SCI Flashcards
C1-C3 functions
- need respirator/ventilator
- limited head and neck movement
- Able to use “sip and puff” wheelchair, eye gaze
- Completely dependent in ADLs and transfers
C4 functions
- full mobility of the head and neck
- no respirator, ADL/transfer dependent
- Possibility of autonomic dysreflexia
- “Sip and puff” mouthstick power wheelchair required
C5 functions
ELBOW FLEXION
- Supination, no finger/wrist movement
- mobile arm support
- Electric wheelchair with hand control may be used
C6 functions
WRIST EXTENSORS
- Independent in transfers from toilet to wheelchair
- can reach forward.
- splint to promote wrist tenodesis.
- Able to do some ADLs : shaving, dressing UB
- Assistance for LB dressing & transfer from bed to wc
C7 functions
TRICEPS for elbow extension
- partial intrinsic hand muscles
- wrist flexion, finger extension (reduced grasp)
- I: self care, transfers
- Mod I: feeding, bathing, grooming, toileting
- Mod I to min: Dressing
- some assistance for bowel/bladder care
- manual wc with wc pushups for pressure relief (depression relief techniques)
C8-T1 functions
- Full UE control, including fine coordination and
grasp - I: personal care (few hours of homemaking assistance each day after d/c)
- Mod I: ADLs, mobility and communication
T6 functions
- Increased endurance
- Larger respiratory reserve
- Pectoral girdle stabilized for heavy lifting
- ADLs Independent (No assistive devices)
- Uses braces with great difficulty for ambulation
T12 functions
- Improved endurance and trunk control.
- ADLs/IADLs independent
- long leg braces and crutches, wc for energy conservation
L4 functions
- Independent in all activities plus ambulation
- involuntary bowel and bladder control
How should sensation testing be conducted in a SCI?
- Tested proximal to distal
- Vision occluded
- Test uninvolved side first
At what SCI level can a person use a universal
cuff?
C5
what stage does tenodesis occur?
C6
What is spinal shock?
can start 30 min after injury, lasts 4-8 weeks
- acute physiological loss or depression of spinal cord function following a spinal cord injury
- Associated loss of sensorimotor function and flaccid paralysis lasting several days
- all reflex activity gone below level of injury
- transitions to spasticity
- cannot evaluate deficit until spinal shock ends
ASIA E
NORMAL motor & sensory function
ASIA D
INCOMPLETE
50% of muscles more than grade 3
Can raise arms or legs off of bed
ASIA C
INCOMPLETE
50% of muscles less than grade 3
Can’t raise arms or legs off of bed
ASIA B
INCOMPLETE
sensory only, no motor
ASIA A
COMPLETE
no motor, no sensory, no sacral sparing
what is the tone of muscles after a SCI?
initially flaccid below level of injury then become spastic
- hyperactive sympathetic functions
- sensory loss below LOI
orthostatic hypotension
low BP while upright
- lean client back/help them lie down to return to normal
- leg wraps to prevent
autonomic dysreflexia
headache, sweating, congestion, high BP, bradycardia
- sit client UP, remove restrictive clothing
- check catheterization (bladder voiding)
- T6 and above
- causes: irritants that would normally cause pain to area below injury, bladder irritants, skin irritants, sexual activity, heterotopic ossification, skeletal fx, appendicitis
- immediately discontinue sesion to allow client to stabilize and recover
what are some driving adaptations for SCI?
- palmar cuff and spinner knob to steer wheel single handedly
- pedal extensions for acceleration/braking for limited LE reach
- hand controls for acceleration/braking (all levels with paraplegia)
AE for SCI
C1-C3: eye gaze, sip & puff
C4: sip & puff
C5: mobile arm support for feeding, universal cuff, wrist cock-up splint
C6: tenodesis splint, built-up handles, sliding board, transfer board for transfers
C7: hook & loop straps
in which SCI level are wrist extensors?
C6
in which SCI level are triceps?
C7
in which SCI level are finger flexors, extensors, intrinsics?
C8
C8 functions
FINGER FLEXORS, EXTENSORS, INTRINSICS
- at risk for heterotopic ossification
- independent car transfers
- same functions as C7
- independent bladder function with intermittent catheterization
what approach is used with SCI (acute phase)?
top down approach
how often do weight shifts occur?
every 30-60 min
stage 1 pressure ulcer
- NO OPEN WOUND or tear in skin
- red
- NO BLANCHING
- Warm
- Surrounding area may feel either firmer or softer
- May report PAIN
Stage 2 pressure ulcer
- Partial thickness skin loss
- Exposed dermis
- Open wound (scrape, blister, tear)
- pain & tenderness
- Warm
- Localized EDEMA
stage 3 pressure ulcer
- Full-thickness skin loss
- Open wound (crater)
- Wound extends into fat layer
stage 4 pressure ulcer
- Full-thickness tissue & skin loss
- Open wound, visible muscle, tendon, bone
- Tunneling or undermining present
unstageable pressure ulcer
- Full thickness skin & tissue loss
- Wound completely covered by eschar or slough
hollow back is
lumbar lordosis
round back is
kyphosis
lateral curvature of the spine is
scoliosis
sciatic pain
nerve trapped by herniated disc
compression fracture
vertebral osteoporosis
spinal stenosis
narrowing of intervertebral foramen (disc)
spondylolysis
Stress fracture through pars interarticularis of lumbar vertebrae
spondylolisthesis
Vertebrae slipping out of position (forward due to pars fracture instability)
causes of low back pain
Poor physical fitness, obesity, reduced muscle strength, poor endurance
osteopenia
- REVERSIBLE weakening of bone, precursor to osteoporosis
- Risk factors: inadequate calcium intake, estrogen deficiency, and a sedentary lifestyle
UMN damage
- CNS
- CVA, TBI, SCI (cortex, brain stem, corticospinal tracts, spinal cord)
- HYPERTONIA: velocity dependent
- flexor/extensor muscle spasms
- NO voluntary movements: dyssynergic patterns, obligatory synergies
LMN damage
- PNS
- polio, Guillain-Barre, PNI, peripheral neuropathy, radiculopathy
- SC: anterior horn cell, spinal roots, peripheral nerves,
- CN: cranial nerves
- LOW TONE: not velocity-dependent
- Involuntary muscle twitching
- Voluntary movements weak/absent if nerve interrupted
windswept deformity
Pelvis rotated laterally to one side, resulting in the spine, trunk, and thighs moving to the opposite side
cauda equina
LMN lesion
- Loss of long nerve roots at or below L1 level (lost sensation, movement)
- no spinal reflex activity, areflexic bowel/bladder, loss of sensation
- nerve regeneration: often incomplete, slows/stops within a year- may become paralyzed
conus medullaris/tethered SC syndrome
- Injury of sacral cord & lumbar nerve roots, L2 lesions
- LE motor & sensory loss, weakness, pain, bowel/bladder issues
- PRESERVED: reflexes if lesion is in sacral segments
- children: lesions, fatty tumors, hairy patches, dimples on LB
posterior cord syndrome
least frequent, injury to posterior columns
- LOST: PROP
- preserved: pain, touch, temperature, motor function to varying degrees
anterior cord syndrome/Beck’s Syndrome/Anterior Spinal Artery Syndrome
UMN lesion- FLEXION INJURIES
- bilateral: loss of motor function, pain, pinprick, temperature
- PRESERVED: prop, light touch
- OH, possible bladder, bowel, sex dysf
Brown-Sequard Syndrome
UMN lesion (trauma-gunshot wound, infection, inflammatory disease) in SC
- opposite side (contralateral): loss of sensation (pain & temperature) BELOW lesion
- same side (ipsilateral): weakness/paralysis (light touch, motor, tactile discrimination, pressure, vibration, prop, spastic paralysis)
- bilateral: loss of pain/temp AT LESION
Central Cord Syndrome
UMN lesion- most common incomplete SCI, HYPEREXTENSION INJURIES
- MORE UE DEFICITS THAN LE
- sensory loss, FM control/paralysis in hands/arms
- mild loss of control in legs, no reflexes
- Bilateral loss of pain and temperature (sensory), motor function (UEs), bladder
- PRESERVED: prop & discriminatory sensation
body mechanics for low back pain
- straight back, min lumbar lordosis (anterior pelvis)
- good posture
- load close to body
- lift with legs
- wide BOS
- lift in sagittal plane
- lift slowly
- semi squat is safest for back
what should be done with bed mobility for low back pain?
log rolling
what type of lift is used for low back pain when removing laundry?
golfer’s lift (lift leg opposite arm used in reach)
anterior pelvic tilt is found in
lumbar lordosis
causes of the incomplete SCIs
- central cord: neck trauma, herniated disc, narrowing of spinal column due to age, HYPEREXTENSION INJURIES
- brown-sequard: tumor, puncture wound to neck/back, tissue death due to obstructed BV, infection, inflammatory disease
- anterior cord: atherosclerosis, aortic block, external compression from herniated disc, trauma (stab wound), FLEXION INJURIES
- conus medullaris: scar tissue secondary to SCI, spina bifida (congenital)
- cauda equina: secondary to ruptured disc (material from disc pushed into spinal canal, compression L & S nerves)z
zone of partial preservation (ZPP)
ONLY WITH COMPLETE INJURIES (ASIA A)
- refers to partially innervated dermatomes/myotomes
- most caudal = extent of sensory or motor ZPP
- record single segments on worksheet
- only include key muscles
if the right sensory level is C5 & some sensation extends from C6 through C8, what is recorded in the right sensory ZPP block on the worksheet?
C8
does someone without a SCI receive a score on the ASIA scale?
no, only with a prior deficit with SC
what is required to receive a grade of C or D on the ASIA scale?
must have either
- voluntary anal sphincter contraction
OR
- sacral sensory sparing at S4/5 or DAP with motor function sparing more than 3 levels below the motor level for that side of the body
- non-key muscle function more than 3 levels below the motor level can be used to determine motor incomplete status (AIS B vs C)
incomplete injury
preservation of any sensory/motor function below level of injury including S4/S5
sacral sparing
sensory/motor function preserved at levels S4/S5
sensory sacral sparing
sensation preservation (intact or impaired) at the anal mucocutaneous junction (S4-5 dermatome) on one or both sides for light touch, pinprick, or deep anal pressure
motor sacral sparing
presence of voluntary contraction of. the external anal sphincter upon digital rectal examination
what is the ASIA impairment scale used for?
grading the degree of impairment
NLI
neurological level of injury
- most caudal segment of the SC with normal sensory & antigravity motor function bilaterally provided there are normal sensory & motor function rostrally
sensory level of NLI
most caudal, intact dermatome for both light touch & pinprick sensation
motor level NLI
most caudal myotome with a key muscle function of at least grade 3
If there is a discrepancy between the most caudal intact section between the four possible levels (R & L sensory level, R & L motor level) what happens?
the NLI is considered the most rostral segment of these 4 levels
what are the 4 different segments which may be identified in determining neurological level?
- R sensory
- L sensory
- R motor
- L motor
(NRI is most rostral of these levels)
how is motor level determined?
examine key muscle function within each of 10 myotomes on each side of body
- lowest key muscle function with grade 3 on MMT while in supine
- may be diff for R/L
motor scores
summary score of motor function
- max score of 25 for each extremity
- total = 50 for UE, 50 for LE
- reflects degree of neurological impairment with SCI
how is sensory level determined?
- examine key sensory points within each of 28 dermatomes on each side of body (R & L)
- most caudal, normally innervated dermatome for both pinprick & light touch sensation
- may be diff for R/L
pinprick sensation
sharp vs dull discrimination
sensory scores
summary score of sensory function
- total = 56 points each for light touch & pinprick
- total = 112 points on each side of body
- degree of neurological impairment due to SCI
skeletal level
level by radiographic exam where greatest vertebral damage is found
myotome
muscles served by spinal nerve root
- set of muscles innervated by specific single spinal nerve
how many muscle groups represent motor innervation to cervical & lumbosacral SC?
10
myotomes for C5-C8
C5: elbow flexion
C6: wrist extension
C7: elbow extension
C8: finger flexion
myotomes for T1-S1
T1: finger abduction
L2: hip flexion
L3: knee extension
L4: ankle dorsiflexion
L5: great toe extension
S1: ankle plantarflexion
dermatome
area of skin innervated by sensory axons within each segmental nerve (root)
- important for assessing/dx SCI on ASIA scale
how many segments are in the SC?
31
- each has pair (R/L) of ventral & dorsal nerve roots innervating motor & sensory function
which SCI level does not have a dermatome
C1
how many spinal nerves are there?
31
8 cervical, 12 thoracic, 5 lumbar, 5 sacral, 1 coccygeal
C2-C8 dermatomes
C2: occipital protuberance
C3: supraclavicular fossa
C4: acromioclavicular joint
C5: lateral antecubital fossa
C6: thumb
C7: middle finger
C8: little finger
how is the vertebral column made up?
7 C, 12 T, 7 L
where is cauda equina?
below L2 (only spinal roots)
atlas
C1
axis
C2
which SC level is the exception in regards to spinal nerves?
C7: set of spinal nerves extending above (at C7) & below (at C8)
- there are 8 spinal nerves, 7 spinal verebrae
muscle innervations for C1-C8
C1-C3: sternocleidomastoid, cervical paraspinal, neck accessories
C4: diaphragm, upper traps, cervical paraspinal muscles
C5: biceps brachii, biceps, brachialis
C6: ECRL, ECRB
C7: triceps
C8: FDP
muscle innervations for T1-S5
T1: abductor digiti minimi
T2-T6: dorsal/palmar interossei, abductor pollicis brevis, full lumbricals, erector spinae of upper back, abs
T7-T12: abs
L2: iliopsoas
L3: quadricep
L4: tibialis anterior
L5: extensor hallucis longus
S1: gastrocnemius, soleus
muscle movements for C1-C8
C1-3: no motor innervations
C4: shrugs shoulders
C5: elbow flexion
C6: wrist extension
C7: elbow extension
C8: middle finger flexion
muscle movements for T1-S5
T1: abduct pinky
T2-T6: finger abduction, adduction of IP, thumb abduction, MCP joint flexion with IP joint extension, thoracic spine extension
T6: ab strength
T7-T12: partial-full innervation for trunk flexion & rotation
L2: hip flexion
L3: knee extension
L4: ankle dorsiflexion
L5: long toe extensors
S1: ankle plantarflexion
communication abilities in SCI
C1-C3: sometimes difficult/impossible (mouth stick)
C4: communication devices may be needed or may be normal
wheelchairs for SCI
C1-C3: power wc with tilt & recline, sip & puff (head control, mouth stick, chin control)
C4: power wc with tilt & recline
C5-C6: power wc with arm drive control for outdoors, manual wc for indoors (level and non-carpeted surfaces)
C7 & up: manual rigid or lightweight folding wc with modified rims
when are leg braces used in SCI?
T7-L2 = possible
L3-L5 = able along with straight cane, may use wc for sports/long distance
when can SCI patients walk without leg braces?
S1-S3 (but may be needed)
complications of SCI
- respiratory: decreased vital capacity, pneumonia
- decubitus ulcer formation
- orthostatic hypotension
- DVT
- autonomic dysreflexia
- UTI
- heterotopic ossification
deep vein thrombosis
inflammation of a vein with formation of a thrombus
- usually in LEs
- deadly- can turn into pulmonary embolism
how to prevent autonomic dysreflexia
- teach client/caregiver pressure relief
- compliance with intermittent catheterization
- well- balanced diet habits
- ensure medication compliance
- educate client/caregivers on prevention methods, recognize signs/symptoms, initiate first aid
heterotopic ossification
formation of bone in abnormal areas
myositis ossificans
reaction to a bruise in a muscle that has been injured
appendicitis
appendix becomes sore, swollen, and diseased
pressure sores are also known as
decubitus ulcers, bed sores
integramouse
joystick or set to keyboard mode – ideal for gaming, has sip & puff selection
- C1-C3 SCI
how can a C1-C3 SCI client operate a computer?
- Integramouse (sip & puff selection)
- morse code with switch operated by tongue, eye movement or other facial muscles
- single switch scanning
- limited voice recognition for commands and using macros/shortcuts
- eye gaze technology
environmental control units
devices that allow people with mobility impairments to operate electronic devices, including televisions, computers, lights, appliances, and more
- C1-C3/C4
Electric Trendelenburg Hospital Bed
for C1-C5
what type of splint is worn at C5?
day: wrist cock up
night: intrinsic plus
- air splints for elbow extension for home exercise program for increasing shoulder/scapula strength.
how can a C3-C4 SCI client operate a computer?
- Mouthstick and holder/mini keyboard
- trackball mounted at chin
- onscreen keyboard
- separate switch and interface for L/R click (operated by sip/puff, cheek, shoulder shrug
- eye movement
- mouse devices designed to be mounted at chin
- mouth, “Hover” or “dwell” software for automatic selection of icons/controls
- single or double switch scanning
- morse code/switch activation
- voice recognition
how can a C5-C6 SCI client operate a computer?
- typing aids ( with/ without wrist support)
- mouthstick as back up, or if UE pain is present
- mini-keyboard
- laptray
- trackball /joystick / touchpad for mouse movement
- separate switch and interface for L/R click
- keyboard shortcuts (Sticky Keys, Hotkeys, etc.)
- word prediction/completion software for rate enhancement
- voice recognition for ease and efficiency
at what level SCI is a client independent with all self care?
T1
side to side weight shifts occur at SCI level
C5
forward weight shifts occur at SCI level
C6
independent feeding, dressing, bathing with adaptive equipment occurs at SCI level
C7
level surface transfers with assistance occur at SCI level
C6
when does spinal shock end? *multiple options
appearance of the bulbocavernosus reflex within the first few days of injury
- recovery of deep tendon reflexes (DTRs) which may not reappear for several weeks
- return of reflexive detrusor function which can happen months following injury
bulbocavernosus reflex
spinal mediated and involves S2-S4
- somatic reflex
- mediated through the pudendal nerve
- contraction of the bulbocavernosus muscle in response to squeezing the penis/tugging on the indwelling Foley catheter or clitoris
- tests the conus medullaris (distal end of the spinal cord) and the S2 to S4 pelvic nerves
- signifies the end of spinal shock, classifies SCI as complete or incomplete
If the BR is present 48 hours following injury, it can be assumed that
client is out of spinal cord shock
Bulbocavernosus Reflex absent =
spinal shock
Bulbocavernosus Reflex present =
severed spinal cord (lesion or injury of the conus medullaris or sacral nerve roots)
stages of spinal shock
- initial hyporeflexia: 0-1 days
- initial return of some reflexes: 1-3 days
- Early hyperreflexia: 4 days to 4 weeks
- Late hyperreflexia: 1 to 12 months
what is the order of reflex return following SCI?
- polysynaptic reflexes
- delayed plantar reflex
- bulbocavernosus reflex
