SCI Flashcards
What is a ASIA B
Incomplete
Sensory but not motor function is preserved below the neurological level & includes sacral segments S4 – S5
What is ASIA C
Incomplete
Motor function is preserved below the neurological level & more than half of key muscles below the neurological level have a muscle grade less than 3
What scale is used to classify SCI
ASIA (American Spinal Injury Association) Scale is accepted at the gold standard for how to classify spinal cord injuries. It is not only used as an initial diagnostic tool but also used by therapists as a comprehensive outcome measure to give insight into areas of recovery that may occur throughout the rehabilitation process.
used to determine:
•Complete or Incomplete Injury [Complete = Asia A]
•ASIA impairment scale grade [A – D]
•Sensory level on both sides
•Motor level on both sides
•Single neurological level- this is determined through identifying the lowest segment where normal and motor function is present.
What is a SCI
Damage to the spinal cord - vital for conveying & integrating sensory & motor information to & from the periphery
A spinal cord lesion may impair motor, sensory and autonomic functions dependent on the extent and level of the lesion
What is the focus of early rehabilitation
Initially the main focus on early rehabilitation will be directly to the areas below:
•Maintaining length of tissues
•Strength
•Balance
•Mobility, incl. transfers
•Wheelchair management
•Pressure care / awareness
What are the main descending pathways?
Corticospinal Tracts (anterior and lateral) = lateral - motor information to limbs, anterior - motor information to axial muscles
Vestibulospinal = Integration of head and neck with trunk and extremities
Reticulospinal = lateral - facilitates flexion & inhibits extension
Rubrospinal = fine motor movements in upper limbs
Tectospinal = control muscles in response to visual stimuli
What is ASIA E
Normal
Motor and sensory function are normal
Name all major ascending tracts and identify the type of sensory information they transmit.
Dorsal Column (Medial Lemniscus) - Gracile fasciculus & cuneate fasciculus - Touch, position sense and vibration
Spinothalamic - Pain and Temperature Information
Spinocerebellar - proprioceptive information
What are the causes of SCI
Traumatic lesions – 84% cases - RTAs, Sport-related injuries
Non-traumatic lesions
Name symptoms as a result of motor function impairment
- Initially Spinal shock
- At level of lesion = complete destruction of nerve cells = flaccidity (low tone) initially
- Gradually anterior horn cells below level of lesion recover but have no control from higher centres = spasticity & spasms (high tone)
UMN lesion = Damage to descending pathways
LMN lesion = Damage to alpha-motor neurone
What areas are affected in a person who is tetraplegic (also known as quadriplegic)?
Impairment or loss of motor control and/or sensory function in cervical segments of the cord - ALL four limbs and trunk affected.
What happens immediately after SCI
Vasogenic oedema and altered blood flow account for clinical deterioration that can occur by 3 different mechanisms:
a. Destruction from direct trauma
b. Compression by bone fragment, hematoma or disc material
c. Ischemia from damage (stated above) or impingement on the spinal arteries
What is the difference in presentation of conus medullaris and cauda equina
Conus medullaris = Sudden, bilateral; less severe radicular pain ; more LBP; perianal sensation (around anus); symmetrical hyperreflexic
Cauda equina = gradual, unilateral; more severe radicular pain; less LBP; saddle area sensation; asymmetrical areflexia (opposite of hyperreflexia)
Name the four types of incomplete SCI
Central Cord Syndrome (whiplash) - Motor dysfunction in UL; Bladder dysfunction; Corticospinal and Spinothalamic tracts dysfunction
Anterior Cord Syndrome from disc herniation (LBP may be seen) - Motor paralysis below lesion; Loss of pain and temp; Retained proprioception and vibration
Brown-Sequard Syndrome (rare) from stab, gunshot wound to cervical or thoracic spine - Motor deficit and numbness to touch and vibration on same side of lesion; Loss of pain and temp sensation on opposite side
Cauda Equina Syndrome from lumbar stenosis, spinal trauma, cancer - Affects peripheral nerve so can be treated if picked early on
Name 5 symptoms that occur as a result of autonomic dysfunction
1) Impairment of vasomotor control
2) Postural hypotension
3) Autonomic dysreflexia
4) Problems with bowel and bladder function
5) Problems with sexual function
Name at least TWO non-traumatic lesions which cause spinal cord injuries
Degenerative disc disease & spinal canal stenosis
- Spinal infarct
- Tumour
- Inflammation of spinal cord
- Viral infection
- Developmental/ congenital abnormalities
What areas are affected in a person who is paraplegic?
Impairment or loss of motor control and /or sensory function in thoracic, lumbar or sacral segments of the cord - DEPENDING on level of injury, trunk, legs and pelvis may be involved
What are some SCI facts
80% of cases occur in males
Typical person = male, aged 15-25 years
Approx half of all SCI occur in people < 30 yrs
What is the focus of long term rehabilitation
Rehabilitation for those with SCI’s into long term rehabilitation, including teaching maintenance and self-management techniques.
Areas of focus in long term rehabilitation will include:
•Dressing
•Transfers
•Pressure awareness
•Bladder and bowel care
•Standing
•Car driving / transport
•Sport
•Employment
•Relationships / parenting
What is a ASIA A
Complete
No motor or sensory function is preserved in the sacral segments S4 – S5
(In order to establish whether the motor and sensory functions of sacral segments remain in tact, a professional who has had training in order to perform an PR (per rectum) examination in order to establish whether any anal sensation and/or tone is present. This is most commonly a doctor as a PR examination must be performed in order to assess this.
Therefore, unless a Physiotherapist gains specialist training, this is mostly conducted by the medial team. The rest of the testing (motor & sensory) can then be completed by the therapist.)
The Autonomic Nervous System is divided into two sections - name these.
Parasympathetic Nervous System and Sympathetic Nervous System
What are the main descending pathways and what type of information do they transmit?
There are 5 main descending tracts, they transmit motor information from the cerebral cortex to peripheral nerves to innervate muscle movement.
How many main ascending tracts are there and what kind of information do they transmit?
There are three main Ascending Tracts - they transmit sensory information from peripheral nerves to the cerebral cortex.
What is needed for recovery of SCI
Need to have normal oxygenation, perfusion and acid/base balance to aid management of the injury - ensure homeostatic stable to aid chance of injury to heal
What are the vulnerable areas of the vertebral column
- Cervical spine, typically C5-7 - 55% of all spinal cord injuries
- Thoracolumbar, typically T12
- Mid thoracic T4-7
- Majority of traumatic cases = fracture dislocation
What is ASIA D
Incomplete
Motor function is preserved below the neurological level & at least half of the key muscles below the neurological level have a muscle grade of more than 3
How is the level of the lesion classified
Most distal uninvolved segment of the cord + Skeletal level and neurological level of the lesion
What are the myotomes
- C5 – sh abd/LR, elbow flexors
- C6 - wrist extensors/flexors, pron/sup
- C7 – sh add/MR, Elbow extensors
- C8 – finger flexors/ext
- T1 – finger abduction
- L2 – Hip flexors
- L3 - Knee extensors
- L4 – Ankle dorsiflexion
- L5 – long toe extensors
- S1 - ankle plantar flexors
- S4-5 anal sphincter
What are the two main types of SCI?
Complete - Complete loss of function below the point of injury; more predictable outcome - Leads to motor function impairment, deep and superficial sensory impairment, autonomic dysfunction
Incomplete (55-65%) - Some sparing of neural activity below the level of the lesion; outcome less predictable; 4 types
Prognosis C2-T1
C2/3:
- Ventilator dependent
- Speak on:
- Inspiration
- Expiration
- Both Function
- Verbally independent
- Independent swallow
- Physically dependent
- 24-hour care
- Assistive technologies (voice/switch)
- Restricted head control: neck flexion/ extension/ rotation and side flexion.
C4:
- Respiratory: Likely to wean off vent in the day
- Function Same as C1-3
- Shoulder retraction, shoulder girdle stabilization, good head control
C5:
- Respiration = independent
- Standing - High support electric standing frame
- Mobility – power wheelchair with joystick control & wrist stabiliser/ power assist/ self-propelling
- (with wrist supports & adapted aids) able to carry out feeding/ drinking/grooming activities)
- touch screen activity
- Partial innervation of all muscles of shoulder ( - lat. Dorsi), elbow flexion, supination
C6:
- Independent grooming, showering with equipment and environmental adaptation and dressing in bed (fatigue and time taken are limiters)
- Independent intermittent catheterisation
- Meal preparation and light domestic activities
-
Bed Mobility and Transfers
- Independent bed mobility using electrically profiling bed
- Level transfers with board Mobility
- Lightweight wheelchair with rubberised hand rims
- Advanced wheelchair skills
- Wheelchair sports
- Standing – Grandstand / Electric OSF
- Driving – automatic car with hands
- Radial wrist extension (tenodesis grip/ release), Good scapula/ G/H joint control, Pronation
C7:
- Independent self-care in bed
-
Mobility and Transfers
- Independent split-level transfers
- Explore floor to wheelchair
- Standing - Electric OSF
- Elbow extension, strong wrist flexion, radial wrist flexion, PIP & DIP flexion, MCP extension thumb extension & thumb abduction
C8 – T1:
- Function - Independent bowel management
- Standing - Electric OSF (for shoulder protection)
- Forearm pronation, ulnar wrist flexion, MCP flexion, PIP & DIP extension, finger add/abduction, thumb flexion, opposition & adduction
Prognosis T2-12
T2 – T6:
- full arm function, partial trunk stability, improved endurance due to increased respiratory capacity
- All muscles of ULs, partial innervation of intercostals, partial abdominal, long muscles of the back (sacrospinalis & semi-spinalis)
T7 - 12:
- Moving towards a normal cough as level descends
- Improving trunk stability and balance as level descends
- Intercostals fully innervated, abdominals partially to fully innervated
Prognosis L1-5
L1/2:
- Majority of time wheelchair user
- Explore walking with callipers and crutches = Potential Complications
- Hip flexion contractures
- Shoulder pain/carpal tunnel from crutch walking
- Hip flexion, hip abduction
L3:
- Wheelchair for convenience, energy conservation and sport
- Ambulate with ankle foot orthoses and crutches
- Sit to stand with upper limb assistance
- Static activities in standing
- Partial Quadriceps (L2-L4), knee extension
L4:
Mobility:
- Wheelchair for long distance/outdoor mobility
- Ambulating with ankle support, insoles and walking sticks
- Flexed gait pattern
- Positive Trendelenberg
- Explore foot pedal driving
- Hamstrings, knee flexion, ankle dorsiflexion & inversion, external hip rotation, partial tib. Ant. innervation
L5:
Mobility
- Ambulating with in shoe orthoses +/- walking sticks
- Ankle eversion, hip abduction, hip internal rotation, hip extension, hip external rotation, Knee flexion, toe extension, first toe extension
Prognosis S1-5
S1 – S3:
Mobile Independently
- Bladder, bowels & sexual function remain disrupted
- Plantarflexion, toe flexion
S3 – S5:
Mobile Independently
- Bladder, bowels & sexual function remain disrupted
- Cauda equina pain+ cramp (poorly understood)
