Dr. Josh Geering, PT, DPT, from the Dallas VA Medical Center's Spinal Cord Injury & Disorders Center presents at the UT Arlington Research Institute's Symposium on Biomedical Technologies.

1. How could technology further help the SCI patient
Presented by
Josh Geering, PT, DPT
Dallas VA Medical Center
Spinal Cord Injury and Disorders Center

2. Dallas VA Physical
M ePMd&iRc Oiuntpaetie/nRt Seecthionab
 Electromyography (EMG) and Nerve Conduction Study (NCS)
 Spine Section
 Physical Therapy (PT)/Kinesiotherapy (KT)
 Occupational Therapy (OT)
 Driver Rehabilitation
 Preservation, Amputation, Care and Treatment (P.A.C.T.)
 Comprehensive Integrated Inpatient Rehabilitation Program
(CIIRP)
 Polytrauma Network Site

3. Dallas VA Spinal Cord Injury
Unit
 The Spinal Cord Injury (SCI) Center has provided inpatient and
outpatient services to Veterans with SCI, dysfunction or multiple
sclerosis since August 1996. The center contains a comprehensive
array of facilities and disciplines that SCI patients ordinarily require.
 The SCI Center is a 65,000 square-foot complex that includes:
 30-bed inpatient unit
 outpatient clinic
 rehabilitation therapy areas
 transitional living apartment
 internet cafe
 recreation therapy areas
 swimming pool
 gymnasium
 pharmacy

4. Objectives for today
 Educate on a few of the challenges that
a patient with SCI may face.
 Provide information on what technology
is available at the Dallas VA to help the
patient with SCI.
 Give some possible ideas for bridging
the gaps in our treatment through
technology.

5. Spinal Cord Injury (SCI):
Who are we caring for?
 Majority are male patients
 Median age is around 55 years old
 Active duty and discharged veterans
 Causes of injury
 Non-traumatic
○ Stenosis/arthritis
○ Cancer
○ Other infections
 Traumatic
○ Accidents
○ Gun shot
○ Falls
 Co-morbidities usually are present
 Previous surgeries
 Diabetes
 Cancer (not SCI
 Fractures
 Age

6. Spinal Cord Injury (SCI):
Current Challenges
 Pressure, pressure, pressure…
 Lack of strength for function
 Mobility and locomotion (walking)

7. SCI Current Challenges:
Pressure
Pressure ulcers
 “an area of localized soft tissue ischemic
necrosis caused by prolonged pressure
higher than the capillary pressure with or
without shear, related to posture which
usually occurs over a bony prominence”.
Karoon Agrawal and Neha Chauhan Indian J Plast Surg. 2012 May-Aug; 45(2): 244–254. Pressure ulcers: Back to the
basics

8. SCI Current Challenges:
Pressure  Wounds cost money
 Nineteen patients with stage IV pressure ulcers (11
hospital-acquired and 8 community-acquired) were
identified and their charts reviewed. The average
hospital treatment cost associated with stage IV
pressure ulcers and related complications was
$129,248 for hospital-acquired ulcers during one
admission, and $124,327 for community-acquired
ulcers over an average of 4 admissions. Am J Surg Oct
2010:200(4): 473-477 High Cost of Stage IV Pressure Ulcers
 Wounds can kill
 Ueda et al, 1990 reported 68.8% mortality amongst
elderly patients with NPUAP stage 3 and 4 pressure
ulcers, because of secondary systemic complications.
 These data indicate that presence of pressure ulcer
hampers quality of life and prevention of pressure ulcer
is an important goal

9. SCI Current Challenges:
Pressure
Pressure Ulcer Causes:
 Shear
 Gravity and friction are involved
 Blood vessels stretch and occlude
 Change the shape of the tissue, undermine
 Friction
 Occurs when 2 surfaces move across one
another
 Microclimate and Moisture
 Alters resiliency of the epidermis
 Both friction and shear increase with mild
mosture

10. SCI Current Challenges:
Pressure
How we mitigate pressure now:
 Surfaces
 Cushions
 Mattresses
 Positioning

11. SCI Current Challenges:
Pressure

12. SCI Current Challenges:
Pressure
Pressure mapping – How we measure
 Sensors and software
 Portability
 Mattresses and cushion assessments

13. SCI Current Challenges:
Pressure
How we manage pressure
 Pressure = Force/Area
 Increase the amount of area
 Redistributing the force over this area
 Controlling microclimate
 So where is the gap?

14. SCI Current Challenges:
Pressure
How could technology help?
 Patient managing their own pressure
 Pressure mapping visible to the patient
 Reminding them to do their pressure reliefs
 Giving them the power to adjust pressure
wirelessly
 Adjustability of surfaces
 A true turning mattress – so caregivers don’t
have to do all of the work

15. SCI Current Challenges:
Strengthening and Function
 Patients with SCI usually gain weight
 Diabetes
 Lack of movement
 Diet control
 Osteoporosis
 Lack of weight bearing
 No pull of muscle on the bone
 Previous behaviors and attitudes toward
exercise.

16. SCI Current Challenges:
Strengthening and Weight
Gain
 Exercise has been shown to decrease the risk
for many of the secondary conditions associated
with SCI, including osteoporosis, cardiovascular
disease, pressure ulcers, urinary tract
infections, diabetes and arthritis, yet this
population is rarely a target for health promotion
efforts.
 Non-exercisers identified barriers to exercise,
including a perceived low return on physical
investment, lack of accessible facilities,
unaffordable equipment, no personal assistance
and fear of injury. M Kehn, T Kroll - BMC Public Health, 2009 - biomedcentral.com

17. SCI Current Challenges:
Strengthening
 The BMI of people with spinal cord injuries
gradually increases during and after
inpatient rehabilitation, with significant
increases in the first year after discharge. It
is recommended that emphasis is placed on
weight-management protocols (diet and
exercise) to encourage a healthy lifestyle.
 de Groot, Sonja; Post, Marcel W. M.; Postma, Karin; Sluis, Tebbe A.; van der Woude, Lucas H. V. Journal of Rehabilitation
Medicine, Volume 42, Number 10, November 2010, pp. 922-928(7)

18. SCI Current Challenges:
Strengthening
Current Technology
Functional Electrical Stimulation (FES)
 FES Bike
 ES Elliptical
 FES Step and Stand
http://www.restorative-therapies.com/rt300leg

19. SCI Current Challenges:
Strengthening and Function
Current Technology -- FES
 Legs – Bioness and Bioness L300 Plus
http://www.bioness.com/L300_Plus_For_Thig
h_Weakness/How_Does_It_Work.php

20. SCI Current Challenges:
Strengthening and Function
Current Technology – FES
 Walkaide -
https://www.youtube.com/watch?v=dB5xk
PnR0oo&feature=player_detailpage

21. SCI Current Challenges:
Strengthening and Function
Current Technology – FES
 Hands – Bioness H200 http://www.bioness.com/H200_for_Ha
nd_Paralysis/How_Does_It_Work.php

22. SCI Current Challenges:
Strengthening and Function
How could technology improve SCI
strengthening?
 More strengthening devices that improve
cardiac output and weight loss. Twice-weekly
evoked resistive training (RT) to the paralyzed lower
extremities resulted in significant skeletal muscle
hypertrophy that was associated with reduction in VAT,
visceral adipose tissue/subcutaneous adipose tissue
ratio, and percent intermuscular fat. Significant
improvements in insulin profile and lipid metabolism
were noted in the RT + diet when compared with diet
alone.
 Med Sci Sports Exerc. 2012 Jan;44(1):165-74. doi: 10.1249/MSS.0b013e31822672aa. Effects of resistance
training on adiposity and metabolism after spinal cord injury.

23. SCI Current Challenges:
Strengthening and Function
 Portability of the FES devices. More
streamline
 Wearable therapy http://www.axiobionics.com//
 Include FES training on all devices.
 Smaller exercise devices that are portable
and easily used
 Wireless charging of devices so can you
can use the device longer.
 Cost effective. Cost is a barrier (maybe not
to the VA but to others with a SCI)

24. SCI Current Challenges:
Ambulation
 Patient goals in spinal cord injury rehab
typically start with walking
 “When Can I Walk?”
 Ambulation has its benefits:
 Weight bearing to prevent osteoporosis
 Muscle control and movement
 Bowel management
 Cardiorespiratory function
 Decreased pain and spasticity
 Quality of life

25. SCI Current Challenges:
Ambulation
 Compensation for deficits to activity-dependent
neural adaptation and
training Physical Therapy October 2006 vol. 86 no. 10 1406-1425
 We are trying to use what plasticity is
available in the spinal cord to get
outcomes.
 Strengthen the muscles and have them
ready.

26. SCI Current Challenges:
Ambulation
 Gait training with body weight-supported
overground training is comparable to
treadmill training for improving
locomotion in people with traumatic
incomplete tetraplegia.
Clin Rehabil. 2014 Jun 25. pii: 0269215514538068. Comparison of body weight-supported treadmill
training versus body weight-supported overground training in people with incomplete tetraplegia: a
pilot randomized trial.Senthilvelkumar T1, Magimairaj H2, Fletcher J3, Tharion G2, George J2.

27. SCI Current Challenges:
Ambulation
 Evidence on the effectiveness of
locomotor therapy is limited. All
approaches show some potential for
improvement of ambulatory function
without superiority of 1 approach over
another. Arch Phys Med Rehabil. 2013 Nov;94(11):2297-308. doi:
10.1016/j.apmr.2013.06.023. Epub 2013 Jul 9. Effects of locomotor training after
incomplete spinal cord injury: a systematic review. Morawietz C1, Moffat F.

28. SCI Current Challenges:
Ambulation
Current technology
 Body Weight Support Treadmill Training
 BWSTT
 Body Weight Support Treadmill Training
with Robotic assist
 Lokomat
 Robotic Exoskeletons
 Ekso Bionics
 Rewalk

29. SCI Current Challenges:
Ambulation
Body Weight Support Treadmill Training
 The improvements achieved by treadmill training are not
significantly different from other techniques such as over
ground training and functional electrical stimulation. The
most effective way of restoring locomotion is through
complete repair; however, regeneration techniques are still
being developed.
 Labor intensive for therapy staff but effective –
 https://www.youtube.com/watch?v=AWj9O-oMFyo&
feature=player_detailpage

30. SCI Current Challenges:
Ambulation
 Body Weight Support Treadmill Training
with Robotic assist
 Lokomat
 http://www.hocoma.com/products/lokomat/lo
komatpro/

31. SCI Current Challenges:
Ambulation
 ReWalk
https://www.youtube.com/watch?v=cBzwbbT
PJg0&feature=player_profilepage
 5’3”-6’3” tall, weight 220lbs max
 Unit weights 49lbs
 Available for home use
 Not available for steps in the US
 Used at the Bronx VA
 Speeds up to .06 m/s
 Limited community ambulators

32. SCI Current Challenges:
Ambulation
 Ekso Bionics
https://www.youtube.com/watch?feature=play
er_detailpage&v=D5bgZ1mO97M
 Cervical level 7 (C7) or lower complete
injury (no sensation or motor below the
level of injury
 5'2" - 6'2" tall, weigh no more than 220 lbs
 Unit weighs around 50lbs (floor supports
weight of the device)
 Not yet approved for home use

33. SCI Current Challenges:
Ambulation
What we need next…
 FES integrated training into bionics
 FES training with activity base training is
effective in motor recovery (hammons et al
2014).
 In those with complete injuries, FES can be
used in the lower limbs to promote muscular
endurance and also improve cardiovascular
fitness. FES can also be used to augment
function and strengthen partially innervated
muscles (Pouran, Garstang & Kida, 2009).

34. SCI Current Challenges:
Ambulation
What we need next…
 More portable system
 Can it be done?
 Will it fit in a car?
 Do you wear it to work?
 Restroom or no restroom?
 Can FES be added?
 More to come…

35. WE SERVE THOSE WHO
SERVED
National Veteran Wheelchair Games
Coming to Dallas, June 2015
http://www.va.gov/opa/speceven/wcg/index.asp#

36. References
1. http://www.medetec.co.uk/slide%20scans/pressure-ulcer-images-a/index.html
2. Karoon Agrawal and Neha Chauhan Indian J Plast Surg. 2012 May-Aug; 45(2): 244–254. Pressure ulcers: Back to the
basics
3. Am J Surg Oct 2010:200(4): 473-477 High Cost of Stage IV Pressure Ulcers
4. Bliss MR. Acute pressure area care: Sir James Paget's legacy. Lancet. 1992;339:221–3.[PubMed]
5. Curry K, Casady L. The relationship between extended periods of immobility and decubitus ulcer formation in acutely
spinal-cord injured individuals. J Neurosci Nurs. 1992;24:185–9.
6. Linares HA, Mawson AR, Saurez E, Biundo JJ. Association between pressure sores and immobilization in the
immediate post-injury period. Orthopedics. 1987;10:571–3.
7. Mawsun AR, Biundo JJ Jr, Neville P, Linares HA, Winchester Y, Lopez A. Risk factors for early occurring pressure
ulcers following spinal cord injury. Am J Phys Med Rehabil. 1988;67:123–7
8. Colen SR. Pressure sores. In: McCarthy JG, May JW, Littler JW, editors. Plastic surgery. Philadelphia: WB Saunders;
1990. pp. 3797–898.
9. Leigh IH, Bennet G. Pressure ulcers: Prevalence, etiology and treatment modalities. A review. Am J Surg.
1994;167:25S–30.
10. Med Sci Sports Exerc. 2012 Jan;44(1):165-74. doi: 10.1249/MSS.0b013e31822672aa.Effects of resistance training
on adiposity and metabolism after spinal cord injury.
11. M Kehn, T Kroll - BMC Public Health, 2009 - biomedcentral.com
12. de Groot, Sonja; Post, Marcel W. M.; Postma, Karin; Sluis, Tebbe A.; van der Woude, Lucas H. V. Journal of
Rehabilitation Medicine, Volume 42, Number 10, November 2010, pp. 922-928(7)
13. Physical Therapy October 2006 vol. 86 no. 10 1406-1425
14. Arch Phys Med Rehabil. 2013 Nov;94(11):2297-308. doi: 10.1016/j.apmr.2013.06.023. Epub 2013 Jul 9. Effects of
locomotor training after incomplete spinal cord injury: a systematic review. Morawietz C1, Moffat F.
15. J Spinal Cord Med. 2014 Jun 29. [Epub ahead of print]Functional electrical stimulation as a component of activity-based
restorative therapy may preserve function in persons with multiple sclerosis.Hammond ER, Recio AC,
Sadowsky CL, Becker D.