PTA Neuro - SCI, MS Flashcards
What functional capability does a patient with injury at level C1 - C3 have?
- require mechanical ventilation
- full time attendants
- totally dependent in all ADLs, transfers, pressure relief
What functional capability does a patient with injury at level C4 have?
- diaphragm
- upper trapezius
- no upper extremity innervation
- dependent in all ADLs and transfers
What key muscles and available movement does the C5 level injured patient have?
- biceps
- brachialis
- brachioradialis
- deltoid
- infraspinatus
- rhomboids
- serratus anterior
- supinator
- teres minor
elbow flexion supination shoulder ER shoulder ABduction to 90 shoulder Flexion to 90
What key muscles and available movement does the C6 level injured patient have?
- extensor carpi radialis
- latissimus dorsi
- pec major (clavicular bit)
- pronator teres (weak)
- serratus anterior
- teres major
- shoulder flexion, extension, IR, ADduction
- scapular ABduction, protraction, upward/lateral rotation
- forearm pronation
- wrist extension
What key muscles and available movement does the C7 level injured patient have?
- triceps
- flexor carpi radialis
- latissimus
- pronator teres
- elbow extension
- wrist flexion
What key muscles and available movement does the C8 level injured patient have?
- flexor carpi ulnaris
- extensor carpi ulnaris
- hand intrinsics
- finger flexors
- can write
- finger flexion
What key muscles and available movement does the T1 - T8 level injured patient have?
- hand intrinsics
- top half of intercostals
- pec major (sternal portion)
- upper abs from T7
- manual wheelchair propulsion
- improved trunk control and breathing capabilities
(barely any abs)
What key muscles and available movement does the T9 - T11 level injured patient have?
- upper and lower abdominal muscles
- upper and lower intercostals (we have deduced this)
- independent wheelchair mobility
- able to initiate cough (because lower abs)
(still no hip flexor)
At what spinal level are the Upper Abdominals active?
T7 - T9
At what spinal level are the Lower Abdominals active?
T9 - T12
What key muscles and available movement does the T12 - L2 level injured patient have?
- quadratus lumborum
still no quads
What key muscles and available movement does the L1 - L3 level injured patient have?
- iliopsoas
- quadratus lumborum
- rectus femoris
- gracilis
- sartorius
- hip flexion
- hip adduction
- knee extension
What key muscles and available movement does the L4 - L5 level injured patient have?
- all the quadriceps group
- medial hamstrings (L5 - S1)
- anterior tibialis (L5)
- strong hip flexion
- strong knee extension
- knee flexion
- ankle dorsiflexion
What key muscles and available movement does the S1 level injured patient have?
- plantar flexors
- gluteus maximus
- gastrocnemius
- peroneals (L5, S1)
- flexor digitorum (L5, S1)
- ankle plantarflexion
- ankle eversion
- toe flexion
What key muscles and available movement does the S2 level injured patient have?
- anal sphincter
At what level spinal cord injury may the patient live independently?
C6
List non-traumatic causes of SCI
- Infections (Transverse myelitis, abscess)
- Spinal Tumors
- Multiple Sclerosis, ALS
- Vascular Problems
- Vertebral Subluxations due to - RA or DJD; Spinal stenosis
- Spina bifida, toxins
What is tetraplegia?
(was quadriplegia)
- Partial/Complete Paralysis of Trunk and Four Extremities
- results from Cervical Lesions
- no trunk control
- strictly UE strength
What is paraplegia?
- Partial/Complete Paralysis of All or Part of Trunk and Both Lower Extremities
- results from Thoracic or Lumbar Cord Lesions
- T1 on down to L5
- Cauda Equina Injury = L1 or Below
How is the level of spinal cord injury designated?
by the most inferior or distal spared nerve root segment
(ex. a C5-level has innervation at C5, but none from C6 and down)
- intact muscle function is at least 3/5 muscle strength per MMT
At what level is a Cauda Equina injury?
below L1
What determines a spinal cord injury to be classified as incomplete?
perianal sensation must be present (sacral sparing)
- voluntary contral RECTAL SPHINCTER
- MAY HAVE NORMAL BOWEL/BLADDER & SEXUAL FUNCTION
- MAY FLEX GREAT TOE
What determines a spinal cord injury to be classified as complete?
sensory and motor function will be absent below the level of the injury
What are complete lesions normally due to?
- severing of the spinal cord
- severe compression
- extensive vascular impairment
What are incomplete lesions normally due to?
- cord contusion (bruising)
- edema
- partial transection (damaged) of cord
Name some traumatic causes of spinal cord injury
- motor vehicle accidents
- acts of violence
- falls
- sports
describe the Brown-Sequard Syndrome
Incomplete Lesion
- Injury to one side (longitudinal half) of spinal cord
- Due to Gunshot or Stab Wounds
- Lose motor function, proprioception, tactile sensation & vibration on same side as injury (because fibers at corticospinal tract and dorsal columns do not cross at the spinal cord level)
- Lose pain & temperature sensation on opposite side a few segments lower ( because Lateral Spinothalamic Tract ascends, then crosses)
- prognosis for recovery is good - many become independent in ADLs and are continent
describe Anterior Cord Syndrome
Incomplete Lesion
- in the anterior (or ventral) column
- due to flexion injury to cervical spine by fracture-dislocation to cervical vertebra
- or due to vascular problem
- lose motor function, pain and temperature sensation below level of the lesion
- keep sense of proprioception, kinesthesia, and vibration (because they are in posterior column)
describe Central Cord Syndrome
Incomplete Lesion
- most common
- in central cord
- due to progressive stenosis or compression due to hyperextension injuries
- UEs more severely involved than LEs (because cervical tracts are located more centrally)
- usually can ambulate
- B, B, and Sex may be spared
- sensory deficits tend to be variable
- three different tracts can be affected - spinothalamic, corticospinal, dorsal
describe Posterior Cord Syndrome
Incomplete Lesion
- rare
- aka Dorsal Column Syndrome
- due to compression of posterior spinal artery by tumor or vascular infarct
- deficits in proprioception and vibration
- keep motor control, pain sensors and light touch (because they are anterior)
What is the Cauda Equina Injury?
(frequently) Incomplete LMN lesion
- due to fracture-dislocation below L1
- flaccidity, areflexia, loss of B&B function are most common clinical manifestations
- regeneration of peripheral nerve possible, depending on extent of damage
List the clinical manifestations of spinal cord injury:
motor deficits sensory loss respiratory dysfunction temperature control impairments spasticity B&B dysfunction sexual dysfunction
What is spinal shock?
The shock that occurs immediately post-injury and lasts several hours to weeks.
- usually resolves in 24 hours
It is a period of areflexia, flaccidity, loss of sensation.
- no reflexes below the injury
What is motor deficit?
complete or partial paralysis
What is sensory loss?
impaired or absent sensation below the lesion level
How is temperature control impaired?
hypothalamus cannot control vasodilation/constriction
- mostly in cervical lesions
- no sweating or shivering below the lesion level (spotty in complete)
- extra a lot of sweating (diaphoresis) above lesion
- body temp greatly affected by external environment
How is respiratory function impaired due to SCI?
- innervation to diaphragm affected with C1-C3 lesion
- muscles of inspriation and expiration affected with upper level lesions
- susceptible to Pneumonia due to ineffective cough and decreased vital capacity
- susceptible to PE
Why does spasticity occur in SCI?
Missing CNS control over still-intact reflex arcs
- clonus,hypertonicity, hyperactive stretch reflexes occur below injury level
- usually plateaus in one year
- moving too quickly sets it off
How can spasticity be helpful with a person with SCI?
- prevent atrophy
- help maintain muscle bulk
- assist maintenance of circulation
- assist patient in performing functional activities (transfers, bed mobility, standing)
How can spasticity be managed?
- baclofen (oral or pump)
- diazepam
- clonidine
- botox
- slow, smooth, controlled movement
- static stretching
- weight bearing
- cryotherapy
- e-stim
What is LMN bladder dysfunction?
flaccid bladder
- don’t feel the urge
- injury in cauda equina or conus medullaris
- injury is above S2 and sacral reflex arc is not intact
- use manual compression (crede maneuver) or catheter
- bladder training - timed voiding
What is UMN bladder dysfunction?
spastic bladder
- bladder empties whether ready or not
- injury is above S2 and sacral reflex arc is intact
- bladder training - timed voiding
- fluid intake control
- intermittent cath
What is the bowel dysfunction in SCI?
Reflex Bowel
- in lesions at T11-12 and above
- can use digital stimulation
Flaccid Bowel
- at or below T12 on conus medullaris and cauda equina lesions
- no digital
- bowel program - high fiber diet, appropriate fluid intake, stool softener, suppositories
What stimuli increase Spasticity?
changes in velocity
- spasticity is velocity dependent
Flaccid Bladder is known by what other designations?
- Autonomous
- Nonreflex
- LMN Lesion of Conus
- Medullaris
- LMN Lesion of Cauda Equina
Spastic Bladder is known by what other designations?
- Reflex
- UMN
- Neurogenic
what are 3 kinds of catheter?
- indwelling
- external
- suprapubic
how does SCI affect sexual function in males?
- erectile capactiy altered
- greater in UMN lesion than LMN or incomplete lesion
- ejacutaion ability alter
- greater in incomplete lesions than complete lesions
- fertility reduced
- may use vibratory stimulation to collect higher quality semen for turkey baster
how doe SCI affect sexual function in females?
- fertility unimpaired
- amenorrhea for 1-3 months post-injury, then resume normal
- pregnancy can cause issues
- affect respiratory function
- can’t feel labor happening (C-section)
- labor may cause Autonomic Dysreflexia
what are some secondary complications to SCI?
- respiratory complications
- pressure ulcers
- DVT
- pain
- osteoporosis
- renal calculi
- heterotopic ossification
- postural hypotension
- autonomic dysreflexia
what are the most common sites for pressure ulcers?
- sacrum
- ischial tuberosity
how can pressure ulcers be prevented?
pressure relief
* every 30 minutes for 2 minutes
what is the major cause of DVT that is secondary to SCI?
lack of mobility and active muscle contraction
- leads to stasis and hypercoagulability
when is DVT most frequent when secondary to SCI?
within the first 2 months of the injury
- most likely to occur during the acute stage of recovery
what is the prevention plan for DVT secondary to SCI?
- prophylactic anti-coagulant drugs for 2-6 months post-injry
- regular turning, PROM exercise, positioning of LEs
- use of elastic support hose
what is Thrombophlebitis?
the inflammation that results from the formation of the thrombus
- characteristic clinical features - swelling, redness, heat
what kind of Pain is associated with SCI?
- pain due to trauma
- nerve root pain due to damage near the spinal cord
- spinal cord dysesthesias
- musculoskeletal pain
what is dysesthesia?
condition in which an unpleasant sensation is produced by ordinary stimuli
- touch sensation experienced as pain
- burning, prickling, tingling, searing, or crawling sensations
how is Pain due to SCI managed?
when due to trauma:
- immobiliization
- analgesics
- TENS
how is Nerve Root Pain due to SCI managed?
drugs
TENS
how are Spinal Cord Dysesthias managed?
drug
- Tegretol (used for seizures, nerve pain, bipolar disorder)
- Dilantin (an anti-epileptic)
what Musculoskeletal Pain due to SCI can be expected?
how can it be prevented?
- pain due to overuse (such as in shoulders - which are now working for the arms and the legs)
- regular ROM and positioning
why does Ostoeporosis occur in the SCI patient?
what is a common fracture in the SCI patient?
- because there is no weight bearing
- no muscle pulling on the bone
- a lack in the hormones
- distal femur fracture
what are Renal Calculi?
why do they develop?
Kidney Stones
- resorption of bone due to Osteoporosis
- hypercalciuria - calcium in the blood is deposited in the kidneys, leading to kidney stones
how can Renal Calculi be prevented?
- maintain good bladder drainage
- follow a diet high in protein, vitamin-rich foods
- restrict calcium intake
- increase water intake
- engage in mobility and standing as early as possible
what is Heterotopic Ossification?
what causes it?
- ectopic bone formation (osteogenesis)
may be due to
- abnormal calcium metabolism
- tissue hypoxia
- local trauma
where does Heterotopic Ossification occur in the SCI patient?
- occurs in soft tissues below the lesion level
- around joints
- extraarticular
- extracapsular
- often Joint Ankylosis at the Hips
how is Heterotopic Ossification treated?
- use Diphosphates to inhibit bone growth
- perform regular ROM exercises
- possibly surgery
(NOTE: inconsistent evidence says that aggressive stretching may aggravate it)
what are the signs and symptoms of Heterotopic Ossification?
- decreased ROM
- swelling
- warmth
- pain
what is Postural Hypotension?
what causes it?
what are the symptoms?
how is it treated?
- Low BP upon standing or sitting up
- Lack of sympathetic vasoconstriction control
- pallor, confusion, dizziness, fainting
- move slowly; monitor vital signs; wear compression stockings & abdominal binder; employ drug therapy
what is Autonomic Dysreflexia?
what can cause it?
- an over-activity of the Autonomic Nervous System specific to SCI patients with lesion above T6
- occurs when an irritating stimulus is introduced to the body below the level of spinal cord injury
- nerve impulses blocked by the lesion at the level of the injury
- a reflex is activated to increase activity of the sympathetic portion of the ANS
- overfull bladder
- sat on a tack
- genitals squished or tucked
- clothing too tight
what are the signs & symptoms of Autonomic Dysreflexia (AD)?
- Hypertension; Bradycardia
- Severe pounding headache; Profuse sweating
- Increased spasticity; Restlessness
- Vasoconstriction below lesion & vasodilation above lesion level.
- Constricted pupils; Nasal congestion
- Piloerection; Blurred vision
what is the treatment for Autonomic Dysreflexia?
!! medical emergency !!
• Bring patient to sitting to lower BP.
• Check for bladder distension & assess drainage system
• Check for irritating stimuli, ie. tight clothing, straps, etc.
• Get medical/nursing assist if no relief
• Antihypertensive drugs may be needed
• Notify all health team members of episodes.
what is the incidence of Multiple Sclerosis?
- ~ 2.5 million people worldwide
- 400,000 people in usa.
- onset ages 20 – 50, peak at 20 - 30.
- 2-3:1 women:men
- primarily caucasians & northern or central european heritage
- rare in africa, asia, s america
- greater frequency farther from equator (decreased vitamin D)
- solar radiation has protective effect
- more common in europe, us, canada, new zealand & parts of australia.
what is the etiology of MS?
- unknown etiology
- immune mediated process; exact antigen unknown
- environmental- exposure to some environmental agent that occurs before puberty may predispose a person to develop MS later
- infectious – many being investigated, but no definitive link yet (epstein-barr virus)
- genetic - increased risk if primary relative has MS
what are the pathological changes that occur with MS?
- inflammation & breakdown of myelin in brain, spinal cord, & optic nerve > symptoms
- demyelinated lesions scattered through CNS white matter
- plaques of hard sclerotic scar tissue after myelin loss
- neural transmission (saltatory conduction) impaired > nerves fatigue rapidly
- new evidence- inflammation in gray matter very early in disease
- may start in the cortex and spread to deep layers
- common areas: optic nerve, subcortical white matter, corticospinal tracts, dorsal columns in sc, cerebellum
what are the most common symptoms of MS?
- Fatigue
- Weakness
- Spasticity – In 90% Of Cases, + Babinski And Clonus, Damage To Corticospinal Tracts And Motor Cortex
- Gait, Balance, Coordination Problems
- Cognitive Changes - 50% Of Patients,
- Sensory Disturbances – Parasthesias (Pins & Needles) Or Proprioception Impairments
- Depression; Other Affective Disorders
- Bladder &/Or Bowel Dysfunction
- Pain – In 55% Of Patients, Dysesthesia (Burning Or Aching), Lhermitte’s Sign (Electric Shock Like Feeling That Goes Down The Back And Extremities W/ Neck Flexion)
- Visual Problems – Optic Neuritis > Blurred Vision, Scotoma (Dark Spot), Nystagmus (Eye Shakes), Diplopia (Dbl Vision)
- Ataxia – (Due To Damage To Cerebellum) No Motor Movement (Not Due To Paralysis Or Paresis)
- Intention And Postural Tremors
- Dysarthria, Dysphagia
what are 3 exacerbating factors of MS?
- Heat – increased body temp of 2 degrees w/ activity or fever
- Decreased overall health
- Emotional or physical stress
what is the prognosis of MS?
- Normal life expectancy
- better prognosis w/ earlier onset
- relapsing remitting better prognosis than primary progressive
