SCI Flashcards
What factors affect function in SC patients?
Complete injury will not be able to strengthen or influence recovery of lost motor function.
Complete injury will need to learn compensation for loss of motor function.
Social history, family support, work history, level of education, home layout (begin modifications early if possible)
What are strategies for teaching bed mobility with SCI?
Rolling: bedrails/devices/objects to grab, use of momentum
Supine to sit: elbows first, work to extend arms, roll to sidelying, hook LEs, push up from side
What are balance activities for SCI?
Short sit: static with UE support, static w/o UE support, dynamic reaching over stable base
Long sit: easier to due b/c of larger BOS, necessary for independent dressing, flexing knees will help if hamstring length is affecting anterior tilt of pelvis
What transfers are done in SCI?
Dependent lift (manual, mechanical) sliding board (lateral, prone push) swing pivot car transfer commode transfer tub bench transfer floor to chair
What are strategies for pressure relief?
Dependent: reclining or tilt in space w/c (65 degrees for actual relief, minimal drop with 35 tilt)
Forward lean
Lateral lean
How does skin change with SCI?
Thinning of epithelial layer, changes to collagen and hyperhidrosis in patient T8 and above
Why are SCI patients at high risk for decubitus ulcers?
Impaired/absent sensation
Physiologic changes
Inability to perform pressure relief
Moisture control issues due to incontinence and sweating
What are considerations for W/C and seating prescription in SCI?
Functional level, Ability to perform pressure relief independently, Type of terrain they will be on, Amount of time they will be in the W/C, Transfer technique, Loading into car by themselves, Weight of chair, Positioning desired, Accessibility at home and other places, Single vs. multiple caregivers, Patient preference regarding style
What are rules of thumb in w/c prescription for tetraplegia?
Manual vs. power (C6 and above- power)
Power controls: head control, sip and puff, joy stick
C7-T1: may be able to propel manual, weigh cost benefit of energy expenditure to exercise benefit, psychological benefit, ease in management vs. more complicated machine
Adjust seat to back angle for balance
What are rules of thumb in w/c prescription for paraplegia?
New user: rigid frame is more efficient
Usually able to manage a manual vs. power
Experienced user: maintain present style of chair
Adjustable axel: position shoulder over axel, adjust for patient confidence in stability
Consider weight of each part
Prescribing cushions for w/c? What are pros and cons of rigid seat backs?
Pressure mapping, look for positioning component to cushion, doesn’t have to feel “good’ to you, combine with back if possible
Pro- better posture and shoulder positioning
Con- hassle loading in car
What are factors limiting tolerance to activity in SCI?
Upright tolerance (BP)
Respiratory status
Endurance
Pain
What are expected outcomes for tolerance to upright positions?
Higher level: more problems maintaining blood pressure
Ace bandages and abdominal binder for maintaining vascular support
Should progress past need for these supports
What may cause reverse of tolerance?
Dysreflexia
Infections or other health changes can cause reverse
What is expected outcome for respiratory function?
C6-7: intact diaphragm, limited intercostals
Possible difficulty weaning from vent
Difficulty handling secretions/coughing
Lower the level= better respiratory function
Potential for pneumonia
What are complications/possible variance of respiratory function?
More difficulty weaning from ventilator due to: history of smoking, pneumothorax, infection
Need for tracheostomy
What is expected outcome for pain
Pain at injury site
Nerve root pain
What are variables to pain?
other injuries not yet identified
Neurogenic pain below level of injury
What are expected outcomes to ROM?
WFL
Flaccid
What are limitations to ROM?
HO Other injury Premorbid contractures Arthritis Contracture from spasticity and insufficient PROM (in patient with longer history of SCI)
What is expected outcome for strength and muscle tone?
Intact above level
Absent below level
Low tone initially
Increased tone after period of spinal shock has passed
What is spinal shock?
Phenomena surrounding physiologic or anatomic transection of the spinal cord that results in temporary loss or depression of all or most spinal reflex activity below the level of injury.
What are variants to strength and muscle tone?
LE stronger than UE: central cord syndrome
Unilateral differences
Spasticity (interfering with function)
Weakness proximal to spinal cord lesion
What is expected outcome for sensation?
Absent below level of injury
Intact above level of injury
What are variances to sensation?
Intact below (or partial preservation)
Absent above level of SCI
Pain below level of injury with absent localization/sensation
What is expected outcome for bladder function?
Neurogenic bladder: won’t empty with voluntary control
Hypo: does not empty
Hyper: empties too much
What are variances to bladder function?
Problems regulating bladder management
Frequent distension can promote UTI
Full bad on external cath doesn’t indicate proper emptying
What is expected outcome for bowel function?
Neurogenic bowel: won’t empty with volitional control
BM (continent) require one or more: suppository, mini enema, digital stimulation, medications like stool softeners
What are variances of bowel function?
Empties too often
Doesn’t respond well to bowel program
Obstruction may present with loose stool passing around obstruction
Ileus (absent or decreased sounds, no flatus, no stool) can cause abdominal distention and impair diaphragmatic breathing
What is expected sexual function in men?
Psychogenic (T10-12) or reflex (S2-S4) erections
Devices, implants, injections, meds can be used to get or sustain erections
Infertility common due to difficulty with temp regulation and prolonged sitting which increases scrotal temp
Phantom/psych orgasm from erogenous zones above level of injury
What is expected sexual function in women?
Continue birth control when desired
Pregnancy: difficulties with pressure sores and respiratory compromise from pressure on diaphragm
May need additional lubrication as primary intervention for sexual activity
Phantom/psychological orgasm
What is initial primary focus for treatment in acute care/early rehab?
prevent secondary complications
Tolerance to upright position
Education
What is treatment for SCI during acute care/early rehab?
Tolerance to upright: reclining wheelchair/cardiac chair/tilt in space wheelchair
Positioning to prevent contracture and skin breakdown: ankle positioning
Prevent pneumonia through OOB
Promote GI function with use of gravity (OOB)
Strengthening
Passive ROM: good time to let patient talk
Educate and teach skin care and pressure relief
Balance in short and long sit: short better as pre transfer, long best on mat
Transfer training for patient and family if appropriate: likely unable to assist at first, empower them to lead
What is recommendation on BWS?
Begin gait training ASAP after incomplete Use BWS (when necessary) or overground (when feasible) Higher intensities are more effective
Can SCI patients walk?
Primary concern
Incomplete and lower lesions may be candidates
Use of KAFO and AFO
Use of AD
Energy consumption vs. wheelchair use can make walking impractical
What are considerations for goal setting in SCI?
Level of injury and ASIA classification Body type Premorbid strength and athleticism Age Male vs. female Adjustment to injury: even with apparent "good" psych adjustment will eventually have period of depression/difficulty Support system
Remember: their true goal is to walk and have full use of body
What is presentation and management of postural hypotension (acute)?
Presents: light headedness, low BP, yawn, pass out
Manage: ace wrap LEs, binder, TED hose, cardiac chair, reclining w/c, medications
What is presentation and management of pressure sores (acute, chronic)?
Presents: redness that doesn’t fade in 20 minutes which may progress to open wounds, causes can change as person’s body changes
Manage: prevention education, proper positioning, minimize shear force, pressure relief, pressure mapping for seating, proper nutrition, moisture management
What is presentation and management for HO (acute)?
Presents: sudden limits of ROM, commonly over knees hips shoulders elbows, may be warm over joint
Manage: early detection so meds can start, no aggressive ROM, follow physicians orders for ROM
What is presentation and management for DVT?
Presents: swollen calf or LE, warm to touch, painful if patient has sensation, HO and DVT may mimic each other
Manage: IVC filter, sequential compression device, meds (heparin, Coumadin, lovenox), spasticity, mobility
How does hypothermia/hyperthermia (acute/chronic) present and manage?
Present: body unable to regulate temp
Manage: education, use of proper clothing, dress for the weather, avoid temperature extremes
When is DVT more likely to occur?
Acute during flaccidity phase
How can burns occur in SCI?
Hot objects in lap (coffee, plate) Touching hot surfaces (concrete, floorboards) Cigarettes Hot pack Hot water from bath/shower
What is presentation and management of pain (acute, chronic)?
Presents: shoulders, area of injury, soft tissue damage that goes along with injury, nerve root pain
Manage: pain modalities (cautious with heat/cold over insensate area), alternative exercise, acupuncture
How does spasticity present and get managed in acute and chronic SCI?
Presents: hypertonicity of extremities denervated distal to lesion (present with all UMN lesions), determine when it interferes with function
Manage: baclofen, valium, flexeril, baclofen pump
What is presentation and management for syringomyelia (chronic)
Presents: progression of weakness proximal to level of injury, problematic for cervical injuries where level can make big difference in function
Manage: surgical
Be alert to change in level of function: decrease in motor function is sign of new pathology
What is presentation and management for contractures (chronic)?
Presents: fixed limitation of ROM over joint or multiple joints, can lead to pressure areas and difficulties with ADLs
Manage: prevention, ROM, proper positioning, for older injuries may need to consider baclofen pump or injection, surgical releases and tendon transfers
What is presentation and management for osteoporosis (chronic)?
Presents: lack of bone density due to lack of weight bearing over time, more susceptible to fractures
Manage: medial management
Assume all patients with history of SCI have osteoporosis, be cautious with PROM
What is presentation and management for spinal deformities?
Present: scoliosis, pelvic obliquities, kyphosis; due to poor w/c positioning and support; over time deformities increase chance of pressure sores, overuse, and respiratory compromise
Manage: proper w/c positioning, for fixed deformities surgery is only option, can be corrected if caught early, include spinal stretching with PROM, lay flat in supine, prone if possible
What is presentation and management of shoulder injuries/carpal tunnel syndrome?
Presents: pain/weakness in shoulder and/or wrist, both are overuse injuries
Manage: proper w/c position and work station set up, use of power chair when stress is too much on shoulders/wrist, surgical repair is an option but it can be very limiting in recovery phase
What are parts of home eval with SCI?
Entrances (2 accessible are desired) Doorway widths Turning radius from hall to rooms Surfaces over which they are propelling Financial resources Height of furniture Accessibility of kitchen/bathroom appliances What is acceptable to the patient
What are adaptation suggestions for the home with SCI?
Ramps: one foot of run for one inch of rise
Replace carpet with hardwood or surface with less friction
Remove throw rugs
Pedestal sink or cut out cabinet in bathroom
Flat surfaces for bathroom sink
Put frequently used items on lower shelves in kitchen
Roll out shelves
Lazy susan
The clapper
Loops on cabinets for easier opening
Level door handles
Raise floor of kitchen
Stackable washer/dryer
What are safety suggestions for the home?
Cordless/cell phone
Emphasize smoke detectors
Encourage patient to call fire department and alert them to person with disability in the home
Adjust hot water heater to lower temp
