Neuromuscular SCI and GBS Flashcards
What are the Traumatic Injuries for SCI?
- Vehicular (MVA) Number 1 cause
- Falls
- Violence
- Sports
What are the Non-traumatic injuries for SCI?
This makes up 39% of all SCIs
- Vascular Dysfunction
- Vertebral Subluxation due to RA or DJD
- Spinal Neoplasm
- Syringomelia
- Abscess
- Infection: Syphilis, Transverse Myelitis
- MS or ALS
What is the demographics of patients with SCI?
- Typically pts ~42 y.o
- Mostly male
- Mostly caucasian
With SCI, what are common MOIs for the Cervical Spine?
- Forces of: Flexion, Axial Loading, Distraction, Extension
- Concomitant Rotation, lateral flexion, shear force
With SCI, what are common MOIs for the Thoracic Spine?
Less common than cervical, more likely to be complete
- GSWs, MVAs, Falls
- Most common site: T12-L1 junction
- Forces: Flexion, Axial Loading, or Combination of Flexion and Rotation
With SCI, what are common MOIs for the Lumbar Spine?
- Falls, MVA, GSW, Direct load onto spine
- Forces: Flexion, Axial Loading, Flexion combined with distraction or rotation
What is the Pathology of SCIs?
- Damage due to impingement and/or compression of cord
-Bony or soft tissue
-Penetrating or non-penetrating - Blunt Trauma= Primary neural damage to cell bodies and/or axons
- Secondary injuries cause most damage:
-Ischemia
-Demyelination of axons
-Edema
-Necrosis
Must Know
What is the Gold Standard for identifying the severity of injury after SCI?
ASIA, American Spinal Injury Association
The International Standards for Neurological Classification of Spinal Cord (ISNCSCI)
- This promotes communication inter-professionally the degree of motor and sensory impairment
- Provides guidance for establishing prognosis
- Used in clinical research trials
Standard Outcome Measure
- ICF: Body Structure Function
- Interpretation: Neurological Level of Function
Must Know
With SCI, What is the Neurological Level of Injury?
- The most caudal level of the spinal cord with normal motor and sensory function on both the left and right side of the body
-Motor level: Most caudal segment with normal motor function bilaterally (Normal 3/5, Tested through key myotomes)
-Sensory level: Most caudal segment with normal sensory function bilaterally (Tested through light touch and pinprick via key dermatomes)
If the Neurological Level of injury is at C5, then everything C5 and above in INTACT and C6 and below are impaired and/or absent
Must Know
What is a Complete Spinal Cord Injury?
- No sensory or motor function in the lowest sacral segments S4 and S5
(No sensory or function 3 levels below the Neurological Level of Injury)
Must Know
What is an Incomplete Spinal Cord Injury?
An SCI having motor and/or sensory function below the neurological level including sensory and/or motor function at S4 and S5
Must Know
How would a physician or PT determine if a pt has a Complete or Incomplete SCI?
By checking the Anal Sphincter control and sensation
(S4 and S5)
- The persons ability to contract or have sensory
Must Know
With ASIA, what does A mean?
A = Complete SCI
- No motor or sensory function is preserved in the Sacral segments S4 to S5
Must Know
With ASIA, what does B, C, and D mean? How can they be differentiated?
These are all Incomplete SCI
B = Sensory but no motor function is preserved below the neurological level and includes the sacral segements S4 to S5
C= Motor function is preserved below the neurological level, and more than half of key muscles below the neurological level have a muscle grade less than 3
D= Motor function is preserved below the neurological level, and at least half of the key muscles below the neurological level have a muscle grade of 3 or more
With ASIA, what does E mean?
Normal
E= Motor and Sensory function is normal
A patient presents with the following:
Motor:
- 5/5 bilateral Bicep
- 2/5 Radial wrist extension
- 0/5 all other key muscles
Sensation:
- C2-C5 Pinprick and light touch 2/2
- C5-C6 Pinprick and light touch 1/2 (impaired)
- Below C7 0/2 (absent)
Senses Deep pressure in rectal areas, but cannot voluntarily contract sphincter
Using the ASIA Form:
What are the Motor and Sensory Levels?
What is the Neurological Level of Injury?
Is this SCI complete or incomplete?
Motor Level:C5
Sensory Level: C5
Neurological Level of Injury: C5
Incomplete SCI: Intact sensation in perianal (S4/S5) Region
Considered ASIA C
SCI: Clinical Syndromes
What is the Brown Sequard Syndrome?
Must Know
This is a Hemisection injury
- Ipsilateral loss of proprioception, vibration and motor function at and below level of lesion
- Contral lateral loss of pain and temperature
SCI: Clinical Syndromes
What is Anterior Cord Syndrome?
Must Know
Flexion injury of C-Spine
- Bilateral loss of motor function, pain, and temperature sensitivity at and below injury level
- Intact light touch and proproception
SCI: Clinical Syndrome
What is Central Cord Syndrome?
Must Know
Most common due to Hyperextension injury
- Paraylsis and sensory loss in UEs
- Varying involvement in trunk and LEs
Cant complete ADLs due to loss of UE control, but can walk
SCI: Clinical Syndromes
What is Cauda Equina Syndrome?
Must Know
Injury to the lumbosacral nerve roots of the cauda equina
- LMN signs
- Flaccid paralysis of LEs
- Areflexic bowel and bladder
However in term of ADL they are still relatively functional
Must Know
What happens when you first have a SCI?
- Spinal Shock
-An immediate period of areflexia post spinal cord trauma
(The entire system dies/stops functioning. Ex. if a pt has injured C6. From C6 and below the pt becomes areflexive/no function)
-This typically evolves within 24 hours
-This typically resolves within 1-3 days - Loss/Dysfunction of motor, sensory and autonomic systems
Primary/Secondary Impairment for SCI
What is Autonomic Dysreflexia (AD)?
Must Know
- A life-threatening dysfunction of autonomic nervous system
- Observed in injuries above T6, most common with complete injury
- Clinical syndrome triggered by noxious stimuli below the level of the lesion
If a patient has Autonomic Dysreflexia, what are some symtoms they may present with?
- Hypertension (Increase of 20-30mmHG)
- Bradycardia
- Headache (may be severe)
- Profuse sweating
- Increased spasticity/hypertonia
- Vasoconstriction below lesion level
- Vasodilation above lesion level (Flushing)
- Constricted pupils
- Nasal congestion
- Piloerection (Goose Bumps)
- Blurred Vision
Must Know
As a PT, what do you do to help the patient with Autonomic Dysreflexia?
- If lying flat, sit up (to reduce orthostatic hypotension)
- Call emergency code
- Find and remove noxious stimuli
-Remove all clothes
-Pinched skin, clothing, urinary retention, wounds, bowel obstruction - Education on triggers and how to resolve
Case Scenario
Your patient who has C8 tetraplegia, has been practicing rolling from supine to prone on a mat. She states that she has a pounding headahe and you notice her face is flushed and damp with sweat. How should you best respond to this clinical presentation?
- Identify noxious stimuli
- Ensure the patient is upright to decrease blood pressure
- Alert the appropriate medial team to take further action if patient does not respond positively to your actions
What is Spastic Hypertonia?
- Associated with UMN injuries
- This is more common with cervical injuries
- Evolving presentation during acute to subacute phase
–Emerges after spinal shock
–Increases through initial 6 months post injury
–Plateaus around 1 year - Altered by various stimuli
SCI: Multi-System Impairments
With SCI, what happens when the Cardiovascular System is affect/impaired?
- Orthrostatic hypotension: Primarily an acute concern, >T6
- Reduce activity tolerance, low cardiac output and stroke volume - subacute and chronic concern
SCI: Multi-System Impairments
With SCI, what happens when the Temperature Control is affect/impaired?
What patients may we see this with?
- Hypothalamus is affected
- Lack ability to shiver below lesion
- Risk of hyperthermia below lesion due to alterted sweat glands
- Patients with tetraplegia and complete SCI chonic impairment
SCI: Multi-System Impairments
With SCI, what happens when the Pulmonary System is affect/impaired?
- Variable depending on level of injury
- High cervical injury, pulmonary problems are the leading cause of death
- Respiratory muscle control may be affected, ranging from C1-T10
- Altered breathing patterns present: Paroxysmal Breathing patterns
Paradoxical breathing happens when your chest contracts when you inhale and expands as you exhale.
SCI: Multi-System Impairments
With SCI, what happens when there is a Bladder Dysfunction?
- UTI’s are common post SCI
Types of Bladder Disfunctions:
- Pt can get a spastic bladder: Lesion above sacral segments/conus medullaris (UMN)
- Flaccid/Areflexic Bladder: Lesions at or below sacral segments/conus medullaris
SCI: Multi-System Impairment
With SCI, what happens when there is a Bowel Dysfunction?
- Pts reported to have the greatest impact affecting daily life
Two Types of Neurologic Bowel:
- Spastic/Reflexic: Lesion above S2
- Flaccid/Areflexic: Lesion of S2-S4 or Cauda Equina (peripheral nerves)
SCI: Multi-System Impairments
With SCI, what happens when there is Sexual Dysfunction?
- Patients with paraplegia report imporved sexual function = Improved QOL
- Patients with tetraplegia = 2nd most important function to recover after use of hands
- This impacts physiologically and psychosocially
Primary/Secondary Impairments for SCI
If a patient with a SCI presents with Orthostatic Hypotension, what are the S/S and treatment?
Must Know
Decrease in BP >20mm during positonal change
- S/S:
-Dizziness, Lightheadedness, sweats (looks like fainting episode) - Treatment: Elevate legs above heart, TIS W/C
For preventative measure have slow progression into upright position. Use Compression stockings (Ace wraps) and abdominal binders, these help push blood back and allow venous return
This is common because pts with SCI are initially bedbound
What are Risk Factors for SCI?
- Prolonged immobility
- Multi-systemic effect
82% of patients with SCI develop secondary impairments and complications
What are Secondary Medical Complications with SCI patient and those bedridden?
- Pressure sores (1)
- Pneumonia (2)
- DVT (3)
- Pain (nociceptive/neuropathic)
- Contractures
- Heterotopic Ossification
- Osteoporosis and fracture
What are PT Examination Considerations for SCI?
- Patient/Family Hx, contextual factors
- Level of injury (ASIA)
-Best predictor of motor recovery - Available and coordination resources
- Diagnosis Specific Measures
What is the Prognosis for SCI?
- This has a earlier neurological return
- ASIA levels: B-C-D indicate greater likelihood of motor recovery
- ASIA Level A: 70% will experience motor recovery one level below the initial neurological injury level
- Pinprick sensation in BLE and/or sacral region: imporved prognosis of motor recovery in 1 year if present 4 months post injury
- Pattern of Neurological Injury: Brown Sequard Syndrome (BSS) > Anterior Cord Syndrome (ACS)
- Age
With ASIA B-C-D are incomplete SCI ; A is complete SCI
SCI outcome measure
What is the ICF category for the SCIM?
Spinal Cord Injury Independence Measure
- Activity
SCI Outcome Measure
What is the ICF category for the WISCI II?
Walking for Spinal Cord Injury II
- Activity
What is Guillan-Barre Syndrome (GBS)?
- Acute inflammatory demyelinating immune-mediated polyneuropathy
- Nerve roots and peripheral nerves affected
- Leading to flaccid paralysis, sensory impairment and autonomic nervous system impairment
More males are affected than females
What are varient forms of GBS?
- Acute motor axonal neuropathy
- Acute motor and sensory axonal neuropathy
- Miller Fischer Syndrome: CN, Ataxia, and Areflexia
- Chronic Inflammation Demyelinating Polyneuropathy: Progressive relapsing or remitting numbness and weakness
What is the Etiology of GBS?
- This is an idiopathic disorder
- There is typically an inflammatory response due to an Infection 2-3 weeks prior
(Common viruses associated are Epstein-Barr Virus and Mycoplasma Pneumoniae)
What is the Pathology and Neuroanatomical Location of GBS?
- Spinal Roots and Peripheral nerves attacked by Microphages and T Lymphocytes
- Damage occurs directly to the Myelin Sheath along the axon
- Severity depends on Axonal damage
-Mild: Axon intact, rapid re-myelination
-Severe: Axonal damage or loss, axonal regeneration required
With MS and GBS
What happens when the Myelin Sheath is Damaged?
There is decreased Action Potential
- Slowed Conduction
- Dyssynchrony of conduction
- Disturbed conduction of higher frequency impulses
- Complete conduction blocked
Must Know
What is the Medical Diagnostic Criteria for GBS?
what are the S/S
- Motor weakness
-Rapid progression
-Symmetrical, Distal to Proxinal
-Areflexive distal tendons (LMN) - Mild sensory symptoms: Parasthesias or Hypesthesias
- Autonomic Dysfunction: Tachycardia, Arrhythmia
- Hx of recent flu-like illness
- Lab results not conclusive
- Nerve conduction study: Abnormal velocity
- Recovery occurs 2-4 weeks AFTER PLATEAU of disease process
What are Common Clinical Presentations of GBS?
- Rapid evolution of bilateral, symmetrical flaccid paralysis
- Fatigue: severity is correlated with older age
- DTRs are diminished or absent
- Sensory Sx: Numbness, tingling, decreased vibratory senses. Stocking glove distibution
- Pain: Muscle aching, large muscle cramps (Progressive worsening as disease progresses)
What Clinical Presentations are Less common with GBS?
- Ventilator Dependent (If attacked so severly, it can attack repsiratory muscles)
- CN Involvement
- ANS Symptoms
-Pooling blood
-Urinary retention
-Ileus
-Poor venous return
What is the Medical Prognosis for GBS?
- Commonly Maximum Paralysis: within 1-2 days of onset
- Greatest Severity reached:
-50% within 1 week
-70% within 2 weeks
-80% within 3 weeks - Once plateaued, motor recovery occurs within 2-4 weeks
The faster we get to the plateau the faster the patient will have motor recovery
What is the Functional Prognosis for GBS? What are common long term deficits with GBS?
- 80% become abulatory within 6 months
- 15% persistent residual impairment
- 50% mild neurological deficits
- Common Long-Term Deficit:
-Weakness of TA, foot and hand intrinsic, glutes and quads
-Fatigue
-Deconditioning/poor endurance
-Sensory deficits may persist 3-6 years post
What are Poor Prognostic Criteria for GBS?
- Severity muscle weakness (Quadriplegia)
- Ventilator support
- CN Involvement: loss of eye movement and swallowing
- Rapidly progressing from initial onset
- Length of time to maximal severity
- Old age
- Pre-morbid GI illness
- Recent CMV
What are System Specific Outcome Measures for GBS?
- Fatigue Severity Scale (FSS)
- Fatigue Impact Scale (FIS)
- Visual Analogue For Fatigue Scale (VAS-F)
What are the Functional Specific Outcome Measures for GBS?
- Barthel Index
- Modified Hughes Scale of GBBS Disability
- Functional Independence Measure
What are Participation related Outcome Measures for GBS?
- Short Form 36
- Nottingham Health Profile
What is the Pharmacological Management for GBS?
- Immunotherapy - Based treatment
-Plasma exhange
-Intravenous immunoglobuin (IvIg) - Corticosteroids
What are some limitations you may encounter with GBS patients?
- Current status of disease process (We want them after the plateau)
- Pain
- Fatigue
- Respiratory Distress
Must Know
What are the Goals for therapy for GBS in Acute Care?
- Improvement of respiratory dysfunction and risk for aspiration
- Manage Pain
- Prevent: Contractures, pressure ulcers, injury to weakened muscles
- Initiate a progressive active exercise program to regain functional mobility
- Monitor and manage fatigue
Must Know
What are the Goals for Therapy for GBS in the Chronic Phase?
Now we look at recovery, the goal is to get them back prior to disorder
- This is recovery of motor recuitment and function
-Neuroplasticity emphasized, remyelination
-Retrain normal movement patterns for functional independence - Compensatory, when appropriate
