CNS class 3 (SCI, stroke, transfer techniques) Flashcards
SCI define
“Occurs from a direct injury to the spinal cord or indirectly from damage to the surrounding bones, tissues, or blood vessels. These events cause paralysis or a complete or total loss of the ability to move or feel sensation in part or most of the body. “
Salvo, Susan; Mosby’s pathology 5th edition
.
SCI classification
direct vs indirect
primary vs secndary
complete vs incomplete
direct vs indirect SCI
Direct: direct trauma on the spinal cord
Indirect: damage to tissues and bones surrounding the spinal cord
primary vs secondary SCI
Primary: immediate damage caused directly from trauma
Secondary: delayed damaged caused by complications after the injury
complete vs incomplete sci
Complete: full lesion of spinal cord → total motor and sensory loss below lesion
Incomplete: partial lesion of spinal cord → partial loss of sensory and motor function
sci etiology
trauma vs non-trauma
trauma sci
Trauma: more common than non traumatic (can be direct & indirect)
Motor vehicle accidents: most common (41% in Canada) - 97% of times, patients did not wear a seatbelt
Diving: often leads to quadriplegia
Contact sports: American football & rugby (6% in Canada, 17% UK)
Violent trauma: gunshot/stab wounds (incidence increasing)
non trauma sci
Spinal hematoma, infection, radiation, neoplasm
Vascular complication: cardiac arrest, aortic aneurysm, surgery
spinal cord injuries (incomplete)
central cord syndrome
Brown-Sequard syndrome
Anteiror cord syndrome
central cord syndrome
What: Damage to centre with periphery unaffected
Most common incomplete injury
Cause: Hyperextension or arthritic changes to c-spine
central cord syndrome SSx
Upper limbs: motor and sensory abilities affected, mm weakness, flaccidity
Lower limbs: less affected
Bowel and bladder control normal or partially affected
Brown-Sequard syndrome
What: Damage to one side of the spinal cord
Cause: stabbing/gunshot wound
Brown-Sequard Syndrome SSx
Ipsilateral impairment: motor function, proprioception, sensation (vibration, 2-point discrimination).
NORMAL: pain and temperature perception
____
Contralateral impairment: loss of pain and temperature perception.
NORMAL: motor function
Anterior cord syndrome
What: damage to anterior spinal artery/anterior spinal cord (corticospinal & spinothalamic tract injury)
Cause: Hyperflexion injury
anterior cord syndrome SSx
bilateral loss of motor function, perception (pain, temperature, crude touch)
vulnerable regions of spine
Most vulnerable part of the spine is C4-C6, where the spinal canal loses stability in favor of mobility.
T12-L1 also commonly injured.
mm function vs level/severity of SCI
C1-C3- No function maintained from the neck down. Need ventilator to breathe
C4-C5- Diaphragm, which allows breathing
C6-C7- Some arm and chest muscles (feeding, dressing, propelling wheelchair)
T1-T3- Intact arm function
T4-T9- Control of trunk above the umbilicus
T10-L1- Most thigh muscles, allows walking with long leg braces
L1-L2- Most leg muscles, allows walking with short leg braces
-plegia etymology & types
plegia = strike
.. types in following cards
monoplegia
Monoplegia- paralysis of one limb
diplegia
Diplegia- paralysis of both upper OR lower limbs
paraplegia
Paraplegia- paralysis of both lower limbs
paraparesis
Paraparesis- muscle weakness in legs
paresis = from paralysis
hemiplegia
Hemiplegia- paralysis upper limb, trunk and lower limb unilaterally
quadriplegia
Quadriplegia- paralysis of all four limbs
quadriparesis
Quadriparesis- muscle weakness in all limbs
autonomic dysreflexia
What is is? an acute exaggerated sympathetic response. People at risk generally are those with a lesion at or above T6
How? by a painful or uncomfortable stimulus in the abdomen or pelvic area eg: distention of a full bladder
…
—> muscles spasms, an extensive stretch placed on the muscle
—> a kink in the catheter bag
—> the presence of infection such as decubitus ulcers
what happens during AD
stimulus sends nerve impulses to the spinal cord - they travel upward until they are blocked by the lesion at the level of injury the impulses cannot reach the brain, a reflex is activated that increases activity of the sympathetic portion of ANS.
This results in spasms and a narrowing of the blood vessels, which causes a rise in the blood pressure.
AD SSx
severe hypertension (300/160), bradycardia
sudden pounding headache
Vasospasms, piloerector response and skin pallor occur
Flushed skin and sweating
AD – what to do?
It is considered a medical emergency and is potentially life threatening
call for paramedic services
MASSAGE & SCI
Most clients are wheelchair-bound, adapt massage to clients need and abilities
Clients are generally inactive so have a larger risk to bone density and blood clots in the legs.
Avoid deep pressure over bones and Forceful PROM because of risk of fractures
Avoid vigorous massage techniques because of risk for clots
—> ALSO B/C DEEP TECHNIQUE IS CI’ed ON ATROPHIED MM
Assess contractures
Assess for potential decubitus ulcers
stroke happens when
when blood flow to the brain is blocked or there is sudden bleeding in the brain
hemiplegia
a non-progressive condition of paralysis on one side of the body
stroke, result
insult/injury/event
The range of consequences is very wide; it may cause death; it may leave a permanent state of dysfunction, it may be partially recovered from, it may be fully recovered from
hemiplegia – sometimes via
It sometimes results from a stroke
It may be caused by many things: genetics, stroke, spinal cord injury, other brain injury…
side of paralysis vs side of brain lesion
Paralysis occurs on the opposite side of the brain lesion
severity of effects (stroke)
duration/severity
Effects depend on the location and how severe the damage to the brain
They can be temporary or permanent, almost imperceptible to severely disabling with profound spasticity and extreme sensory or perceptual loss
(FYI)
LEFT brain damage result
right side paralysis
speech and memory deficits
cautious and slow behaviour
(FYI)
RIGHT brain damage result
left side paralysis
perceptual and memory deficits
quick and impulsive behaviour
hemiplegia SSx post-stroke
Immediately post stroke:
muscles on the affected side will be weak or flaccid - acute phase
gradually, flaccid paralysis leads to spastic paralysis (some flaccidity can remain)
—> lesions interfere with the brain’s control over spinal cord activity = uninhibited alpha motor neuron firing
flexor vs extensor pattern of paralysis
most common pattern UE?
most common pattern LE?
This type of paralysis can become a flexor or extensor pattern based on the uninhibited dominant reflexes
—> Most common pattern: flexor pattern in upper limbs combined with extensor pattern in the lower limb
other SSx hemiplegia
Altered posture due to spasticity
Altered gait - circumducted
Hemiplegic shoulder - GH ADd, IR, scapular retraction
Seizures, edema, pain, compensatory changes
Sensory deficit
Shoulder-hand syndrome - decreased ROM of GH & hand, followed with throbbing pain & edema
Neglect of affected side
Behavioral & emotional changes
Visual impairment, speech difficulties
Cognitive impairment
more observations/clinical manifestations/SSx (hemiplegia)
Spasticity pattern on the affected side
Circumducted gait, balance and weight shifting may be impaired
Ambulatory aids - canes, walkers
Muscle bulk differences between affected and unaffected sides
Functional abilities will vary depending on severity of stroke and spasticity or flaccidity
Postural asymmetries
Neglect of the affected side
stroke occurs when
A stroke occurs when blood supply to any part of the brain is interrupted, leading to the impairment of brain cells. The level of impairment depends on the location and degree of damage done.
3 main types of strokes:
ischemic stroke
hemorrhagic stroke
transient ischemic attack (TIA)
TIA lasts how long?
less than 24 hours
“A transient ischemic attack, commonly known as a mini-stroke, is a temporary stroke with noticeable symptoms that end within 24 hours.”
“Transient ischemic attacks usually last a few minutes. Most symptoms disappear within an hour. Rarely, symptoms may last up to 24 hours.”
rare causes of stroke
In rare cases, an underlying condition such as a tumor, an infection, or brain swelling due to an injury or illness can cause a stroke.
stroke risk factors (within control)
Unhealthy weight - hypertension (high BP) high cholesterol, diabetes, heart disease
Physical inactivity
Excessive alcohol & drug abuse
Smoking
Stress
Birth control/ hormones replacement therapy (HRT)
stroke risk factors
Gender
Age
Family history
Ethnicity
History of stroke or TIA
main modifiable risk factors (stroke)
Blood pressure (hypertension is associated with hemorrhagic strokes)
Atherosclerosis (atherosclerosis is associated with ischemic strokes)
stroke FAST signs
Face – facial numbness or weakness, especially on one side
Arm – arm numbness or weakness, especially on one side
Speech – slurred speech or difficulty speaking or understanding
Time – time is important; call EMS/9-1-1 immediately
warning signs (stroke)
Sudden numbness or weakness in the face, arm or leg (especially on one side of the body).
Sudden confusion or trouble speaking or understanding speech.
Sudden vision problems in one or both eyes.
Sudden difficulty walking or dizziness, or problems with balance & coordination.
Severe headache with no known cause.
Brunnstrom stages of recovery (stroke)
- Flaccidity (immediately after the onset)
No “voluntary” movements on the affected side can be initiated - Spasticity appears
Basic synergy patterns appear Minimal voluntary movements may be present - Patient gains voluntary control over synergies
Increase in spasticity - Some movement patterns out of synergy are mastered (synergy patterns still predominate)
Decrease in spasticity - If progress continues, more complex movement combinations are learned as the basic synergies lose their dominance over motor acts
Further decrease in spasticity - Disappearance of spasticity
Individual joint movements become possible and coordination approaches normal - Normal function is restored
Stage 1 - Flaccidity
PROM
Passive stretching (gentle)
Position to support upper limb, especially shoulder (subluxations common in this stage)
Stage 2 – Spasticity develops and abnormal synergies may be present
Continue with PROM (very slow, gentle to not provoke spasticity)
Massage for sensory stimulation
Stage 3 – Spasticity increases
Continue with above techniques
Increased emphasis on stress reduction
Massage to relax spastic/synergistic areas
May be using splints
Stage 4 – Spasticity decreases
Continue with above techniques
Added emphasis on using the recovering arm as much as possible with home care and ADLs
PNF patterning (PROM, AROM)
Stage 5 – Spasticity continues to decrease (minimal)
Continue with above
Begin strengthening routine (as opposed to ROM-based exercises)
PNF patterning (RROM)
Stage 6 – Spasticity disappears and coordination reappears
Continue with above and focus on fine motor skills (e.g. hand and finger exercises)
stroke hx q sample
goals
energy levels
ADLs?
P? where? hm? when?
rehab
presentation? sensory? motor?
when?
stress/mental health
meds
stroke ax sample
palpation
MMT
ROM (goniometer)
postural
stroke goals sample
decrease SNS
—> inh ROOD, DB, heat, slow GSM
decrease spasticity
—> GTO, inh ROOD
increase strength of weak mm (E.g. extensors)
—> neural tapping, stim ROOD, isometric/RROM
maintain jt health
JM, PROM, circumduction
increase ROM
slow stretch, PROM
Synergy
A whole series of muscles are recruited when just a few are needed.
For example, when trying to reach forward, the shoulder abducts and elevates, and the wrist flexes
synergy patterns (stroke)
5 patterns
1 (AKA Flexor synergy (spastic?) pattern)
= IR, add (GH)
= flexion (HU)
= supination (RU)
= flexion (RC)
2
= same as 1, except wrist = extension
3
= same as 1, except forearm/wrist are neutral
4
= same as 1, except forearm = pronation
5 (AKA extensor synergy (spastic?) pattern)
= IR, retroversion (GH)
= extension (HU)
= pronation (RU)
= flexion (RC)
—> Looks like waiter’s tip
E.g. Ax
Palpation / postural
ROM
Sensory testing
E.g. goal
Promote relaxation
Decrease pain
Addressing postural changes/ muscle imbalances
Decrease edema
Decrease spasticity
Maintain joint health
Full body integration
Tx/goals rationale
Relaxation and stress management because stress makes spasticity worse
PROM and stretching are important to prevent neglect of the affected limb, to maintain sensory mapping of the area, and to prevent contracture formation
Trying to lower the tone of spastic or overused muscles is important to decrease contracture formation
Decreasing edema is important for tissue health
Trying to stimulate muscles outside of synergy or opposite to spasticity
PROM and joint play to maintain joint health
Full body integration for overall wellbeing
