SCI Flashcards
Which nerves can be affected in SCI?
Nerves
- motor
- sensory
- autonomic
What are the implications for loss of autonomic NS function?
Implications
- Blood pressure
- Bladder/bowel
- Sexual
- Respiratory
UMN vs LMN lesions
Upper (above conus)
- Spinal reflexes
- Spastic paralysis
Lower (cauda equina)
- Loss of SC mediated reflexes
- Flaccid paralysis
What is the ASIA SCI level defined as?
Lowest intact neural segment
Motor impairment after SCI is due to:
- Damaged ascending/descending tracts
- Poor spinal/cortical reorganisation
Physiotherapy Assessment in SCI?
Ax
- Same as stroke except no dexterity training
- Fitness
- Activity Ax
What are the primary and secondary impairments in SCI?
Primary
- strength
- sensation
- spasticity
Secondary
- loss of muscle length
- disuse weakness
- cardiovascular deconditioning
What muscle innervations does a C6 Quad lack/is weak in?
No
- Elbow extensors
- Finger/thumb muscles
- Trunk or below
Very weak
- Elbow pronators
- Wrist flexors
What is the optimal functional outcome for a C6 quad?
Optimal functional outcome
- Totally independent at home alone
- Lift body weight and transfer (shoulders in locked external rotation and elbows passively extended)
- Manual wheelchair over level surfaces
- Tenodesis grip
What does a T1-4 paraplegic lack in terms of muscular innervations?
? no abdominals and erector spinae above lesion level
Research on strength training below the level? (2)
Hicks et al 2011 (systematic review)
- Mod-high intensity exercise 2-3x/week
= increased strength in chronic SCI
= unsure about functional outcome
Kloosterman et al 2009 (systematic review)
- PRE for upper limb in partially paralysed mm
- 3-5x/week (20-45 mins) for 3-6m
= increased strength and function (T/Fs, w/c)
How much training? Research (1)
van Langevelde et al 2011
- PT/OT/exercise
- Average 8.9 sessions/week at 43 mins/session
- Strength training and modified activity practice
Training function (sitting) in complete lesions (2)
Boswell-Ruys et al 2010
- Chronic thoracic paraplegia
- 1hr/3x wk/6wks
- No improvements
Harvey et al 2011
- Sub-acute thoracic paraplegia
- Usual plus 30mins task specific 3x wk/6wks
- All improved, no different
Training function in INcomplete lesions (2)
Harvey et al 2009 (systematic) = gait training to improve walking
Spooren et al 2009 (systematic) = repetitive motor task training improved UL and hand function
How can tendons be kept strong? (research)
Harvey et al 2010
- ES for keeping tendons strong before tendon transfer
Why is training function in SCI different to stroke?
Training new skills (whole, modified, part)
How frequent is spasticity in SCI and how detrimental is it?
- present in up to 80% of SCI Pts.
- more detrimental in incomplete lesion
What is the leading cause of death in long term SCI?
CV disease
Evidence for increasing ROM?
Positioning, splinting, casting, PROM and tilt table are not effective
(Rx for 30mins 3-5x/week for 4-12 weeks)
Ben and Harvey 2010
- Self-administered hamstring stretches for 30mins, 5x wk/6wks
- Average 10 deg improvement!
Rx to maintain and increase ROM
ROM Rx
- Assess accurately
- Prevent (not reverse)
- Target mm susceptible to shortening
Essential components of lying to sitting in a C6 quad
Components
- Roll onto side
- Lift upper body off bed
- Support the upper trunk
- Hook top hand under leg
- Shuffle bottom elbow around the body
- Move into upright position
Techniques to train rolling
Pre-swing phase
- Small weight
- Splints
- Arms low and close to the body
Swing phase
- Pillow behind trunk
- Cross the ankles
- Flex contralateral side knee
- Begin 1/4 off supine
Essential components of lying to sitting in a T4
- Rolling
- Walking on hands
- Lifting/pushing up trunk
- Hooking around leg and pushing to get into upright sitting
Essential components of transfers for a C6
- Move to front of w/c (cushion, slide-sheet)
- Hook under legs to sit up
- Lift first leg onto bed (feet on raised stool, strap used to help lift leg)
- Lift the second leg onto bed
- Position the hands
- Lift and shift body onto the bed (slide board)
Essential components of transfers for a T4
- Position feet on the floor
- Move to the front of w/c
- Position hands
- Lift and shift body onto bed (slideboard)
- Final sitting or lift legs onto bed (feet on stool, strap to help lift legs)
Measures in SCI:
Measures
- Impairment, activity limitations, participation limitations
- Specific physio measures - 10m walk, TUG
- ASIA classification
- WISCI (walking index for SCI)
Measures of overall mobility
Overall mobility
- Functional Independence Measure (FIM)
- Spinal Cord Independence Function (SCIM)
Cardiovascular training considerations in SCI
CV considerations:
- Medical clearance and supervision
- Use BORG (HR is unreliable)
- Task specific
Gait training (who, considerations)
Who
- Thoracic paraplegia and incomplete lesions possibly
Consider
- Musculoskeletal overuse
- Orthotic requirements
- Strength and fitness
What are pressure areas?
Area of skin or underlying tissue that is dead or dying due to loss of blood flow to the area
Risk factors for pressure sores
Risks
- Limited mobility
- Lack of sensation
- Bladder and bowel accidents
- Spasticity
Strategies to prevent pressure sores
Strategies
- Check skin regularly
- Appropriate positioning and equipment
- Pressure relief (cushions, moving chairs)
- Care with T/Fs
- Refer to specialist seating clinic
What is autonomic dysreflexia?
Exaggerated reflex response of sympathetic NS to noxious stimuli
(E.g. pupil dilation, sweating, CV)
What sort of noxious stimuli are common to cause autonomic dysreflexia?
Stimuli
- Distended bladder/bowel
- Pressure areas
- Infections
- Fractures
How is autonomic dysreflexia treated?
Rx
- Remove cause
- Elevate head/lower feet
- Meds
What do social workers do?
Social workers:
- Support/counsel
- Information
- Access to services
- Advocacy
- Discharge planning
What do neuropsychs do?
- Capacity Ax (consent, D/C destination)
- Environmental safety
- Behaviour concerns
- Cognitive defect Ax
What can nurse practioners do?
NP
- Bladder and bowel management
- Sexual function
- Pressure care
- Medication review
