SCI Flashcards
Upper Motor Neuron Lesion
lesion above anterior horn cells
typically cortical
increased spasticity with hyerreflexia
loss of motor &/or sensory function
Lower motor neuron lesion
at or below the level of anterior horn cells
flaccidity with hyporeflexia
*spasticity can be present-just not as common
loss of motor and/or sensory funciton
Tetrapelgia
complete paralysis of all four extremities and trunk
paraplegia
complete paraylsis of all or part of the trunk and lower extremities
neurological level
most caudal level with normal sensory and motor function
*what most injuries are named after
motor level
most caudal level with normal motor function
c1-c3 motor level
talking
mastication
sipping
blowing
c4 motor level
respiration and scap elevation
c5 motor level
shoulder ER abduction to 90 limited flexion elbow flexion forearm supination
c6 motor level
shoulder flex/ext abduction/adduction elbow flex forearm pro/sup wrist ext-tenodesis***
C7 motor level
elbow extensors all of the shoulder elbow flex forearm sup/pron wrist flex/ext
C8 motor level
full innervation of UE muscles
finger flexors
T1 motor level
full innervation of UE muscles
finger abductors
T2-T6 motor level
improved trunk control
increased respiratory capacity
T7-12 motor control
additional improved trunk control
increased endurance
L1-L4
hip flexion
hip abduction
knee ext
L2 specifically
hip flexors
L3
knee extensors
L4
ankle dorsiflexors
L5
big toe extension
L4-L5
strong hip flexion and knee extension
weak knee flex
improved trunk control
S1
ankle plantar flexion
Sensory Level
-most caudal level with normal sensory function sharp/dull light touch deep pressure proprioception t4-nipple line t10-umbilicus
skeletal level
level where there is the most bony damage
complete injury
absence of sensory and motor function below the neuro level
incomplete injury
partial preservation of sensory and motor function below the neuro level
more common
American Spinal Injury Association Impairment Scale-ASIA classifications
- A- complete injury-no motor or sensory function
- B- incomplete-sensory function present but not motor function below neuro level
- C-incomplete-motor function preserved w/ more than 1/2 the key muscles below neuro level
* muscle grade less than three
* *no sensory - D- Incomplete: motor function preserved with more than 1/2 key muscles below neuro level
* muscle grade 3 or higher
* no sensory - E- Normal: motor and sensory function is normal
5 types of incomplete SCI
Central cord Syndrome brown-sequard syndrome anterior cord syndrome posterior cord syndrome cauda equina syndrome
Central cord syndrome
UE weakness is greater than lower extremity
almost always a cervical level lesion
Damage to all three tracts: spinothalamic, corticospinal and sensory
Brown-sequard syndrome
loss of voluntary motor control and loss of sensation in the dermatome segment corresponding to the level of the lesion on the ipsilateral side as the cord damage
loss of pain and temperature sensation on controlateral side
common with penetration wounds
Anterior Cord Syndrome
loss of motor function
loss of pain and temperature sensation
intact proprioception, knesthesia and vibration sensation
all voluntary motor control is lost
Posterior Cord Syndrome
Very Rare
damage to posteriour spinal artery from tumor or vascular infarct
pt. with lose ability to perceive proprioception and vibration
Loss of epicritic sensations-two point discrimination, graphesthesia, sterognosis
intact motor function, pain and light touch
Cauda Equina Syndrome
injury to L-S nerve roots *lower motor neuron injury Areflexic bladder flaccidity loss of bowel/bladder LE weakness regeneration of involved peripheral nerve root possible but depends on extent of damage
ROM factors
1 range of motion: extreme ranges will compensate for strength deficit
2 decrease ROM can influence level of functional independence -decrease ability to ambulate
3 selective tightness:
- lumbar ext-lift transfer and trunk stability
- long finger flex, wrist ext=tenodesis
Functional Strength
C6-T1: pectoralis major-rolling
C5: biceps-feeding, bed mobility, hooking over WC, transfers
C6: wrist ext-tenodesis
C7: triceps- improved ADL and transfer
Balance
need one UE for stability and the other UE for function
Spasticity/Tone
Mild:
resistance to passive stretch but tone doesnt interfere with ROM or functional movement
Moderate:
more resistance to stretch, full ROM, tone starts to interfer with functional movement
Severe:
ROM compromised, some functional movement skills are not available or possible due to tone
Quality Characteristics of Tone
constant vs. intermittent
influenced by position
symmetrical vs. asymmetrical
time of day
factors that influence independence
ROM Strength Balance Spasticity/Tone Respiratory Orthopedic problems Alterations in bowel/bladder Other: -skin -age -body size in relation to trunk -cognition -premorbid personality -family/SO support
Pressure Sores
common sites:
scapula, elbow, sacrum, AIS, trochanters, ischium, knees, heels, malleoli
Prevention:
Lying: turn every 2 hours
Sitting: 10-15 seconds of wt. shift or pressure relief every 10 minutes
Autonomic Dysreflexia-Hyperreflexia
Occurs in lesions above T6
-exaggerated autonomic response to stimulus that normally would be considered normal
AD: initiating Stimuli
bladder/bowel distention bladder infection urinary stones kidney malfunction urethral or bladder irritation excessie PROM, stretch-especially at hip noxious cutaneous stimuli pressure sore environment temp change
AD: symptoms
hypertension-life threatening bradycardia-life threatening headache profuse sweatingincreased spasticity restlessness vasoconstriction below level of lesion vasodilation above level of lesion constricted pupils nasal congestion piloerection blurred vision
AD: interventions
considered medical emergency
find the source of stimulus and remove it
unable to find stimulus-contact MD ASAP
treat symptoms
Postural Hypotension
loss of sympathetic vasoconstriction control and further enhanced by decrease muscle tone
Intervention:
-gradually progress to vertical position while monitoring vital signs=tilt table, anti-gravity system
-LE compression garment, abdominal pressure garment
-Medication to increase BP
Heterotropic Ossification
extra-articular and extra-capsular abnormal bone growth
typically occurs adjacent to large joints: shoulder, elbow, spine and hip/ knee
Symptoms of Ossification
swelling
decreased ROM
Erythemia
local warmth near joint
Intervention for HO
medication to inhibit calcium phosphate
ROM exercise to prevent LOM
surgery to remove bone if LOM occurs
Contracture
decreased ROM
prevention: positioning, orthotics, ROM
Deep Venous Thrombosis
loss of normal pumping mechanism in LE muscle contraction
Prevention: medications-anticoagulants PROM,AAROM repositioning LE compression garments Elevate LE
4 types of pain
traumatic
nerve root
spinal cord dysesthesia
musculoskeletal
traumatic pain
initial injury to soft tissues interventions: immobilize medications TENS
Nerve Root
irritation to nerve roots
invervention:
medications
TENS
Spinal Cord Dysesthesia
Uknown etiology
Symptoms:
diffuse, below level of lesion and similar to amputee “phantom” pain
Intervention:
gentle positioning
medication
musculoskeletal pain
typically at shoulder and due to overuse
prevention:
ROM
positioning
bladder dysfunction
T12 or below, increase intra-abdominal pressure using Valsalva maneuver or Crede maneuver
Bladder retraining-intermitten catheterization, timed voiding program
bowel dysfunction
location of cord lesion
- above conus medullaris: spastic or reflex bowel-UMN
- cord lesion in conus: flaccid or non-reflex bowel-LMN
Bowel Programs: -spastic or reflex management use suppositories digital stimulation -flaccid or non-reflex straining with available musculature mannual evacuation techniques
Respiratory Management
patients injured above T12 are lacking proper bronchial hygiene and adequate inspiratory volume are at risk:
- pulmonary infection
- activity limitations
- increased frequency of hospital admissions
- increased mortality
C1-2 respiration
loss of phrenic nerve-no diaphragm movement
mechanical ventilation
if reflex arc not damaged, may be able to get a nerve stimulator
C3 respiration
LMN damaged and prohibits use of phrenic nerve stimulator
mechanical ventilation
tracheostomy required for bronchial hygienee due to cough impaired
C4-C5 respiration
unilateral or bilateral damage to a portion of the phrenic nerve
decrease in vital capacity
pt. requires a tracheostomy but may be removed after vital capacity and ability to mobilize secretions has improved
pt. usually does not require mechanical ventilation after acute period
cough assistance usually necessary
risk of complications due to poor cough ability
C6-T6 respiration
interference with ability to deep breath and produce adequate cough
cough assitance and incentive spirometry needed
individual may be independent with self-assit cough
pt. can easily develop problems due to illness
T6-T12 respiration
major muscles for ventilation are usually intact
pt. may have weak, ineffective cough due to loss of abdominal and intercostal muscles
cough assitance and incentive spirometry needed
Respiratory Evaluation
function of muscles vital capacity respiratory rate chest expansion cough fucntion/effectiveness breathing pattern
Respiration Treatments General
done by whole team
diaphragmatic re-education muscle strengthening breathing exercises chest mobility pulmonary hygiene home instructions
PT and OT treatments for respiratory
inspiratory and expiratory force and endurance developed by using sip and puff tasks and control tasks
glosspharyngeal breathing
airshift maneuver
strengthening exercises
assisted coughing
abdominal support
stretching
Incentive spirometry
helps with diaphragmatic breathing
Selective strengthening
during first few weeks following injury
application of resistance during exercise to these areas may be contraindicated due to lack of spinal stability
- Tetraplegia: scap and shoulder
- Paraplegia: pelvis and trunk
Pts. with tetraplegia emphasis on:
anterior deltoid
shoulder extensors
biceps
lower trap
If present:
radial wrist extension
triceps
pectoralis
Pts. with paraplegia emphasis on
all UE musculature especially: shoulder depressors triceps latissimus dorsi
Skin inspection
must be regular and a lifelong component of daily routine
all patients can direct skin inspection
Manual Wheel Chair
intact triceps-C7
Power WC
C6 or C5 and higher
**Especially C4
Push Rim: PAPAW
manual with power assist wheels
requires less energy and lower stroke frequency
less shoulder ROM needed
beneficial for mid to lower cervical C5-C6
In order to ambulate after SCI a patient must have what?
adequate muscle strength
adequate postural alignment
adequate ROM
sufficient cardiovascular endurance
If pt. does not become functional ambulator, standing will still help benefit what?
improved circulation skin integrity bowel and bladder function sleep feeling of well being
factors that restrict ambulation
energy consumption severe spasticity loss of proprioception: esp. hips&knees pain presence of secondary complication decubitus ulcer heterotropic bone formation at hips deformity financial cost frustration and motivation
Levels of ambulation
Community: L2 or below
Household: T9-T12
* only within house on level surfaces
Emergency T6-T8:
- 2-3 steps with orthotics and AD to bedroom or through narrow areas WC cannot access
- *not wheel chair bound
Gait Training for individuals with complete SCI
orthotic Rx:
Thoracic lesion: KAFO’s
Reciprocating Gait Orthosis RGO: KAFO joined
Gait training strategies
Donning and Doffing orthosis in bed or on a mat table
need special equipment to put it on and off
**prevent jack-knifing=releasing Y ligament
Types of ambulation for complete SCI
standing from WC with crutches
UE push up from crutches
Crutch balancing
Falling safely
Locomotor training for incomplete SCI
distinct and specific task of walking with aim of tapping into the intrinsic neural pathways responsible for generating steps
- partial body weight support
- treadmill
- manual assistance by trainers
Train LIke you walk locomotor training
LE maximally loaded for weight-bearing-minimize or eliminate loading of arms
posture trunk, pelvis and limb kinamatics coordinated and specific to the task of walking
compensatory strategies for movement
Self LE ROM for C5, C6, C7-C8
C5:
Ind. direct ROM
depended with ROM
C6:
Ind Direct ROM
assist or perform parts of self LE ROM
C7-C8
Ind direct ROM
independent with self LE ROM
Sitting C5 C6 C7-C8
C5:
direct sitting method
assist w. head, scap and some shoulder movement
dependent with everything else
C6:
direct sitting method
ind. with sitting with AD
ind with POE or supine on elbows
C7-C8:
direct sitting method
independent w/ sitting via UE push-up
Bed mobility C5 C6 C7-C8
C5:
Direct bed method
assit with head, scap and some shoulder movement
C6:
direct bed method
independent with bed mobility with adaptive equipment
C7-C8:
independent with bed mobility w/ or w/o equipment
Pressure Relief C5, C6, C7-C8
C5:
Direct method
ind. with motorized recline WC w/ head control
C6:
DM
Ind. w/ self-pressure relief skills
C7-C8:
DM
Ind. w/ all self-pressure relief skills including WC push-up
Transfers C5, C6, C7-C8
C5:
DT
assit w/ head, scap and shoulder mvmt
POE transfer
C6:
DT
assit with head, scap, shoulder mvmt and biceo
Ind. or assist w/ transfer with slide board
C7-C8:
DT
Assist with head, scap, shoulder mvmt, bicep and wrist ext.
ind. w/ all trasnfers w/ or w/o slide board
WC mobility C5, C6, C7-C8
C5:
DWCM
ind. maneuver elec. WC w/ adaptive controls
ind. maneuver manual with oblique protection
C6:
ind. maneuver w/ vertical projections or plastic coated hand ribs w/ WC mitts
C7-8:
ind. maneuver of WC w/ or w/o plastic hand rims w/ mitts on smooth or slight uneven terrain
Ambulation T6-8
independent in // bars ambulation with bilateral KAFOs and bilateral swing to pattern via abdominal control
supervision w/ ambulation w/ walker and bil. KAFOs
Ambulation T9-12
ind. household ambulation w/ bil. KAFO and walker or crutches on level surface
sing to or swing through pattern
supervision on elevations and rough surfaces
Ambulation L2-3
ind. functional ambulation with bil. KAFOs w/ forearm crutches on level surface
Elevations w/ swing to, swing through or 4pt. pattern
Ambulation L4-5
ind. functional ambulation w. bil. AFOs w/ bil. forearm crutches or canes on level surface
2 or 4 pt. pattern
L1-L4
Hip Flexors
L4-S1
hip abductors
L2-L4
Hip adductors
L5-S2
Hip Extensors
Knee Flexors
L3-L4
knee extensors
L4-L5
Ankle Dorsiflexors
S1-S2
ankle plantarflexors
