Page 18 - Mobility Management, June 2017

ATP Series
SCI: It’s Complicated
sitting position for mobility, it’s crucial to dial the seat in so that it provides the right kind of support as much as possible.”
A past pressure injury, even one that has healed, is important to consider, Bernstein said.
“It still influences the amount of healthy loading tissue that somebody has to redistribute the weight,” she explained. “A lot of people who had to have debridement or surgeries don’t even know what tissues have been removed. They don’t know if they’ve had osteotomies that have removed part of the bony pelvis. That is a huge influence to a seating clinic therapist: You’re looking at the sitting surface and maybe, for example, you’re using a pressure imaging system. You see there’s no pressure on one side or in one location. It could be that [the
client] had bone removed from that area, so the overall pressure distribution is completely different than what you would see in an intact pelvis.”
“The literature definitely shows us that a person who’s broken down once is at an even higher risk to break down in the future,” Merring said, “whether it’s over a different area or the same one. Tissue that heals is [only] a certain percentage of full. Once you have a pressure injury, it never gets back to 100 percent.”
Therefore, a full understanding of the pressure injury is critical. “I want to know where it was,” Merring said, “I want to know if you haven’t had these issues in the last five years, what have you done to not have these issues? I’m going to probably replicate that as much as possible.”
SCI Complications: What About Weight Gain?
“I can’t use a power chair, I’ll gain weight!”
Unwanted weight gain can be a common concern for clients
with spinal cord injury (SCI), particularly as they age. That fear could cause clients to continue to self-propel their ultralight- weight manual chairs, even if they’re experiencing shoulder pain or other physical issues.
The Self-Propulsion Assumption
Such clients usually believe that propelling is preventing them from gaining weight — or helping to. But is that true?
Jennith Bernstein, PT, DPT, ATP, a clinical education manager for Permobil, served as a physical therapist at Shepherd Center and
specialized in SCI rehabilitation there for more than 10 years. “They’re not burning calo-
ries sufficiently enough to lose
weight,” she said of typical self-propelling SCI clients. “For someone with SCI, gaining weight
is most correlated with the amount of calories consumed. To lose a pound a month, someone with paraplegia can only eat some- thing like 1,200 calories a day.”
That’s because after SCI, a client’s body changes.
“Muscle mass is lost, and it converts to adipose, or fat,” Bernstein said. “It’s the composition of tissues that are no longer burning the same rate of energy that intact musculature is.”
More Effective Weight Management Strategies
Curtis Merring, OTR/L, MOT, a clinical education manager for Permobil, also spent years assessing and working with SCI clients.
When a client expressed concern about gaining weight, Merring said, “It starts with a discussion, always, and then we figure out what kinds of strategies we can put in place to help manage weight from a therapy side: Do you have access to equipment? Do you have access to all the resources? In our city, we have three wheelchair-accessible gyms that are specifically made for wheelchairs. Not only do the facilities exist, but there’s a
community here. Let’s go cycle every day, let’s go FES [functional electrical stimulation] bike every day, let’s go stand every day. We also have a nutritionist here in town who likes to give talks to people with spinal cord injuries. Make sure they get in front of someone like that.”
Merring said preserving shoulder health is a priority. “If they’ve been paralyzed for 15 years now, they’ve still got a good 20 or
25 years in this chair, but their shoulders are starting to go. If
they love ultralights, the first thing I’m going to do is say, ‘Have you tried an active assist?’ Let’s [try] an eMotion wheel or a SmartDrive.’ If they’ve been independent for this long and they only need a little bit of assist, they could have the choice of ‘Do I want to do power today, or do I want to do manual today?’”
Abdominal Girth Could Have Another Cause
While a thickening waistline is usually blamed on weight gain, Bernstein said there could be other explanations.
“You have the loss of abdominal muscle,” she noted, “and when you’re talking about C6-level [SCI], when you don’t have that abdominal wall — that’s what keeps your organs in. When you’re not wearing a binder and you don’t have active abdominal musculature, gravity takes a hold just like it does with everything else. Your organs shift and your intestines expand, so it’s not always just weight gain that causes increased intra-abdominal girth. If somebody is doing everything the same way for 10 years, but they start seeing that their stomach is getting larger, it could just be the stretching of ligaments, it could be the lack of that active muscle, the lack of burning of energy, the converting to soft tissue vs. muscle.”
Whatever is causing the bigger waistline, Bernstein said that self-propelling is not the best preventive answer.
“Mobility should not be exercise. I’m not going to run a mara- thon to go to the grocery store. I’m going to go to the grocery store and get my groceries in the most efficient and effective way that I can. Then I’m going to take an hour out of my day and do my exercise, get my strengthening, get my heart rate in the zone it needs to be in.” m
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