SCI Flashcards
Neurological level
last 100% fully functional level
Functional level
How they actually perform
Osteological level
where the damage is
Complete
No motor or sensory function at S4-S5
Incomplete
Zones or partial preservation
Does not mean curable
What type of wheelchair would be most appropriate for a C6 complete spinal cord patient?
Manual chair with knobs
Central cord syndrome
Muscle and sensory loss is greater in the UE than the LE, often seen in older pts due to arthritis
Brown-Sequard Syndrome
Lateral damage
One side of cord is damaged
Loss of motor and proprioception on ipsilateral side
Loss of pain, temp, and touch on contralateral side
Anterior cord syndrome
Proprioception is present
Loss of pain, temp, and touch
Cauda Equina injury
PNS
Common in L2 fracture
Flaccid paralysis, but good recovery
Conus Medullaris Syndrome
Involves injury of sacral cord and lumbar nerve roots within the neural canal
Results in arreflexic bladder, bowel, and LE’s
SCI recovery
CNS does not regenerate
Spinal shock can cause the return of some motor and sensory
Incompletes have a better chance of recovery, but no guarantee
Most recovery occurs in the first few (6) weeks
They can continue to progress functionally
No amount of hard work can make nerve function return
Rehab will not affect the degree of recovery, only the quality
Treatment process for SCI
Stabilize client
ROM in bed
Prism glasses so they can lay back and still see what’s in front of them
Communication to direct their care
Complications to consider with SCI
Skin break down
- Special beds
- Turning
- Wheelchair and cushions
- Teach wt shift or pressure relief
Self examinations
- Mirrors
Education
SCI decreased vital capacity
C1-C3: full vent
C4-T9: may need vent sometimes but not all the time
T10: full respiratory function
Can’t cough big
Osteoporosis
Can occur with 2-6 weeks of injury
Especially in long bones
Can cause pathological fracture
Standing frames can help prevent it
Orthostatic hypotension
Decrease of 20mmHg or more of systolic BP
Common during acute phase of rehabilitation with postural change
Increased issues with T6 and above
Autonomic dysreflexia
T6 and above
Abnormal response to a noxious event
- pretty much anything uncomfortable
Always emergent
Can lead to a stroke or aneurysm
Spasticity
Any stimulation below the level of injury can result in spasticity
Can be painful, can throw patient out of their wheelchair
There are three primary medications used to treat spasticity:
- Baclofen
- Valium
- Dantrium
* Can also use a Baclofen Pump or surgical Rhizotomy (cut the nerve root)
Can also be a good thing - early warning of infection
Heterotrophic ossification
Bone growing where bone shouldn’t grow
Reflexive bladder issues
Reflexive or Spastic Bladder
- Stretch receptors still work
- T12 and above
Crede Method - This is done by gently pressing down on the bladder.
Tapping - This is done by tapping over the bladder with the fingertips. This stimulates the detrusor muscle.
Valsalva - Involves leaning forwards and bearing down to increase pressure in the abdomen, thus triggering the detrusor muscles.
Flaccid bladder issues
LMN - T12 and below
Over fill, reflux (can cause kidney damage)
Catheter (increases risk for UTI)
- Indwelling (internal and connects to urethra) or suprapubic (create a hole above the pubis)
- Sheath: looks like a condom
- Self
- Leg bag
Bowel care
Can’t do a catheter
Diapers
Program or routine
- One hour is the acceptable time for sitting on the toilet
- Have to do weight shifts while on the toilet
- For reflexive bowels: should poop every other day
- For flaccid bowels: should poop every day
Chemical or digital stim
- Chemical doesn’t work on T12 and below
- Risk of constipation or impaction
- Digital stim: stimulate rectum and produce a poop
- Rimming: stretch anus to produce a poop
Sexual function
Women
- Still works
- Pregnancy
* Birth controls- types like the pill (blood clots) may not be an option
- Menstruation
* Usually stops for weeks to months after injury but typically resumes
* TSS, autonomic dysreflexia if tampon is put in incorrectly
Men
- Erection and ejaculation vary
- Sperm count decreases even when function is near normal
Evaluation process for SCI
Top down is recommended but we also look at bottom up
1. What did they do before, what will they be returning to?
2. Physical status
- Assess PROM first to determine pain, contractures
- Then AROM and MMT
- Be reasonable
- Shoulder Movement and Pain- just like CVA’s this is a problem
- Spasticity
- Hand and wrist function
- Sensation
- Endurance
- Cognition
* Determine type of wheelchair they should use, bowel and bladder programs, self-catheterization
3. Functional Status
- What are they doing
- Endurance
Intervention for SCI
Acute and Early Phase
1. Maintain or increase ROM
2. Positioning
- Splinting or in bed
- Shoulder
* With tetraplegia shoulder pain is common, should periodically be positioned in 80º of shoulder abduction, external rotation, and full elbow extension
- Wrists
* If they don’t have 3+ for wrist extensors the go in resting hand splint
* Dorsal splints are preferred (why??)
* C5: universal cuff
* C6-7: tenodesis action
3. AROM and AAROM, muscle re-education and strengthening
Remember you can’t re-educate a muscle that isn’t innervated!
Active phase
Once cleared to move about
Client in wheelchair
Orthostatic hypotension
Transfers – sliding board
Tenodesis action (C6-7)
- Wrist is flexed when digits are extended.
- Wrist is extended when digits are flexed.
Strengthening
- Resistive, grading tasks
Functional task with adaptive equipment
- Environmental controls
- High tech and low tech
Functional expectations for C1-C3
External breathing full time (some short time without)
Require suctioning and great deal of medical care
At risk for ulcers, UTI
Teaching them to:
- Direct their own care
- Use a mouth stick
- Total assist for ADL
- Head, chin or sip and puff chair
- Environmental controls
Functional expectations for C4
Usually need external breathing initially, but as diaphragm strengthens, they become independent
Require suctioning and great deal of medical care
At risk for ulcers, UTI
Teaching them to:
- Direct their own care
- Use a mouth stick
- Total assist for ADL
- Head, chin or sip and puff chair
- Environmental controls
Functional expectations for C5
Deltoids and biceps work
May use a mobile are support or ball bearing feeder (if less than 3+)
If greater than 3+, can go without support and use a universal cuff
Can feed themselves, shave, answer phone, write, and drive electric chair or knobby manual chair
Still have poor trunk control below the shoulders
Usually dependent for dressing and bathing
Known to return to work
Functional expectations for C6
Tenodesis action
May need a splint
They get rotator cuff, biceps
They can:
- Roll in bed
- Still may use a universal cuff
Level of independence with modifications
Have the potential to be independent with all ADL’s, transfers, and can drive with modification
Work on trunk control (will never be 100%), strengthening, transfers, adaptive equipment, endurance
Functional expectations for C6-C7
Tenodesis action
May need a splint
They get rotator cuff, biceps, and triceps
They can:
- Roll in bed
- Still may use a universal cuff
- Reach above head
- Easily push a standard manual chair
Work on trunk control (will never be 100%), strengthening, transfers, adaptive equipment, endurance
Level of independence with modifications
Have the potential to be independent with all ADL’s, transfers, and can drive with modification
Functional expectation of C8
Extrinsic flexors and extensors and thumb musculature (still don’t have intrinsic)
- They present with Claw hand or intrinsic minus hand
Functional expectations for T1
They have full hand use
Independent with all ADL’s and transfers without modification
Drive with hand controls
Functional expectations for T1-T9
They have full hand use
Independent with all ADL’s and transfers without modification
Drive with hand controls
Independent with wheelchair
Some degree of standing in frame or braces but not functional
Functional expectations for T10-L1
Ambulation with forearm crutches
Functional expectations with L2-S5
Functional and independent with KAFO or AFO, crutches, or as needed
SCI after discharge
Outpatient rehab
Job retraining
Education
Home adaptations
- May mean moving
Community groups
- Almost like a minority group
Aging and spinal cords
- Importance of ergonomics
