SCI Flashcards
Spinal Cord Anatomy (White matter)
myelinated tracts in peripheral
Spinal Cord Anatomy (Gray matter)
neuronal cell bodies, glial cells, and located centrally
o Anterior horns: control somatic muscles
o Posterior horn: control sensation
Do afferent nerves transport messages “to” or “away” from the brain?
To the Brain
Do efferent nerves transports messages to or away from the brain?
Away from the Brain
What is the Somatic nervous system involved in?
transports voluntary motor and sensory
What is the automatic/visceral nervous system involved in?
messages for involuntary systems
o Sympathetic
o Parasympathetic
Upper Motor Neuron
Initiate in cerebral cortex and synapse in the anterior horn. Damage occurs within spinal cord
What does the Upper Motor Neuron do to muscle tone, reflexes, and spasticity?
o Increased muscle tone, reflexes, spasticity
Where does the Lower Motor Neuron initiate and exit
initiates in anterior horn and exit through spinal nerves. Damage anterior horn cell
What does the Lower Motor Neuron do to muscle tone, reflexes, and spasticity?
o Decreased muscle tone, reflexes, spasticity
Sensory and Motor Tracts (suffix or prefex)
- Beginning with “spino” = sensory tract
- Ends with “spinal” = motor tract
Spinal Tracts: Sensory
Ascending/afferent
Spino= sensory
Spinothalamic Tract
Dorsal/Posterior Column Tract
Spinocerebellar Tract
Spinothalamic Tract:
- Lateral spinothalamic tract: pain and temperature sensation
- Anterior spinothalamic tracts: crude touch and pressure sensation
- Injury results in: contralateral or ipsilateral loss of pain and temperature
Spinal Tracts: Motor
Descending/efferent = motor
Corticospinal: skeletal muscle with voluntary control
Subconscious tract: balance, muscle tone, UE position
- Vestibulospinal
- Tectospinal
- Reticulospinal
- Rubrospinal
What are the 4 Subconscious motor Spinal Tracts?
Vestibulospinal
Tectospinal
Retculospinal
Rubrospinal
Reticulospinal tract
Is a descending tract from reticular formation to the spinal cord. Part of the subconscious motor Tracts
* Controls proximal and axial muscles, gross movements such as gait, reaching and posture, no fine motor
* controls muscle tone in flexor muscle groups
* Damage results in decreased postural control
Rubrospinal tract
Regulation of flexion and extension tone of large muscles and fine motor.
❑From the red nucleus to the spinal cord
❑Works with the corticospinal tract to control fine motor movement of the hand
❑Damage results in impaired fine motor control, gross motor not effected
Vestibulospinal tract
Inner ear info to assess head position
❑From vestibular nuclei to anterior horn of spinal cord
❑Facilitates activity in all antigravity (extensor) muscles)
❑Results in ataxia and postural instability to the side of damage
Tectospinal tract
Orients the eyes and head in response to loud noise, sudden movement, brightness
❑Superior colliculi: visual info
❑Inferior colliculi: auditory info
Autonomic Nervous System Innervation
- Sympathetic nervous system:
o Located in T1-L2/3 and contain afferent/sensory nerves - Parasympathetic nervous system:
o Located in brainstem- cranial nerve 3,7,9,10
o Located in sacral spinal cord- S2-S4
Autonomic Nervous System Functions (Sympathetic nervous system function)
o Increase heart rate and blood pressure, piloerection, perspiration
o Blood flow to skeletal muscles and the lungs is enhanced
o Increases heart rate and the contractility of cardiac cells
o Provides vasodilation for the coronary vessels of the heart
o Constricts all the intestinal sphincters and the urinary sphincter
o Inhibits peristalsis and decreases motility
o Stimulates orgasm
Autonomic Nervous System Functions (Parasympathetic nervous system function:)
o Dilating blood vessels leading to the GI tract, increasing the blood flow and relaxes sphincters
o Bladder - contraction of smooth muscle of bladder wall; relaxes urethral sphincter - promotes voiding
o Dedicated cardiac branches of the vagus and thoracic spinal accessory nerves impart parasympathetic
control of the heart
o Stimulates erection and sexual arousal
Background of SCI
- Spinal cord injury is defined as “the occurrence of an acute
traumatic lesion of the neuronal elements in the spinal canal
resulting in temporary or permanent sensory deficit, motor deficit,
or bowel and/or bladder dysfunction” - Results in devastating lifestyle changes due to loss of mobility
- Common cause of SCI is motor vehicle collision and falls
- 47 % of cases reported are incomplete tetraplegia/quadriplegia
- Less than 1% experience complete return of neurological function
prior to hospital discharge
Significance of SCI (stats)
- 18,000 new cases per year in the United States
- Estimated 299,000 living with SCI in the United States
- Average age at onset of injury is 43 years
- Average acute hospital stay is 11 days
- Over 78% are males
- 48-52% annual household income at 1-5 years post injury is less than $25,000
Level of Injury
Quadriplegia/ tetraplegia: C1-C7
Paraplegia: T1-S5
Complications of SCI
- Pressure sores
- Respiratory complications
- Heterotopic ossification
- Osteoporosis
- Pain
- Decreased range of motion
- Gastrointestinal
- Urinary tract infections
- Thromboembolism
- Autonomic Dysreflexia
- Cardiovascular disease
C5 Muscle Innervation
Elbow flexion, supination, weak shoulder flexors
- Inherently weak shoulder girdle
- Lack of shoulder internal rotators and shoulder adductors significantly limits function
C5 Muscle Innervation (Partial Innervation)
o Biceps
o Supinator
o Clavicular head of Pectoralis
o Anterior, middle, posterior deltoid
o External rotators and rotator cuff
No innervation of major trunk muscles with exception of trapezius
C5 Muscle Innervation (Full Innervation)
Rhomboids
C6 Muscle Innervation
- Stability and power of shoulder joint
- Full innervation of deltoid, rotator cuff, biceps
- Teres Major and latissimus provide shoulder adduction
- Wrist Extensors
- Pronator Teres
- Weak Latissimus dorsi
- Teres major
- Shoulder internal rotators
- Subscapularis
C7 Muscle Innervation
- Triceps
- Wrist flexors
- Pronators
- Strengthened Serratus Anterior, Latissimus Dorsi, Pectoralis Major
C8 Muscle Innervation
- Active grip and release of hand
- Shoulder girdle and muscles that attach to trunk are fully innervated
L1 Muscle Innervation
- Partial innervation of:
o Quadratus Lumborum
o Iliopsoas
o Psoas major
L2 Muscle Innervation
- Partial innervation of hip flexors and adductors:
o Flexors:
❑Psoas Major (L1-L3)
❑Iliacus (L1-L3)
❑Sartorius (L2-L4)
o Adductors (L2-L4):
❑Obturator externus
❑Adductor longus
❑Adductor magnus, and brevis
❑Gracilis
L3 Muscle Innervation
- Partial innervation of knee extensors (L2-L4)
- Rectus femoris
L4 Muscle Innervation
Ankle dorsiflexors: Tibialis Anterior (L4-L5)
L5 Muscle Innervation
- Great toe ext/flex
o Extensor Hallicus (L5-S1)
o Flexor Hallicus (L5-S1) - Ankle eversion/inversion
o Peroneus Longus/Brevis (L5-S1), Tibialis Posterior (L4-L5) - Hip abductors (L4-S1)
o Gluteus medius
o Gluteus minimus
o Tensor fasciae latae
S1 Muscle Innervation
- Ankle Plantarflexors
o Gastroc/Solues (S1-S2) - Knee flexors (L5-S2)
o Hamstrings (semitendinosus, semimembranosus, biceps femoris)
Spinal Shock (Autonomic Dysfunction and Shock)
Due to trauma to the spinal cord
- Absent sensation
- Absent motor control
- Areflexia
- Loss of autonomic control
Neurogenic Shock (Autonomic Dysfunction and Shock)
loss of autonomic function (injuries above T6)
- bradycardia
- Hypotension
- Thermoregulation
What are the Clinical Presentation of Autonomic Nervous System Injury
- Cardiovascular: neurogenic shock, orthostatic hypotension, autonomic dysreflexia, cardiac dysrhythmia
- Bowel: absent sensation, incontinence, constipation
- Bladder: detrusor sphincter hypo, hyper, or dyssynergia activity
- Sweating: hyperhidrosesis, hypohidroses, reflex sweating below injury
- Temperature: intolerance of hot/cold, poikliothermia
- Sexual functions : erectile dysfunction, ejaculation, vaginal lubrication
Autonomic Dysreflexia Signs and Symptoms
o Hypertension
o Bradycardia
o Pounding Headache
o Diaphoresis
Thermoregulation
- Inability of the body to adapt to environment to adjust to cold or warm
- Side effect of autonomic dysfunction
How to address Autonomic Dysreflexia
- Medical Emergency
- Sit the patient up!
- Remove noxious stimulus
What is Orthostatic Hypotension
A decrease in systolic blood pressure by 20 mmHg or diastolic blood pressure by 10
mmHg with the progression of upright positioning
Orthostatic Hypotension Symptoms
lightheadedness, fatigue, nausea, headache and heart palpitations
Autonomic Dysreflexia Signs and Symptoms
o Hypertension
o Bradycardia
o Pounding Headache
o Diaphoresis
Common Cardiovascular Complications (Sympathetic System)
❑Decreased heart rate- bradycardia
❑Decreased contractility
❑Decreased cardiac output
Common Cardiovascular Complications (Parasympathetic System)
❑Increased heart rate
❑Increased contractility
❑Increased cardiac output
Respiratory Muscles
- Diaphragm
- Internal Intercostals
- External Intercostals
- Abdominals
- Accessory Breathing
Diaphragm (C3-C5)
- Injury at this level will likely result in the need for mechanical ventilation
- C2/C3, C3/C4 difficult to wean from mechanical ventilation
Internal Intercostals
- Assist with forced expiration (coughing)
- Depression of ribs for expiration
External Intercostals
- Inhalation, elevation of ribs for expansion of chest cavity
T/F. Abdominals help with coughing
True
Accessory Muscles
Scalenes, sternocleidomastoid, pectoralis major, trapezius
Volume Level associated with the need for mechanical ventilation?
<1000 mL
C2 and higher level respiratory dysfunction outcome
Need mechanical Ventilation
C3-C4 level respiratory dysfunction outcome
- Need initial ventilation
- Potential to wean (50-83%)
C5 and below level respiratory dysfunction outcome
- Weak Cough
- May breathe independent
- May need initial vent (2/3)
T1-T5 level respiratory dysfunction outcome
Weak Cough
T6-T12 level respiratory dysfunction outcome
Weak Cough
L1 and below level respiratory dysfunction outcome
No Impairment
What is the Goal of respiratory management
Decrease/prevent atelectasis, enhance clearance of secretions, prevent pneumonia
What is a complete Injury?
loss of motor and sensory below the level of injury including the sacral segments
Examples of complete Injury
o Tetraplegia / Quadriplegia
o Paraplegia
What is an incomplete injury?
partial damage the cord with sensory or motor function spared in the sacral segments of the spinal cord
Examples of incomplete Injury
o Central cord syndrome (40-90% will become ambulators, heavily influenced by age)
o Anterior cord syndrome (low ambulation potential)
o Brown Sequard syndrome (~75% will become ambulators if UE’s effected>LE’s)
o Cauda Equina syndrome
Central cord syndrome
- Form of incomplete SCI characterized by impairments in arms and hands and, to a lesser
extent, in the legs. - Also referred to inverse paraplegia since UE are weaker than LE
Is Central cord syndrome prognosis good, fair, or poor?
Good Prognosis
Anterior cord syndrome
- Flexion type injury to cervical spine that causes damage to to the anterior portion of
the spinal cord and/or the blood
supply from the anterior spinal A. - Light touch, proprioception (sense
of position in space), and sense of
vibration remain intact. - Sensation to pain, crude touch and
temperature is lost
Is Anterior cord syndrome prognosis good, fair, or poor?
Poor Prognosis
Brown Sequard syndrome
- occurs when the spinal cord is
hemi-sectioned or GSW or knife stab wound - Ipsilateral Side: loss of motor
function, proprioception, vibration,
and light touch. - Contralateral Side: there is a loss of pain,
temperature, and crude touch
sensations.
Is Brown Sequard syndrome prognosis good, fair, or poor?
Fair
Cauda Equina syndrome
- Cauda equina syndrome, or injury between the conus and the lumbosacral nerve roots w/i the spinal canal, also results in areflexic bladder, bowel, and lower limbs.
- Recovery affected by perineal sensory deficits and unilateral vs bilateral involvement
- The cauda equina functions as the peripheral nervous system, and there is a possibility of return of function of the nerve rootlets if they have not been completely transected or destroyed.
What kind of incomplete SCI injury is associated w/ a hyperextension injury in older adults?
Central Cord Syndrome
What kind of incomplete SCI injury is associated w/ flexion type injuries to the cervical spine?
Anterior Cord Syndrome
Predictors of Motor function
- Degree of impairment
- Complete versus Incomplete injuries
- Preserved Motor Function
- Preserved Pin Prick Sensation
- Sacral region or extremities
- Pattern of Neurological Injury
- Central cord and brown-sequard syndrome have better prognosis than anterior cord syndrome
- Early Neurologic Return
- Change in grade of muscles strength in the first month versus six months
Predictors of Ambulation
- AIS A have very limited potential for future ambulation
- AIS B and absent sensation to pin prick have limited potential for ambulation
- AIS B and sensation to pin prick preserved-33% chance of future ambulation
- AIS C and <50 years old- 80-90% chance of ambulation
- AIS C and >50 years old- 30-40% chance of ambulation
- AIS D 72 hours after injury will likely be ambulatory upon discharge from
inpatient rehab
C1/C2 Injuries
- Dependent for all self-care – full time caregiver
- Modified independent with power wheelchair mobility and pressure reliefs
with sip-n-puff or chin/lip control, power tilt and recline. - Highly specialized equipment (environmental controls and augmentative
communication) can facilitate some activities: Assistive technology evaluation - Likely dependent on mechanical ventilation
- Encourage the ability to direct care and advocate for themselves
C3/C4 injuries
o Dependent with all self-care - full-time caregiver
o Modified independent with power wheelchair mobility and pressure reliefs with sip-n-puff or chin/lip control, power tilt and recline.
o Highly specialized equipment (environmental controls and augmentative communication) can facilitate some activities: Assistive technology evaluation
o Mouth stick for writing, typing, page turning
o Ventilator weaning is possible: initiate respiratory and diaphragm strengthening
o Encourage the ability to direct care and advocate for themselves
C5 Injuries
o Ability to participate in some ADLs:
❑Supervision after set-up for feeding, light grooming, shaving, handwriting, typing, phone use
❑Assist with upper body dressing and bathing
❑Dependent for lower body dressing and toileting
o Independent in power wheelchair mobility using joystick and power tilt/recline.
o Manual wheelchair alternative with projections
o Can begin to assist with sliding board transfers
C6 Injuries
o Highest SCI level with potential to be independent WITH adaptive equipment
o Potential to be modified independent with level surface transfers
o Modified independent with ADLs: Feeding, grooming, UE dressing, skin inspection, writing, typing, phone use light kitchen activities
o Modified independent with manual/power wheelchair mobility
o May still require assist with LE dressing, bathing, and bowel and bladder management
C7/C8 Injuries
o Modified Independent with ADLs: feeding, grooming, UE/LE dressing, writing,
computer use
o May still require assist with bowel and bladder management
o Performs level transfers to/from bed, wheelchair and commode modified independent with or without sliding board
o Driving with hand controls
Paraplegia
- T1 and below injuries allow for full upper extremity and hand function
- T1-6: Intercostals and trunk muscles
o Some trunk function for sitting balance, bed mobility and transfers - T7-L1: Abdominal muscles
o Improved function of trunk muscles for sitting balance, bed mobility and transfers - L1-S2: Lower extremity function
o Leg function depends on level of injury
o Standing and ambulation
Treatment Strategies
- Compensation versus Restoration
- Muscle substitution
o Using gravity
o Tension of passive structures- Tenodesis grip
o Using fixation of distal extremity - Momentum
Tenodesis grip
Extrinsic finger and thumb flexors tightness, do not stretch finger flexors
Foundations of Mobility Skills
- Break the skill down into steps
- To set your patient up for success, make the skill easier and then build progression
- Sitting balance
- Muscle substitution strategies
Bed mobility Training (Rolling)
- Requires momentum of UEs
- Head lift is optimal (no pillows) however can be limited by individual
precautions/braces. - Punch trailing arm across body as roll progresses to complete into side lying
- Progression: rolling wedged at 45 degree angle with legs crossed vs
uncrossed, rolling from supine to side lying, rolling supine to prone
Multiple techniques for supine to/from sit
o Supine on elbows
o “Log roll”
o Specific adaptive techniques for patients with C5-C6 level of injury
Sitting Balance
- Build a foundation of static balance/stability and progress to more challenging dynamic activities
- Sitting balance positions:
o Circle sitting
o Long sitting
o Short sitting at edge of mat/bed
Pre-transfer Training and Concurrent Skills
- Sitting balance
- Locking elbows out using muscle substitution strategies if C5-C6 level of injury.
- Anterior propping
- Scooting: forward and laterally
- Work on depression lifts vertically and horizontally using head/hips relationship and trunk/shoulder girdle muscles
- Practice scooting and lifts in long/circle sitting
Transfer Training
- Hoyer Lift vs. Slide Board/Sit-Pivot Transfer
- Pre-transfer training skills (seated transfers):
o Sitting balance and anterior propping
o Head-Hips Relationship
o Scooting forward and laterally
o C5-6 will need to know how to lock out elbows with muscle substitution strategies
Outcome measures (Activity)
o 10 Meter Walk Test
❑MCID 0.06 m/s and MDC 0.13 m/s
❑Excellent test-retest reliability, and intrarater and interrater reliability
❑Excellent correlation with the TUG and 6MWT
o Timed Up and Go
❑MDC 10.8 sec (Lam et al 2007)
❑Excellent Interrater and intrarater reliability
❑Excellent correlation with 10MWT and 6MWT
Outcome measures (Structure and Function)
o ISNCSCI (ASIA scale)
❑MDC: Light touch (4.1), Pin-prick (5.9) and UEMS (2)
❑Excellent intrarater and interrater reliability for all domains
❑Predictive Validity: excellent for AIS UEMS for hand function and LEMS for ambulatory capacity
❑Separate AIS UEMS and LEMS were more predictive of subsequent FIM motor scores than that ASIA
motor score alone
o Hand Held Myometry
❑Excellent intrarater and interrater reliability
❑Myometry detected changes in elbow muscle strength that MMT did not
Outcome measures (Participation)
o WHOQOL-BREF
▪ Assess the QOL : 26 items in 4 domains
❑Physical Health
❑Psychological Health
❑Social Relationships
❑Environment
▪ Higher score = better QOL
Psychological Adjustment
- Loss of control
- Grieving
o Mourning a loss
o Social impact - Adaptation
- Consider outside influences
- Constructive practices in rehab
o Promote independence and
autonomy
o Positive atmosphere
Spinal Cord Anatomy (White matter)
myelinated tracts in peripheral
Spinal Cord Anatomy (Gray matter)
neuronal cell bodies, glial cells, and located centrally
o Anterior horns: control somatic muscles
o Posterior horn: control sensation
