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Bilateral Foot Drop s/p Laminectomy: A Clinical Presentation Katie Blow Slide 2 Patient Information 61 year old female s/p decompressive bilateral laminectomy L3-S1 for lumbar spinal stenosis Complicated by bilateral foot drop, loss of proprioception, and decreased sensation Admitted to inpatient rehab 4 days after surgery due to impaired mobility and difficulty performing ADLs 2 Slide 3 Patient Information Prior Level of Function Independent with all ADLs without AD Full time occupation: behind deli counter at grocery store Past Medical History Hypertension Renal cysts Past Surgical History Abdominal exploratory Social History Current smoker 3 Slide 4 Physical Therapy Evaluation A&O x4 Pain: 5/10 lower back Sensation: Paresthesia bilaterally both dorsal and plantar aspects. Decreased light touch bilaterally in L5 and S1 distribution below knees Strength/ROM of LE: ROM WNL Strength WFL except: Proprioception: Decreased bilaterally in great toes Mobility: Sit to stand/stand to sit mod A Ambulated 20 ft with RW with min A Stairs not assessed due to safety concerns Bed mobility min-mod A Presented with right non- articulating AFO (left AFO was delivered 3 days after eval) B Hip Abduction3/5 L Knee Extension3/5 Ankle Dorsiflexion0/5 Ankle Plantarflexion2/5 4 Slide 5 Physical Therapy Evaluation Gait Impairments Bilateral foot drop Decreased heel strike Decreased hip extension Step-to gait pattern Balance Static stance: poor Static and dynamic sitting: good Patient Goals Get strength and sensation back in legs Return home with being able to complete all ADLs Return to work as soon as possible 5 Slide 6 ICF Model Bilateral foot drop Pain Decreased strength Impaired sensation Impaired balance Transfers Stair climbing Bed mobility Ambulatory distance ADLs Unable to RTW Social outings with friends/husband Motivated, optimistic General health Strong support system Insurance limitations 6 Slide 7 Therapy Goals Short Term Goals: In 1 week, patient will perform bed mobility with SPV. perform sit to stand/stand to sit with SPV. ambulate 75 ft with RW with minA. ambulate with step-through gait pattern with RW with minA. Long Term Goals: In 2 weeks, patient will perform bed mobility modI. perform sit to stand/stand to sit modI. ambulate 150 ft with RW with SPV. 7 Slide 8 Plan of Care/Treatment 5 days/week, 1.5 hr/day, 2 weeks Patient Education Spinal precautions, AFOs, nature of condition, equipment, exercise program Strengthening Supine, sidelying, sitting, standing, parallel bars Balance Upright posture with static stance, tandem stance, eyes closed, foam surface, single limb stance 8 Slide 9 Treatment Gait Training Heel strike, hip extension, step to step through pattern, decrease weight through upper extremities, facilitate increased step length on right LiteGait Stair Training Step to pattern with correct ascending/descending foot pattern Complications : bilateral DVTs 9 Slide 10 Discharge Status Bed Mobility: independent Transfers: independent with RW Gait: 150 feet with RW with supervision using step through pattern Independent with short distances (in room) Stairs: 8 stairs using bilateral rails with min A 2+/5 bilateral ankle DF Improvements in sensation, decreased paresthesia 10 Slide 11 Nerve Overview 11 Slide 12 For a 61 year old female with bilateral foot drop s/p laminectomy, is there an effective intervention to enhance peripheral nerve regeneration in order to promote functional recovery? Intervention Question 12 Slide 13 Strategies to promote peripheral nerve regeneration: electrical stimulation and/or exercise Gordon, English European Journal of Neuroscience, June 2015 13 Slide 14 Conclusions The efficacy of daily exercise after nerve surgery remains to be determined in human patients Further studies of the efficacy of electrical stimulation in humans are ongoing The mechanisms by which electrical stimulation and/or exercise enhance nerve regeneration remain relatively poorly understood, however the efficacy of electrical stimulation and/or exercise in accelerating nerve regeneration is very encouraging Gordon, English 2015 14 Slide 15 Effects of treadmill training on functional recovery following peripheral nerve injury in rats Boeltz, Ireland, Mathis, Nicolini, Poplavski, Rose, Wilson, English Journal of Neurophysiology, March 2013 15 Slide 16 Purpose 16 Report the results of nerve conduction studies and EMG activity on the effects of exercise on functional recovery following sciatic nerve injury in rats Boeltz et al. 2013 Slide 17 Procedure 17 Three groups for analysis: Six trained rats Six untrained rats Intact group (pre-transection pool) Sciatic nerve cut just above its branching into tibial, common fibular, and sural trunks; cut nerve then secured using fibrin glue & site closed with appropriate sutures Recording electrodes implanted for chronic readings in soleus (SOL) and tibialis anterior (TA) Boeltz et al. 2013 Slide 18 Procedure 18 Exercise Treadmill training began on day three after nerve repair Trained rat group walked on custom treadmill on a level surface at 10 m/min for 1 hr, 5 days/wk for two weeks Untrained group not exposed to treadmill except during locomotion studies done at 2, 4, 10 wks Relevant Outcomes: Nerve Conduction EMG Activity Boeltz et al. 2013 Slide 19 Results 19 Nerve Conduction Boeltz et al. 2013 Earliest M Response Earliest H Reflex Trained20.00 days * Untrained27.80 days29.25 days Slide 20 Results 20 Boeltz et al. 2013 10 weeks post op EMG Activity Slide 21 Discussion 21 Moderate daily exercise applied immediately after nerve injury promotes regeneration of axon elongation and muscle fiber reinnervation Moderate exercise linked with long term positive effects on regeneration process Muscle pattern activity of SOL and TA in exercised rats is similar to that of intact rats (reciprocal action) Unexercised rats show coactivation of muscles We feel that exercise as a therapy for peripheral nerve injury has significant potential for translation to clinical use. Boeltz et al. 2013 Slide 22 Article Critique Strengths of article Generally clear/understandable analysis Variety of outcome measures Control group Strengths for patient Timeline of onset and duration of intensive exercise Endurance (treadmill) based exercise Limitations of article Small number of rats No relation to human nerves Limitations for patient Rats Mechanism of injury? 22 Boeltz et al. 2013 Slide 23 23 Electrical stimulation combined with exercise increases axonal regeneration after peripheral nerve injury Asensio-Pinilla, Udina, Jaramillo, Navarro Experimental Neurology, June 2009 Slide 24 Purpose 24 Studied if chronic daily application of electrical stimulation could improve the effects observed with acute treatment (just 1 hr after nerve repair) Further elucidate the effects of activity, induced by nerve stimulation or by treadmill exercise, on axonal regeneration and spinal plastic changes Asensio-Pinilla et al. 2009 Slide 25 Procedure 25 Five groups of rats Acute electrical stimulation (ESa) Immediately after surgery for 1 hour 0.1 ms duration, 3V intensity, 20 Hz delivery Chronic electrical stimulation (ESc) 1 hr, 5 days/wk, 4 weeks Treadmill (TR) 2 hr, 5 days/wk, 4 weeks beginning 5 days after repair Speed 5 m/min; two 30 min sessions with a 10 min break Treadmill + acute electrical stimulation (ESa + TR) Injured and untreated (C) Asensio-Pinilla et al. 2009 Slide 26 Procedure 26 Nerve conduction tests to assess muscle reinnervation 7, 21, 31, 49, and 60 days postop M & H waves Latency to onset of the responses measured in milliseconds At 60 days, nerve was dissected and measurements of the cross-sectional area of the whole nerve, and counts of the myelinated fibers were performed using image software Total number of regenerated myelinated fibers calculated by multiplying the myelinated fiber density per the cross-sectional area Asensio-Pinilla et al. 2009 Slide 27 Results 27 Nerve Conduction & Latency Asensio-Pinilla et al. 2009 Slide 28 The number of regenerated fibers in groups that received ESa and/or TR was higher than in intact nerves, indicating sustained regenerative sprouting Results 28 Asensio-Pinilla et al. 2009 Slide 29 Discussion 29 Acute electrical stimulation + treadmill training significantly enhanced the onset of muscle reinnervation, although motor recovery at 60 days was similar when each treatment was applied individually Chronic electrical stimulation could be detrimental to axonal regeneration Possible mechanisms of action: Exercise & E-stim- Neurotrophin BDNF and its receptor trkB Exercise- cell circuitry Asensio-Pinilla et al. 2009 Slide 30 Article Critique Strengths of article Included a variety of testing groups Control & uninjured group Understandable analysis Strengths for patient Onset of treadmill training Introduction of electrical stimulation Limitations of article Various number of rats in each group No link to human nerves Limitations for patient Rats Mechanism of injury? 30 Asensio-Pinilla et al. 2009 Slide 31 For a 61 year old female with bilateral foot drop s/p laminectomy, is there an effective intervention to enhance peripheral nerve regeneration in order to promote functional recovery? 31 Promising preliminary research Human studies required for confirmation HOWEVER, known benefit of physical exercise Slide 32 References 32 Asensio-Pinilla, Elena, Esther Udina, Jessica Jaramillo, and Xavier Navarro. "Electrical Stimulation Combined with Exercise Increase Axonal Regeneration after Peripheral Nerve Injury." Experimental Neurology: 258-65. Boeltz, T., M. Ireland, K. Mathis, J. Nicolini, K. Poplavski, S. J. Rose, E. Wilson, and A. W. English. "Effects of Treadmill Training on Functional Recovery following Peripheral Nerve Injury in Rats." Journal of Neurophysiology (2013): 2645-657. Gordon, Tessa, and Arthur W. English. "Strategies to Promote Peripheral Nerve Regeneration: Electrical Stimulation And/or Exercise." European Journal of Neuroscience Eur J Neurosci. Slide 33 Questions? 33