An operant approach to rehabilitation medicine: overcoming learned nonuse by shaping.

A new approach to the rehabilitation of movement, based primarily on the principles of operant conditioning, was derived from research with deafferented monkeys. The analysis suggests that a certain proportion of excess motor disability after certain types of injury involves a learned suppression of movement and may be termed learned nonuse. Learned nonuse can be overcome by changing the contingencies of reinforcement so that they strongly favor use of an affected upper extremity in the chronic postinjury situation. The techniques employed here involved 2 weeks of restricting movement of the opposite (unaffected) extremity and training of the affected limb. Initial work with humans has been with chronic stroke patients for whom the approach has yielded large improvements in motor ability and functional independence. We report here preliminary data suggesting that shaping with verbal feedback further enhances the motor recovery.

Incidence of respiratory complications following spinal cord injury.

From 1985 to 1990 five Model Regional Spinal Cord Injury (SCI) Care Systems participated in a collaborative effort to prospectively document the occurrence of adult respiratory distress syndrome (ARDS), aspiration, atelectasis, bronchitis, bronchospasm, lung abscess, pleural effusion, pneumonia, pneumo/hemothorax, pulmonary edema, pulmonary thromboembolism, tracheitis, upper respiratory infection, and ventilatory failure in patients admitted within 48 hours of SCI with a level of C1-T12 and Frankel Grade A, B, or C. The mean, standard deviation and range was calculated for the time of onset and duration of each complication. Of the 261 patients who entered the study, 175 (67%) experience 544 respiratory complications with atelectasis being the most common (36.4%) followed by pneumonia (31.4%) and ventilatory failure (22.6%). These complications occurred on the average of 17.7 days, 24.5 days and 4.5 days postinjury and lasted 12.8 days, 15.5 days, and 35.9 days, respectively. Twenty-two percent, 47%, and 31% had injury levels at C1-4, C5-8, T1-12, respectively with the majority being Frankel Grade A (78%). Eighty-four percent of C1-4, 60% of the C5-8, and 65% of the T1-12 had respiratory complications. Statistical analysis revealed complications to be significantly greater (p < .05) and of longer duration (p < .05) for the C1-4 group. Ventilatory failure and aspiration were the earliest to occur (at 4.5 days) for all SCI patients. Surprisingly, however, complications overall occurred significantly sooner (p < .05) in the T1-12 group. In conclusion, patients who sustain SCI have a high incidence of respiratory complications; however, some occur earlier and more frequently depending on the level of injury.

Orthostatic hypotension after spinal cord injury: treatment with fludrocortisone and ergotamine.

We report a case of a 28-year-old woman with C5 quadriplegia, unresponsive to conservative treatment for orthostatic hypotension. Ergotamine, daily combined with fludrocortisone, successfully prevented symptomatic hypotension. In this report, neural, renal, and hormonal blood pressure regulatory mechanisms are described. Experiences obtained from this case and the existing literature suggest that (1) in persons with quadriplegia, plasma catecholamine levels show little increase with sitting, indicating an inability to activate baroreceptor and chemoreceptor reflexes, (2) elevated plasma aldosterone and renin levels indicate a renal compensatory response to decreased renal perfusion secondary to low plasma volume and/or chronic hypotension, and (3) the net effect of ergotamine and fludrocortisone is probably a combination of plasma volume expansion and direct peripheral vasoconstriction.