. Neuroscientist. 2006 Oct;12(5):379-89.

[6] Illis LS. Is there a central pattern generator in man? Paraplegia. 1995 May;33(5):239-40.

Other references:

Body Weight Support Treadmill Training. Summary by: Lisa Taipalus BScPT, NEO Regional Stroke Best Practice Consultant for Physiotherapy, December 2009 (updated June 2011).

Duncan PW, Sullivan KJ, Behrman AL, Azen SP, Wu SS, Nadeau SE, et al. Body-weight-supported treadmill rehabilitation after stroke. N Engl J Med 2011;364(21):2026-2036.

Senthilvelkumar T, Magimairaj H, Fletcher J, Tharion G, George J. Comparison of body weight-supported treadmill training versus body weight-supported overground training in people with incomplete tetraplegia: a pilot randomized trial. Clin Rehabil 2015; 29(1):42-49.

Morawietz C, Moffat F. Effects of locomotor training after incomplete spinal cord injury: a systematic review. Arch Phys Med Rehabil 2013;94(11):2297-2308.

Hicks AL, Ginis KA. Treadmill training after spinal cord injury: it’s not just about the walking. J Rehabil Res Dev 2008; 45(2):241-218.

Image credits:

  1. Image by SCIRE Community Team
  2. ‘Figure 1. Device for body weight support (LINAK, Silkeborg, Denmark) and treadmill (FITEX T-5050; Fitex, Gwangju, Korea) and treadmill’ from: Joon Lee B, Lee HJ, Lee, WH. The effects of intensive gait training with body weight support treadmill training on gait and balance in stroke disability patients: a randomized controlled trial. Phys Ther Rehabil Sci. 2013;2(2),104-110.
  3. Image by SCIRE Community Team
  4. Image by SCIRE Community Team
  5. Image by SCIRE Community Team
  6. Image by SCIRE Community Team
  7. ‘Figure 3 `Central’ tonic input, external train of electrical stimulation, delivered by SCS can induce stepping movements’ from: Pinter, M. M., & Dimitrijevic, M. R. (1999). Gait after spinal cord injury and the central pattern generator for locomotion. Spinal cord, 37(8), 531.

 

Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication.
Nov 21
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Autonomic Dysreflexia Emergency Treatments (Overview)

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Oct 12
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Autonomic Dysreflexia

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Author: SCIRE Community Team | Reviewer: Andrei Krassioukov and Janice Eng | Published: 12 October 2017 | Updated: ~

Autonomic dysreflexia is a medical emergency that can happen after spinal cord injury (SCI). This page provides an overview of what autonomic dysreflexia is and how it is managed.

For information about emergency treatments, see How is autonomic dysreflexia treated?

Key Points

  • Autonomic dysreflexia is a potentially life-threatening medical emergency that can affect people with SCI at T6 and above.
  • Autonomic dysreflexia involves a sudden rise in blood pressure, which may be accompanied by heart rate changes, headaches, sweating, and other symptoms.
  • Autonomic dysreflexia can be triggered by any strong, irritating, or ‘painful’ stimulus below the level of the injury, such as bladder and bowel problems, tight clothing, or pressure ulcers.
  • Emergency treatment involves sitting upright, monitoring blood pressure, loosening tight clothing, and searching for and eliminating the cause of the episode (usually problems related to the bladder, bowel, and skin). If the episode does not resolve, emergency medical treatment involves the use of medications to rapidly lower blood pressure.
  • Prevention is an important part of managing autonomic dysreflexia. This typically involves maintaining good bladder, bowel, and skin care, and using medications during procedures that could trigger autonomic dysreflexia.

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What is autonomic dysreflexia?

Autonomic dysreflexia (also called autonomic hyperreflexia) is a potentially life-threatening medical condition that can happen after spinal cord injury. Autonomic dysreflexia involves a sudden rise in blood pressure accompanied by changes in heart rate and other symptoms like headaches and sweating. The blood pressure responses in the body are poorly controlled because of the SCI and can become dangerously high.

Flowchart showing the pathophysiology of AD

Pathophysiology of autonomic dysreflexia.1


Autonomic dysreflexia typically affects people with SCI at T6 and above (although occasionally as low as T8). In general, people with higher level of injury and complete injuries are more likely to experience autonomic dysreflexia. Autonomic dysreflexia can occur at any time after the SCI.

What are the signs and symptoms of autonomic dysreflexia?

Autonomic dysreflexia involves a sudden rise in blood pressure of 20 to 30 mmHg above your normal systolic blood pressure. Since the normal blood pressure of people with SCI is often 20 to 30 mmHg lower than in those without SCI, blood pressure can be in a range that is commonly  considered ‘normal’ or ‘slightly elevated’ and still be high for that person.

This rise in blood pressure is usually accompanied by symptoms. Symptoms will be different for everyone and can range from some mild discomfort to life threatening and severe.

Signs and symptoms of autonomic dysreflexia

  • A sudden rise in systolic blood pressure (20 to 30 mmHg above normal)
  • Changes in heart rate, usually a slow heart rate which sometimes becomes rapid
  • A pounding or throbbing headache
  • Sweating, flushing, or blotching of the skin above the SCI
  • Goosebumps or hair standing on end above the SCI
  • Dry and pale skin below the SCI
  • Worsening of muscle spasms
  • A metallic taste in the mouth
  • Feeling anxious or a feeling of ‘impending doom’
  • A stuffy or runny nose
  • Blurred vision or seeing spots
  • Nausea
  • Difficulty breathing

What can happen if autonomic dysreflexia goes untreated?

Cartoon female doctorAutonomic dysreflexia can be life threatening when severe. If left untreated, uncontrolled elevated blood pressure can lead to serious conditions like stroke, heart attack, detached retinas, seizures, and even death.

Although these complications are uncommon, it is important that autonomic dysreflexia is recognized and treated immediately. Talk to your health providers about setting up a plan for managing episodes of autonomic dysreflexia as soon as they happen.

What can trigger autonomic dysreflexia?

high voltage sign with electric arrow bolt

Autonomic dysreflexia can be triggered by any strong stimulation below the SCI, including anything that could be considered uncomfortable, irritating, or painful if it could be felt. For example, a wound can trigger autonomic dysreflexia even if it the person does not feel it. Autonomic dysreflexia can also be caused by normal body processes that are strongly stimulating, such as a full bladder or sexual stimulation. The most common triggers are related to the bladder or bowel.

Common causes of autonomic dysreflexia

  • A bladder that is full – this may be caused by a blocked or kinked catheter, an overfilled collection bag, or incomplete emptying of urine
  • Other bladder causes such as urinary tract infections or bladder procedures (like when putting in a catheter)
  • A bowel that is full or impacted (contains a hard mass of stool that is stuck)
  • Other bowel causes such as constipation, infections, haemorrhoids, or bowel procedures (such as during digital rectal stimulation)
  • Pressure ulcers, wounds, or burns
  • Skin irritation from pressure, pinching, ingrown toenails, or tight clothing
  • Hot or cold temperatures
  • Strong sexual stimulation
  • Menstrual cramping
  • Labour and delivery
  • Broken bones and heterotopic ossification
  • Surgery and other medical procedures (including functional electrical stimulation)
  • Ulcers and other abdominal conditions

Why does autonomic dysreflexia happen?

Autonomic dysreflexia is caused by dysfunction of the autonomic nervous system after SCI that leads to poorly controlled blood pressure responses.

The autonomic nervous system

The autonomic nervous system controls largely unconscious bodily processes such as blood pressure, heart rate, breathing rate, body temperature, digestion, bladder, bowel, and sexual function. It has two divisions:

The sympathetic nervous system prepares the body for stressful or emergency situations. It is often called the ‘fight or flight’ system, because it prepares the body for action. For example, it increases heart rate and constricts blood vessels.

The parasympathetic nervous system prepares the body for normal, non-emergency situations. It is often called the ‘rest and digest’ system, because it allows the body to restore itself. For example, it slows heart rate and relaxes blood vessels.

The sympathetic and parasympathetic systems have different (and often opposite) effects on the organs and work together to control bodily functions according to the situation.

 

Blood pressure cuff and pillbox

Blood pressure is carefully controlled by the autonomic nervous system to ensure that circulation works properly. The body monitors blood pressure and makes adjustments to maintain blood pressure within an optimal range. This is done in part by tightening (constricting) or relaxing (dilating) the blood vessels and changing heart rate.

What happens in autonomic dysreflexia

Transparent body showing circulatory systemWhen the body below the SCI detects strong stimulation, it activates the sympathetic nervous system, causing the constriction of blood vessels in the lower body. This causes blood pressure to rise.

Pressure sensors in the arteries then detect the elevated blood pressure and relay this message to the brain. Under normal circumstances, the brain sends signals through the spinal cord and cranial nerves to relax the blood vessels and slow heart rate. This restores blood pressure to normal.

However, when there is an SCI, the signal to relax the blood vessels is blocked from travelling to the lower body. Because of this, the blood vessels remain constricted and the body cannot restore blood pressure to normal. This causes the uncontrolled elevated blood pressure that happens during autonomic dysreflexia.

Why does autonomic dysreflexia happen at T6 and above?

The level of T6 is important because nerves from this part of the spinal cord constrict a large group of blood vessels in the abdomen called the splanchnic vascular bed. These blood vessels contain a large volume of blood, so when the blood vessels are constricted, it causes the blood pressure to rise significantly. Injuries below T6 do not usually cause enough of a change in blood pressure to cause autonomic dysreflexia.

How is autonomic dysreflexia treated?

Autonomic dysreflexia is a medical emergency and needs to be treated immediately. Emergency treatment involves a series of steps to lower blood pressure and remove the cause of the episode. If these steps are unsuccessful, emergency medical treatments are used to try to reduce blood pressure quickly.

Immediate treatment of autonomic dysreflexia

  • Get into an upright sitting position (or bring your head up) and if possible, lower your legs
  • If possible, check your blood pressure and re-check it every 5 minutes
  • Loosen tight clothing or devices (including tape, straps, and equipment)
  • Search for and remove the cause of the episode:
    • Check for bladder problems
      • If your catheter is kinked or blocked, reposition or flush the catheter
      • If your bladder or collection bag is full, drain
      • If your urine is cloudy or smells bad, it could be a bladder infection – contact a health provider
    • Check for bowel problems
      • If your bowel is full, use your bowel management routine to empty it (such as digital rectal stimulation)
      • Check for other problems like hemorrhoids
  • Check for skin problems and remove them if possible (such as ingrown toenails, skin irritation, pressure ulcers, infections, or wounds)
  • Check for other problems (such as broken bones)
  • Seek medical attention if blood pressure remains high (150 mmHg or above) after following these steps

If blood pressure returns to normal, continue to monitor your symptoms and blood pressure to make sure they do not return and report the incident to a health provider.

This approach is considered to be the most effective first treatment for autonomic dysreflexia. However, although this procedure is commonly used and recommended by health providers, it is supported primarily by expert opinion rather than evidence from research studies.

Emergency medical treatments

Cartoon teal ambulanceIf the steps above do not reduce blood pressure and it remains high (150 mmHg or above), seek emergency medical attention by calling an ambulance or visiting an emergency department. Emergency medical treatments involve the use of medications that rapidly lower blood pressure. The health providers may also run a series of tests to identify the cause of the episode if one has not been found.

The most commonly used drugs for autonomic dysreflexia are:

  • Captopril
  • Nifedipine (Adalat, Procardia)
  • Nitrates (Nitroglycerine, Depo-Nit, Nitrostat, Nitrol, Nitro-Bid)

However, there is little research evidence to suggest which medications work best for treating autonomic dysreflexia. Speak to your health providers for more information about medications used in autonomic dysreflexia emergencies.

How can autonomic dysreflexia be prevented?

The most effective way of managing autonomic dysreflexia is to prevent triggering it in the first place. People who get autonomic dysreflexia may be able to take steps to avoid triggering episodes, especially during procedures that are known to cause autonomic dysreflexia.

Learn to recognize autonomic dysreflexia and your triggers

In order to be able to manage episodes of autonomic dysreflexia, it is important to be able to recognize an episode and know what to do when it happens.

  • Learn about and educate family members and friends about what autonomic dysreflexia is, how to recognize it, and what to do if it happens.
  • Work with your health providers to identify your risk for autonomic dysreflexia, how to prevent it, and what to do if it happens.
  • Carry an autonomic dysreflexia medical emergency card. These wallet-sized cards describes autonomic dysreflexia and its symptoms and treatments for use in an emergency – it can be used to quickly describe the condition and its treatment to your health providers.

 

Preventing autonomic dysreflexia from bladder problems

Cartoon of the kidneys and bladderBladder problems are the most common triggers of autonomic dysreflexia. Methods that may be used to prevent bladder problems from triggering autonomic dysreflexia include:

  • Maintaining a bladder routine is the most important way to prevent problems like bladder distension and urinary tract infections.
  • Preventing irritation during bladder procedures (such as catheterization) using anaesthetic medications (such as capsaicin or lidocaine).
  • Managing reflex spasms of the bladder muscles (detrusor hyperreflexia) through methods including botulinum toxin (Botox) injections or sacral denervation (deafferentation) surgery.
  • Bladder surgeries, such as bladder augmentation, may be used for some individuals with bladder dysfunction after an SCI and have been shown to help reduce episodes of autonomic dysreflexia.

See our article on Urinary Tract Infections to learn more!

Preventing autonomic dysreflexia from bowel problems

Cartoon of the stomach and intestinesBowel problems are another common trigger of autonomic dysreflexia. Methods that may be used to prevent bowel problems from triggering autonomic dysreflexia include:

  • Maintaining a bowel routine and management (including fibre and fluid intake) to prevent problems like bowel distension, faecal impaction, and constipation.
  • Preventing irritation during invasive bowel procedures or medical procedures (such as digital rectal stimulation) using anesthetics (such as lidocaine gel or lidocaine anal blocks).
  • Bowel surgeries, such as colostomy or ileostomy, may be considered for people with chronic bowel problems that cause autonomic dysreflexia and other problems.

See our article on Bowel Changes after Spinal Cord Injury for more information!

Preventing autonomic dysreflexia from skin problems

A silhouette of a person lying on a recliner chair with red circles highlighting common areas where pressure ulcers developPressure ulcers, ingrown toenails, and burns can all be additional causes of autonomic dysreflexia. Methods that may be used to prevent skin problems from triggering autonomic dysreflexia include:

  • Maintain an effective skin care routine, which involves regular pressure relief, inspection of skin, and proper cleaning.
  • Avoid wearing tight clothing and keep clothing and sheets smooth.
  • Maintain regular foot care.
  • Treat skin injuries and infections early.

Preventing autonomic dysreflexia from other causesCartoon graphic of task list

  • Although individuals with SCI do not have sensation in areas where surgeries may occur, anesthesia should be used to avoid triggering autonomic dysreflexia during surgery.
  • Anesthesia (spinal or epidural if possible) is needed with vaginal, Caesarean, or instrumental delivery to prevent autonomic dysreflexia during labour.
  • Be aware that strong sexual stimulation can cause autonomic dysreflexia. Take precautions and be aware of your responses to stimulation.

See our article on Pressure Injuries for more information! 

The bottom line

The bottom line

Autonomic dysreflexia is a serious medical condition that requires immediate recognition and treatment. First line treatment involves sitting up, removing tight clothing, and removing the cause of episode. This is supported by expert opinion. Emergency medical treatments for episodes of autonomic dysreflexia involve fast acting anti-hypertensive agents such as nifedipine, nitrates, and captopril, although the best treatment to use has not been determined.

It is best to discuss treatment options with your health providers to find out which treatments are suitable for you. For a review of how we assess evidence at SCIRE Community and advice on making decisions, please see SCIRE Community Evidence.

Reference list

Parts of this page have been adapted from the SCIRE Project (Professional) “Autonomic Dysreflexia” Chapter:

Krassioukov A, Blackmer J, Teasell RW, Eng JJ (2014). Autonomic Dysreflexia Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors.

Spinal Cord Injury Rehabilitation Evidence. Version 5.0. Vancouver: p 1- 35. Available from: http://scireproject.com/evidence/rehabilitation-evidence/autonomic-dysreflexia.

 

Barton CH, Khonsari F, Vaziri ND, Byrne C, Gordon S, Friis R. T http://scireproject.com/evidence/rehabilitation-evidence/autonomic-dysreflexia The effect of modified transurethral sphincterotomy on autonomic dysreflexia. J Urol 1986;135:83-85.http://scireproject.com/evidence/rehabilitation-evidence/autonomic-dysreflexia-re/

Sidi AA, Becher EF, Reddy PK, Dykstra DD. Augmentation enterocystoplasty for the management of voiding dysfunction in spinal cord injury patients. J Urol 1990;143:83-85.

Perkash I. Transurethral sphincterotomy provides significant relief in autonomic dysreflexia in spinal cord injured male patients: Long-term followup results. J Urol 2007;177:1026-1029.

Ke QS, Kuo HC. Transurethral incision of the bladder neck to treat bladder neck dysfunction and voiding dysfunction in patients with high-level spinal cord injuries. Neuro Uro 2010;29:748-752.

Hohenfellner M, Pannek J, Botel U, Bahms S, Pfitzenmaier J, Fichtner J, et al. Sacral bladder denervation for treatment of detrusor hyperreflexia and autonomic dysreflexia. Urol 2001;58:28-32.

Kutzenberger J. Surgical therapy of neurogenic detrusor overactivity (hyperreflexia) in paraplegic patients by sacral deafferentation and implant driven micturition by sacral anterior root stimulation: methods, indications, results, complications, and future prospects. Acta Neurochir Suppl 2007;97:333-339.

Coggrave MJ, Ingram RM, Gardner BP, Norton CS. The impact of stoma for bowel management after spinal cord injury. Spinal Cord 2012;50:848-852.

Cosman BC, Vu TT. Lidocaine anal block limits autonomic dysreflexia during anorectal procedures in spinal cord injury: a randomized, double-blind, placebo-controlled trial. Dis Colon Rectum 2005;48:1556-1561.

Cosman BC, Vu TT, Plowman BK. Topical lidocaine does not limit autonomic dysreflexia during anorectal procedures in spinal cord injury: a prospective, double-blind study. Int J Colorectal Dis 2002;17:104-108.

Furusawa K, Sugiyama H, Tokuhiro A, Takahashi M, Nakamura T, Tajima F. Topical anesthesia blunts the pressor response induced by bowel manipulation in subjects with cervical spinal cord injury. Spinal Cord 2009;47:144-148.

Cross LL, Meythaler JM, Tuel SM, Cross LA. Pregnancy, labor and delivery post spinal cord injury. Paraplegia 1992;30:890-902.

Hughes SJ, Short DJ, Usherwood MM, Tebbutt H. Management of the pregnant woman with spinal cord injuries. Br J Obstet Gynaecol 1991;98:513-518.

Cross LL, Meythaler JM, Tuel SM, Cross AL. Pregnancy following spinal cord injury. West J Med 1991;154:607-611.

Skowronski E, Hartman K. Obstetric management following traumatic tetraplegia: case series and literature review. Aust N Z J Obstet Gynaecol 2008;48:485-491.

Lambert DH, Deane RS, Mazuzan JE. Anesthesia and the control of blood pressure in patients with spinal cord injury. Anesth Analg 1982;61:344-348.

Eltorai IM, Wong DH, Lacerna M, Comarr, AE, Montroy R. Surgical aspects of autonomic dysreflexia. J Spinal Cord Med 1997;20:361-364.

Matthews JM, Wheeler GD, Burnham RS, Malone LA, Steadward RD. The effects of surface anaesthesia on the autonomic dysreflexia response during functional electrical stimulation. Spinal Cord 1997;35:647-651.

Kim JH, Rivas DA, Shenot PJ, Green B, Kennelly M, Erickson, JR, O’Leary M, Yoshimura N, Chancellor MB. Intravesical resiniferatoxin for refractory detrusor hyperreflexia: a multicenter, blinded, randomized, placebo-controlled trial. J Spinal Cord Med 2003;26:358-363.

Giannantoni A, Di Stasi SM, Stephen RL, Navarra P, Scivoletto G, Mearini E, Porena M. Intravesical capsaicin versus resiniferatoxin in patients with detrusor hyperreflexia: a prospective randomized study. J Urol 2002;167:1710-1714.

Igawa Y, Satoh T, Mizusawa H, Seki S, Kato H, Ishizuka O, Nishizawa O. The role of capsaicin-sensitive afferents in autonomic dysreflexia in patients with spinal cord injury. BJU Int 2003;91:637-641.

Dykstra DD, Sidi AA, Scott AB, Pagel JM, Goldish GD. Effects of botulinum A toxin on detrusor-sphincter dyssynergia in spinal cord injury patients. J Urol 1988;139:919-922.

Schurch B, Stohrer M, Kramer G, Schmid DM, Gaul G, Hauri D. Botulinum-A toxin for treating detrusor hyperreflexia in spinal cord injured patients: a new alternative to anticholinergic drugs? Preliminary results. J Urol 2000;164:692-697.

Chen SL, Bih LI, Huang YH, Tsai SJ, Lin TB, Kao YL. Effect of single botulinum toxin A injection to the external urethral sphincter for treating detrusor external sphincter dyssynergia in spinal cord injury. J Rehabil Med 2008;40:744-748.

Kuo HC. Satisfaction with urethral injection of botulinum toxin A for detrusor sphincter dyssynergia in patients with spinal cord lesion. Neurourol Urodyn 2008; 27: 793-796.

Chen SF, Kuo HC. Improvement in autonomic dysreflexia after detrusor onabotulinumtoxinA injections in patients with chronic spinal cord injuries. Tzu Chi Medical Journal 2012;24:201-204.

Giannantoni A, Di Stasi SM, Scivoletto G, Mollo A, Silecchia A, Fuoco U, Vespasiani G. Autonomic dysreflexia during urodynamics. Spinal Cord 1998;36:756-860.

Bycroft J, Shergill I, Choong E, Arya N, Shah P. Autonomic dysreflexia: a medical emergency. Postgraduate Medical Journal. 2005;81(954):232-235.

 

Image Credits

  1. Image by SCIRE Professional Team
  2. Headache ©8thBox, CC0 1.0
  3. Doctor1 ©Clker-Free-Vector-Images, CC0 1.0
  4. Voltage ©Clker-Free-Vector-Images, CC0 1.0
  5. Highbp ©stevepb, CC0 1.0
  6. Headshock ©Geralt, CC0 1.0
  7. Body vessels © Clker-Free-Vector-Images, CC0 1.0
  8. Stetho ©Clker-Free-Vector-Images, CC0 1.0
  9. Ambulance ©Pettycon, CC0 1.0
  10. Excretory system ©Olena Panasovska, CC BY 3.0 US
  11. Digestive System ©Design Science, CC0 1.0
  12. Modified from: Man Resting on Long Chair ©Gan Khoon Lay, CC BY 3.0
  13. Tasklist ©Pettycon, CC0 1.0

 

 

Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication.
Oct 10
0

Functional Electrical Stimulation (FES)

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Author: SCIRE Community Team | Reviewer: Shannon Sproule | Published: 10 October 2017 | Updated: ~

Functional electrical stimulation is a treatment that activates muscles below the spinal cord injury (SCI) during exercise and activity. This page outlines basic information about functional electrical stimulation and its use for movement and strength after SCI.

Key Points

  • Electrical stimulation can be used to activate muscles that are weak or paralyzed after an SCI.
  • Functional electrical stimulation (FES) involves stimulating the muscles during an activity like exercise or movement.
  • FES is relatively safe and widely available treatment option for improving muscle strength and fitness after SCI.
  • Overall, the research evidence suggests that FES is most likely effective for improving muscle strength after SCI. It may also improve fitness, walking skills, bone density and other symptoms, although more high quality research is needed to confirm.

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What is "functional electrical stimulation" (FES)?

Functional electrical stimulation (FES) is a type of neuromodulation where electrical stimulation is applied to the nerves located outside the spinal cord and brain. This stimulation causes the muscles to contract and can assist with purposeful or functional movement in weak or paralyzed muscles.

FES is delivered using a variety of handheld or specialized commercial electrical therapy machines connected to electrodes that are placed on the skin’s surface. Systems are also available with implanted electrodes in the muscles, although this is very specialized and not widely available.

FES electrodes are placed on the leg muscles to be used during stationary cycling.1

Muscle stimulation is used for several reasons after SCI:

To promote movement and strength in weak or paralyzed muscles: Muscle stimulation is used early in rehabilitation to promote movement in muscles that are not moving or only producing a flicker of movement. It may promote recovery of movement function by assisting with normal movements and with repetition of movements.

To improve fitness and health: When FES is used as part of a rhythmic exercise like cycling, walking, or rowing, it can help to maintain health of the heart, lungs, and circulation. It may also help to maintain healthy bones.

To assist with functional movement activities like stepping, getting up to standing, and grasping: FES can be used to assist with purposeful movements by improving muscle contractions (for weakened muscles), mobility or range of movement as well as possibly decreasing spasticity.

To maintain muscle mass below the SCI: Regular use of FES may help to prevent muscle loss that happens when the muscles that are paralyzed are not used. Unless neurological return occurs this improvement will stop if the FES is discontinued.

To control the muscles of breathing and bladder function: This includes the use of surgically implanted diaphragmatic pacers (FES systems that create muscle contractions in the diaphragm to stimulate regular breaths) and bladder control systems (FES systems that stimulate the muscles of urination). However, this page will focus on FES used for movement and strength after SCI.

Watch our YouTube video about FES!

Other names for FES of muscles

You may hear other names for FES such as “neuromuscular electrical stimulation” (NMES) or simply “electrical stimulation” (ES). These terms are often used to refer to electrical stimulation of the muscles during more passive activities (like lying down or sitting), while ”FES” usually describes stimulation during purposeful activities like cycling or walking. However, in practice these terms are often used interchangeably to describe similar or related treatments and the goals of all are to promote strength, movement and function and decrease pain and spasticity.

There are a number of other neuromodulation techniques that are used for various purposes in SCI, including transcutaneous electrical nerve stimulation, sacral nerve stimulation, and intrathecal Baclofen, described in other SCIRE Community articles.

How is FES done?

It is important to speak with a health provider about using FES to make sure it is safe and suitable for you and to learn how to use the equipment correctly.

FES is usually applied through electrodes that are placed on the surface of the skin, although electrodes can also be implanted into the muscles. Electrodes are placed over nerves or part of the muscles below the SCI that respond well to electrical stimulation. The electrodes are then attached to an adjustable machine that generates the stimulation. Your health provider will determine the settings that are used for the treatment and how long it will last.

The electrical stimulation is then gradually turned up until the muscles begin to tense or contract. Depending on your sensation, as the machine is turned up, you may feel pins and needles or other unusual sensations, which may take some time to get used to. The aim is to create a forceful but tolerable muscle contraction.

FES is applied through electrodes on the leg muscles during assisted walking.2

If the electrical stimulation goes well, it is then combined with a movement task. This may be as simple as lifting a wrist or ankle or more complex such as cycling on a stationary bike, rowing on a rowing machine, grasping, or stepping in parallel bars or a body weight support treadmill system.

The length of each session will vary depending on the goals of the treatment. Time may be required to enable your muscles to tolerate longer sessions as the muscles may fatigue quickly. Sessions are usually done several times per week for several weeks to gain training benefits.

Your health provider will monitor your response to the treatment and inspect the skin for any redness or irritation after the treatment has ended. Once you have learned to use FES safely, you may be able to use it on your own.

How does FES work?

Our bodies naturally use electrical signals as part of the nervous system. When we move, the brain generates and sends electrical impulses along the spinal cord and nerves to tell the muscles to move.

Spinal cord injury can interrupt this pathway, preventing electrical impulses from passing through the spinal cord to reach the muscles. However, if the nerves and muscles below the injury are not damaged, they can still respond to electrical signals.

A leg with two electrodes on the thigh for functional electrical stimulation execise therapy

FES electrodes are placed over nerves or over electrically-sensitive parts of the muscles below the SCI. The specific type of electrical stimulation used with FES can trigger the nerve cells of movement (motor neurons) to send signals that cause muscle movement. An intact peripheral nerve and healthy muscle tissue are required to enable the external source of electricity to facilitate muscle contraction.

FES does not work for nerve injuries outside the spinal cord

FES can only be used for muscle weakness or paralysis caused by injuries to the spinal cord, but not injuries to the conus medullaris, cauda equina, or the nerves outside of the spinal cord. The nerve cells in these structures (called lower motor neurons) must to be intact for FES to work.

Like exercise, regular treatment with FES is usually needed to maintain the effects of the treatment. For people with complete injuries, when FES treatments are stopped, the treatment effects will usually go away over time. For people with incomplete injuries, the goal is for some carryover of strength and movement be retained after the treatment is stopped.

Are there restrictions or precautions for FES?

A cartoon pen and clipboard with check marks and x marksThere are some situations in which FES may be unsafe to use. This not a complete list, speak to a health provider about your health history and whether FES is safe for you.

FES should not be used in the following situations:

  • Near implanted medical devices like heart pacemakers
  • On areas of active cancer, or by people with bleeding disorders or other major medical conditions
  • On areas with blood clots, bleeding, damaged skin, infection, or poor circulation
  • By pregnant women
  • Electrodes should not be placed over the eyes, through the head, through the chest or abdomen, or on the front of the neck or genitals
  • By people with recent broken bones
  • By people with damage to the nerves or muscles near the area where FES is used

FES should be used with caution in the following situations:

FES is often used with the following conditions after SCI but should be monitored closely. Speak to your health provider for more information.

What are the risks and side effects of FES?

FES is generally well tolerated by people who can use it safely (see above for when FES may be unsafe). Serious medical complications from FES are rare. However, there are risks and side effects that should be discussed with a health provider before using FES.

More common risks and side effects of FES include:

Other less common risks and side effects of FES include:

  • Mild electrical burns near the electrodes
  • Skin breakdown near the electrodes
  • Fainting
  • Worsening of muscle spasms (spasticity)
  • Muscle and joint injuries, such as joint swelling or muscle strains
  • Broken bones
  • Mild electrical shocks (from improper use or faulty equipment)

In some cases, risks and side effects may be caused by improper use of the equipment. It is essential to learn to use the equipment from a health provider and to only use FES according to their direction and with the settings that they recommend.

For some people, side effects of FES may be stronger at first, but as their body gets used to FES with repeated treatments, their physical reactions may reduce over time.

Does FES improve strength and fitness after SCI?

Several studies have shown that FES helps to improve strength and fitness after SCI.

Strength

Cartoon of a flexed armStudies have shown that both FES arm exercise and FES cycling helps to maintain or improve strength after SCI. However, FES cycling may be more effective for maintaining strength after injury than improving strength that has already been lost. This is supported by moderate evidence from five studies.

Cardiovascular fitness

Heart with a barbellFifteen studies have looked at FES for improving many different aspects of fitness after SCI. Taken altogether, these studies provide weak evidence that FES training done at least 3 days per week for 2 months helps to improve many aspects of cardiovascular fitness after SCI.

Walking

A person walking between parallel bars with his wheelchair behind him. A heathcare provider on the side watches him.Studies show that FES improves walking speed and distance in people with both incomplete and complete SCI. Some of these studies also showed that regular use of FES carried over to improve walking even without FES. This is supported by weak evidence from eight studies.

Does FES help with other complications of SCI?

The effects of FES treatment may also help to prevent complications of SCI like pressure sores, bone loss, spasticity, and orthostatic hypotension. These benefits may accompany gains in strength or fitness related to FES treatment.

Pressure sores

A woman lifting up her buttocks off her wheelchair by straightening her armsAlthough it is commonly thought that increased muscle bulk from FES will reduce the risk of pressure sores, there are not very many studies which have looked at whether this actually happens. One study provides weak evidence that FES cycling for 2 years reduced the number of pressure ulcers that occurred after SCI. Another study showed that regular FES cycling showed a trend toward reducing seat pressures.

Bone health

Silhouette of a fractured boneResearch studies show that FES cycling does not prevent bone loss after SCI (moderate evidence from two studies). However, it may help to increase bone density that has already been lost, although the evidence for this is conflicting (based on six studies). It is not clear whether any gains in bone density last long-term or if continued FES treatment is needed for them to be maintained.

For more information on bone density, read our article about Osteoporosis.

Spasticity

It is not clear what effects FES has on spasticity after SCI. There is conflicting evidence from three studies about whether FES cycling can help to reduce spasticity after SCI.

Click here for our article on Spasticity.

Orthostatic hypotension

Three studies provide moderate evidence that FES of the legs during a single change in position reduced orthostatic hypotension. However, this only shows that FES prevents orthostatic hypotension while it is applied, and further research is needed to look at what benefits this could have to people living with SCI.

Click here for our article on Orthostatic Hypotension.

The bottom line

Overall, the research evidence suggests that FES is most likely effective for improving muscle strength after SCI. It may also have effects on fitness, walking skills, bone density, skin health, spasticity, and orthostatic hypotension, although more high quality research is needed to confirm. FES appears to be safe when used appropriately and is widely available in most rehabilitation settings. Discuss this treatment with your health providers to find out if it is a suitable treatment option for you.

For a review of how we assess evidence at SCIRE Community and advice on making decisions, please see SCIRE Community Evidence.

Reference list

Parts of this page have been adapted from the SCIRE Professional “Lower Limb”, “Upper Limb”, “Bone Health”, “Cardiovascular Health and Exercise”, “Orthostatic Hypotension”, “Pressure Ulcers”, and “Spasticity” chapters:

Lam T, Wolfe DL, Domingo A, Eng JJ, Sproule S (2014). Lower Limb Rehabilitation Following Spinal Cord Injury. In: Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 5.0. Vancouver: p 1-74.
Available from: http://scireproject.com/evidence/lower-limb/

Connolly SJ, McIntyre A, Mehta, S, Foulon BL, Teasell RW. (2014). Upper Limb Rehabilitation Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 5.0: p 1-77.
Available from: http://scireproject.com/evidence/upper-limb/

Craven C, Lynch CL, Eng JJ (2014). Bone Health Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 5.0. Vancouver: p 1- 37.
Available from: https://scireproject.com/evidence/bone-health/

Warburton DER, Krassioukov A, Sproule S, Eng JJ (2014). Cardiovascular Health and Exercise Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 5.0. Vancouver: p. 1-48.
Available from: https://scireproject.com/evidence/cardiovascular-health-and-exercise/

Krassioukov A, Wecht JM, Teasell RW, Eng JJ (2014). Orthostatic Hypotension Following Spinal Cord Injury. In: Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 5.0. Vancouver: p. 1-26.
Available from: https://scireproject.com/evidence/orthostatic-hypotension/

Hsieh J, McIntyre A, Wolfe D, Lala D, Titus L, Campbell K, Teasell R. (2014). Pressure Ulcers Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 5.0. 1-90.
Available from: https://scireproject.com/evidence/skin-integrity-and-pressure-injuries/

Hsieh JTC, Connolly SJ, McIntyre A, Townson AF, Short C, Mills P, Vu V, Benton B, Wolfe DL (2016). Spasticity Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Curt A, Mehta S, Sakakibara BM, editors. Spinal Cord Injury Rehabilitation Evidence. Version 6.0.
Available from: https://scireproject.com/evidence/spasticity/

 

Evidence for “Strength” is based on the following studies:

[1] Baldi JC, Jackson RD, Moraille R, and Mysiw WJ. Muscle atrophy is prevented in patients with acute spinal cord injury using functional electrical stimulation. Spinal Cord 1998;36:463-469.

[2] Scremin AM, Kurta L, Gentili A, Wiseman B, Perell K, Kunkel C, and Scremin OU. Increasing muscle mass in spinal cord injured persons with a functional electrical stimulation exercise program. Arch Phys Med Rehabil 1999;80:1531-1536.

[3] Crameri RM, Weston A, Climstein M, Davis GM, and Sutton JR. Effects of electrical stimulation-induced leg training on skeletal muscle adaptability in spinal cord injury. Scand J Med Sci Sports 2002;12:316-322.

[4] Gerrits HL, de Haan A, Sargeant AJ, Dallmeijer A, and Hopman MT. Altered contractile properties of the quadriceps muscle in people with spinal cord injury following functional electrical stimulated cycle training. Spinal Cord 2000;38:214-223.

[5] Needham-Shropshire BM, Broton JG, Cameron TL, Klose J. Improved motor function in tetraplegics following neuromuscular stimulation-assisted arm ergometry. J Spinal Cord Med 1997;20:49-55.

[6] Cameron T, Broton JG, Needham-Shropshire B, Klose KJ. An upper body exercise system incorporating resistive exercise and neuromuscular electrical stimulation (nms). J Spinal Cord Med 1998;21:1-6.

Evidence for “Cardiovascular Fitness” based on:

[1] Berry HR, Kakebeeke TH, Donaldson N, Perret C, Hunt KJ. Energetics of paraplegic cycling: adaptation to 12 months of high volume training. Technology and Health Care 2012; 20: 73-84.

[2] Griffin L, Decker MJ, Hwang JY, Wang B, Kitchen K, Ding Z, et al. Functional electrical stimulation cycling improves body composition, metabolic and neural factors in persons with spinal cord injury. J Electromyogr Kinesiol 2009;19(4):614-22.

[3] Zbogar D, Eng JJ, Krassioukov AV, Scott JM, Esch BT, Warburton DE. The effects of functional electrical stimulation leg cycle ergometry training on arterial compliance in individuals with spinal cord injury. Spinal Cord 2008;46(11):722-6.

[4] Crameri RM, Cooper P, Sinclair PJ, Bryant G, Weston A. Effect of load during electrical stimulation training in spinal cord injury. Muscle Nerve 2004;29(1):104-11.

[5] Hjeltnes N, Aksnes AK, Birkeland KI, Johansen J, Lannem A, Wallberg-Henriksson H. Improved body composition after 8 wk of electrically stimulated leg cycling in tetraplegic patients. Am J Physiol 1997;273(3 Pt 2):R1072-9.

[6] Mohr T, Andersen JL, Biering-Sorensen F, Galbo H, Bangsbo J, Wagner A, et al. Long-term adaptation to electrically induced cycle training in severe spinal cord injured individuals. Spinal Cord 1997;35(1):1-16.

[7] Barstow TJ, Scremin AM, Mutton DL, Kunkel CF, Cagle TG, Whipp BJ. Changes in gas exchange kinetics with training in patients with spinal cord injury. Med Sci Sports Exerc 1996;28(10):1221-8.

[8] Faghri PD, Glaser RM, Figoni SF. Functional electrical stimulation leg cycle ergometer exercise: training effects on cardiorespiratory responses of spinal cord injured subjects at rest and during submaximal exercise. Arch Phys Med Rehabil 1992;73(11):1085-93.

[9] Hooker SP, Figoni SF, Rodgers MM, Glaser RM, Mathews T, Suryaprasad AG, et al. Physiologic effects of electrical stimulation leg cycle exercise training in spinal cord injured persons. Arch Phys Med Rehabil 1992;73(5):470-6.

[10] Gerrits HL, de Haan A, Sargeant AJ, van Langen H, Hopman MT. Peripheral vascular changes after electrically stimulated cycle training in people with spinal cord injury. Arch Phys Med Rehabil 2001;82(6):832-9.

[11] Ragnarsson KT, Pollack S, O’Daniel W, Jr., Edgar R, Petrofsky J, Nash MS. Clinical evaluation of computerized functional electrical stimulation after spinal cord injury: a multicenter pilot study. Arch Phys Med Rehabil 1988;69(9):672-7.

[12] Taylor JA, Picard G, Widrick JJ. Aerobic capacity with hybrid FES rowing in spinal cord injury: comparison with arms-only exercise and preliminary findings with regular training. PM R 2011;3(9):817-24.

[13] Kahn NN, Feldman SP, Bauman WA. Lower-extremity functional electrical stimulation decreases platelet aggregation and blood coagulation in persons with chronic spinal cord injury: a pilot study. J Spinal Cord Med 2010;33(2): 150-8.

[14] Hakansson NA, Hull ML. Can the efficacy of electrically stimulating pedaling using a commercially available ergometer be improved by minimizing the muscle stress-time integral? Muscle Nerve 2012; 45:393-402.

Evidence for “Walking” is based on the following studies:

[1] Thrasher TA, Flett HM, and Popovic MR. Gait training regimen for incomplete spinal cord injury using functional electrical stimulation. Spinal Cord 2006;44:357-361.

[2] Ladouceur M, and Barbeau H. Functional electrical stimulation-assisted walking for persons with incomplete spinal injuries: changes in the kinematics and physiological cost of overground walking. Scand J Rehabil Med 2000a;32:72-79.

[3] Ladouceur M, and Barbeau H. Functional electrical stimulation-assisted walking for persons with incomplete spinal injuries: longitudinal changes in maximal overground walking speed. Scand J Rehabil Med 2000b;32:28-36.

[4] Wieler M, Stein RB, Ladouceur M, Whittaker M, Smith AW, Naaman S, Barbeau H, Bugaresti J, and Aimone E. Multicenter evaluation of electrical stimulation systems for walking. Arch Phys Med Rehabil 1999;80:495-500.

[5] Klose KJ, Jacobs PL, Broton JG, Guest RS, Needham-Shropshire BM, Lebwohl N, Nash MS, and Green BA. Evaluation of a training program for persons with SCI paraplegia using the Parastep 1 ambulation system: part 1. Ambulation performance and anthropometric measures. Arch Phys Med Rehabil 1997;78:789-793.

[6] Granat MH, Ferguson AC, Andrews BJ, and Delargy M. The role of functional electrical stimulation in the rehabilitation of patients with incomplete spinal cord injury–observed benefits during gait studies. Paraplegia 1993;31:207-215.

[7] Stein RB, Belanger M, Wheeler G, Wieler M, Popovic DB, Prochazka A, and Davis LA. Electrical systems for improving locomotion after incomplete spinal cord injury: an assessment. Arch Phys Med Rehabil 1993;74:954-959.

[8] Granat M, Keating JF, Smith AC, Delargy M, and Andrews BJ. The use of functional electrical stimulation to assist gait in patients with incomplete spinal cord injury. Disabil Rehabil 1992;14:93-97.

Evidence for “Bone health” is based on the following studies:

[1] Eser P, de Bruin ED, Telley I, Lechner HE, Knecht H, Stussi E. Effect of electrical stimulation-induced cycling on bone mineral density in spinal cord-injured patients. Eur J Clin Invest 2003;33:412-419.

[2] Lai CH, Chang WHS, Chan WP, Peng CW, Shen LK, Chen JJJ, Chen SC. Effects of Functional Electrical Stimulation Cycling Exercise on Bone Mineral Density Loss in the Early Stages of Spinal Cord Injury. J Rehabil Med 2010; 42:150-154.

[3] Mohr T, Podenphant J, Biering-Sorensen F, Galbo H, Thamsborg G, Kjaer M. Increased bone mineral density after prolonged electrically induced cycle training of paralyzed limbs in spinal cord injured man. Calcif Tissue Int 1997;61:22-25.

[4] Chen SC, Lai CH, Chan WP, Huang MH, Tsai HW, Chen JJ. Increases in bone mineral density after functional electrical stimulation cycling exercises in spinal cord injured patients. Disabil Rehabil 2005;27:1337-1341.

[5] Frotzler A, Coupaud S, Perret C, Kakebeeke TH, Hunt KJ, Donaldson Nde N, Eser P. High-volume FES-cycling partially reverses bone loss in people with chronic spinal cord injury. Bone. 2008 Jul;43(1):169-76. Epub 2008 Mar 20.

[6] Pacy PJ, Hesp R, Halliday DA, Katz D, Cameron G, Reeve J. Muscle and bone in paraplegic patients, and the effect of functional electrical stimulation. Clin Sci (Lond) 1988;75:481-487.

[7]  Leeds EM, Klose J, Ganz W, Serafini A, Green BA. Bone mineral density after bicycle ergometry training. Archives of Physical Medicine and Rehabilitation 1990;71:207-9.

[8] BeDell KK, Scremin AM, Perell KL, Kunkel CF. Effects of functional electrical stimulation-induced lower extremity cycling on bone density of spinal cord-injured patients. Am J Phys Med Rehabil 1996;75:29-34.

Evidence for “Pressure Ulcers” is based on the following studies:

[1] Dolbow DR, Gorgey AS, Dolbow JD, Gater DR. Seat pressure changes after eight weeks of functional electrical stimulation cycling: a pilot study. Top Spinal Cord Inj Rehabil. 2013 Summer;19(3):222-8.

[2] Petrofsky JS. Functional electrical stimulation, a two year study. J Rehabil. 1992;58(3):29–34

Evidence for “Spasticity” is based on the following studies:

[1] Kapadia N, Masani K, Craven B, et al. A randomized trial of functional electrical stimulation for walking in incomplete spinal cord injury: Effects on walking competency. J Spinal Cord Med 2014;37:511-24.

[2] Manella K & Field-Fote E. Modulatory effects of locomotor training on extensor spasticity in individuals with motor-incomplete spinal cord injury. Restor Neurol Neurosci 2013;31:633-46.

[3] Ralston K, Harvey L, Batty J, et al. Functional electrical stimulation cycling has no clear effect on urine output, lower limb swelling, and spasticity in people with spinal cord injury: A randomised cross-over trial. J Physiother 2013;59:237-43.

[4] Kuhn D, Leichtfried V, Schobersberger W. Four weeks of functional electrical stimulated cycling after spinal cord injury: a clinical cohort study. Inter J Rehabil Res 2014;37:243-50.

[5] Mazzoleni S, Stampacchia G, Gerini A, Tombini T, Carrozza M. FES-cycling training in spinal cord injured patients. Eng Med Biol Soc 2013:5339-41.

[6] Sadowsky C, Hammond E, Strohl A, et al. Lower extremity functional electrical stimulation cycling promotes physical and functional recovery in chronic spinal cord injury. J Spinal Cord Med 2013;36:623-31.

[7] Reichenfelser W, Hackl H, Hufgard J, Kastner J, Gstaltner K, Gföhler M. Monitoring of spasticity and functional ability in individuals with incomplete spinal cord injury with a functional electrical stimulation cycling system. J Rehabil Med 2012;44:444-9.

[8] Krause P, Szecsi J, Straube A. Changes in spastic muscle tone increase in patients with spinal cord injury using functional electrical stimulation and passive leg movements. Clin Rehabil 2008;22:627-34.

[9] Mirbagheri M, Ladouceur M, Barbeau H, Kearney R. The effects of long-term FES-assisted walking on intrinsic and reflex dynamic stiffness in spastic spinal-cord-injured

[10] Granat M, Ferguson A, Andrews B, Delargy M. The role of functional electrical stimulation in the rehabilitation of patients with incomplete spinal cord injury–observed benefits during gait studies. Paraplegia 1993;31:207-15.

[11] Thoumie P, Le C, Beillot J, Dassonville J, Chevalier T, Perrouin-Verbe B et al. Restoration of functional gait in paraplegic patients with the RGO-II hybrid orthosis. A multicenter controlled study. II: Physiological evaluation. Paraplegia 1995;33:654-9.

Evidence for “Orthostatic Hypotension” is based on the following studies:

[1] Faghri PD, Yount J. Electrically induced and voluntary activation of physiologic muscle pump: a comparison between spinal cord-injured and able-bodied individuals. Clin Rehabil 2002;16:878-885.

[2] Elokda AS, Nielsen DH, Shields RK. Effect of functional neuromuscular stimulation on postural related orthostatic stress in individuals with acute spinal cord injury. J Rehabil Res Dev 2000;37:535-542.

[3] Sampson EE, Burnham RS, Andrews BJ. Functional electrical stimulation effect on orthostatic hypotension after spinal cord injury. Arch Phys Med Rehabil 2000; 81: 139-143.

Other references:

Electrophysical Agents – Contraindications And Precautions: An Evidence-Based Approach To Clinical Decision Making In Physical Therapy. Physiother Can. 2010 Fall;62(5):1-80.

Gibbons RS, Shave RE, Gall A, Andrews BJ. FES-rowing in tetraplegia: a preliminary report. Spinal Cord. 2014 Dec;52(12):880-6.

Martin R, Sadowsky C, Obst K, Meyer B, McDonald J. Functional electrical stimulation in spinal cord injury: from theory to practice. Top Spinal Cord Inj Rehabil. 2012 Winter;18(1):28-33.

Warms CA, Backus D, Rajan S, Bombardier CH, Schomer KG, Burns SP. Adverse events in cardiovascular-related training programs in people with spinal cord injury: a systematic review. J Spinal Cord Med. 2014 Nov;37(6):672-92.

Image credits

  1. E-Stim Therapy ©Rankn Jordan, CC BY-NC-SA 2.0
  2. Functional electrical stimulation ©MilosRPopovic, CC BY-SA 4.0
  3. Image by SCIRE Community Team
  4. Checklist ©lastspark,CC BY 3.0 US
  5. Muscle © Smalllike, CC BY 3.0 US
  6. cardio ©emma Mitchell, CC BY 3.0 US
  7. Image by SCIRE Team.
  8. Image by SCIRE Team.
  9. fracture ©fahmionline, CC BY 3.0 US

 

Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication.