SCI case study Flashcards
Gabapentin
o Anti-epileptic medication (anticonvulsant) – affects chemicals and nerves in the body that cause seizures and pain (taken orally)
o Used to relieve neuropathic pain post spinal cord surgery and restless leg syndrome
o Decreases overfiring of pain receptors
o Side effects – dizziness, headaches, ‘spaced’ out
ADE
o SC injury above T6 – parasympathetic and sympathetic interruption – SNS overreacts to external or internal stimuli acute uncontrolled hypertension in areas below the lesion level
o Unbalanced physiological response results from strong sympathetic stimulus below the level of the lesion – unable to be counteracted by PNS, cannot pass below level of lesion (increased splanchnic and peripheral vasoconstriction below injury level)
o Mechanism – Over-reactivity of ANS, noxious/strong stimuli starting below the injury level sent through the spinal cord to a level where it can’t travel any further – impulse cannot reach brain activates reflex to increase SNS activity (BV narrow = increased BP, detected by nerve receptors and message sent to brain message to heart, HR slows and BV above injury level dilate – BP not regulated
o Triggers – expanded bladder, urinary retention and constipation, functional electrical stimulation in complete spinal cord injury
o Symptoms – Racing irregular heart beat, BP>200mg systolic, headaches, sweating, dizziness and confusion
o Diagnosis – Immediate medical response
o Treatments – Emergency (decreased BP and eliminates causal stimulus), increased blood flow to feet, check catheter, remove tight clothing and vasodilator medicine
ASIA
- American Spinal Injury Association – defines and decribes extent and severity of patient’s SCI, and deteremines rehab and recovery (72-hours post-injury) – feel at multiple points and test motor function
- A = complete lack below injury level, B = some sensation, C = 50% below can’t move against gravity, D = >50%, E = all neurological function returned
Neuropathic pain
- Chronic and complex pain state usually accompanied by tissue NF, they themselves may be damaged, dysfunctional or injured
- Thought to arise from ever-stimulation of sodium channels (key pain sensation role) and activation of NMDA pathways (maintain sensitization of pain receptors) – damaged fibres send incorrect signals to pain centres (fibred can be damaged at both injury site and around injury)
- Can be central or peripheral, depending on injury site – likely suffer central neuropathic pain from SCI injury
- Symptoms vary in individuals – burning pains or sharp shooting pains
Oxford scale
- Manually assess muscle strength
- 0/5 = no contraction, 1 = flicker, 2 = gravity counterbalanced full activity range, 3 = full activity range against gravity, 4 = full range against some resistance, 5 = full range strong resistance
- Poor functional relevance, non-linear, variation over time. Inter-rate reliability, only assess muscles when eccentrically contracting
Muscle spasms
- Spasticity = paralysis side effect, varies from mild muscle stiffness to severe uncontrollable leg movements
- More common in cervical spinal injuries – 65-78% SCI population have some spasticity
- Common triggers- stretching muscles, movement, skin irritation, pressure sores, UTI, fracture amd tight clothing (anytime stimulation below injury level, stretched/noxious stimuli)
- Initial injury – muscles flex and weak due to spinal shock – reflexes below injury level absent (weeks months) – reflex activity returns
- Leg extensors are a common group
- Remodelling of CNS motor output control – descending UMN exert am inhibitory effect on local spinal circuits that control motor output. Local spinal reflexes lose inhibitory input in SCI – loss of corticol inhibition allows local reflex circuits to become hyperactive manifested in extensor/flexor muscle spasms
Respiratory muscles
• Inspiratory – diaphragm and external intercostal muscles (cranial and upper body)
• Expiratory – internal intercostals (upper body), rectus abdominis, obliques (lower body T8-T12)
• Accessory – sternocleidomastoids, scalene, upper trapezius (upper body)
• Lesion – T5 (ASIA complete T4) – no sensory/motor below T4
o Intercostal T1 to T7, abdominals T8 – 12
o Impaired rib movement when breathing, specifically on inspiration
o Independent breathing (auto NS) still possible, controlled via diaphragm by cranial nerve C3/C4 – unassisted by intercostals/abdominals
o Trouble to take deep breath and exhale forcefully – anything requiring forced respiration
o Susceptible to resp infections, inability to cough, causes dust and mucus build up, unable to clear – may lead to bronchitis and pneumonia (lung tissue inflammation)
• Treatment
o Core/upper body ex – improve vent function – abdominal muscles use of med ball
o Cough assistance – technique of pressure to chest/abdomen clears mucus etc.
o Abdominal binder – maintain abdominal pressure, prevent organs in abdomen falling, allows diaphragm better positioning and more efficient inspiration
o Resp training – resistance (inspiratory pressure threshold loading IPTL) – use of breathing device contains a pressure loaded inspiratory valve and unloaded expiratory valve
♣ Endurance – voluntary isocapnic hypervent for extended period of time
o Posture – maintain to keep resp muscles healthy
o Breathing ex – vary in duration of breath hold, deepness of breath, exhale speed, hypervent, multiple breaths at once
• Oswestry standing frame – used for core balance and strength exercises of upper body
o Prevent atrophy, improve circulation lower body, decrease muscle spasms
Bladder dysfunction
- SCI patients may be unable to tell when their bladder is full or may not be able to push urine out when necessary – intermittent catheterization ICP common method of urine emptying
- High risk of UTI
- Kidneys filter blood and produce urine bladder holds and removes urine (post-SCI urine still produced but may not be able to be removed)
- Spastic (reflex) bladder is when you bladder fills with urine and a reflex automatically triggers bladder emptying – spastic bladder usually occurs when injury above T12
UTI
- Source of infection is bacteria – easily bought into bladder with catheters and bacteria likely to grow in urine that stays in bladder
- Symptoms – fever, chills, nausea, headache, increased spasms, and autonomic dysreflexic episode (AD) – you may feel burning while urinating and/or discomfort in lower pelvic area, abdomen, or lower back
- Key to preventing UTI is to halt spread of bacteria into bladder – proper cleaning of urinary care supplies (2-4 hours) can help prevent infection – sediment can collect in tubing and connectors making it harder for urine to drain and make it easier for bacteria to spread (clean skin and hydration also important)
Psych issues
• ADJUSTMENT TO INJURY BY RESTORING ELEMENTS OF NORMAL LIFE IS KEY (PSYCHOSOCIAL)
• DEP/ANXIETY DUE TO – LOSS OF INDEPENDENCE AND PRIVACY, HELPLESSNESS, SELF-IMAGE AND SELF-EFFICACY, FUTURE UNCERTAINTY
• LINDEMANN AND KUBLER-ROSS CAN RELATE TO ADJUSTMENT OF SCI INJURY:
o SHOCK AND DENIAL DEPRESSION ANXIETY ANGER BARGAINING ADAPTATION
• NEED TO CREATE ACHIEVABLE GOALS
• RECREATIONAL SPORTS
• PSYCHOTHERAPY AND SUPPORT GROUPS
• SPECIFIC TO REHAB – GATHER INFO AND BUILD RELATIONSHIP, DAILY ROUTINES, GOALS, GROUP THERAPY, FIND IDENTITY, ADJUST TO NEW LIFESTYLE
Sitting balance
• Background – major problem is loss of use of any abdominal muscles, due to their innervation from the 5th to 12th thoracic area (below injury) – any muscles which can provide lumbar support innervated above T5, are muscles of the upper back
o Trapezius – elevates upper fibres, retracts scapula and extends head
o Lat dorsi
o Levator scapulae
o Rhomboid major and minor
• Neck can remain upright but an abdominal support would still be required for core stability alongside the titanium rods already in place
• Solutions
o Wheelchair assistance – adjustable height seat, non-slip surfaces and seat cushions
o Exercises – upper back, improve propulsion muscles, therabands for extensors and flexors
♣ Lateral shoulder raises, seated row and deltoid press
o Transfers – special focus on upper limbs as above T5 level there is still innervation of large muscle groups allowing for gross movement
♣ Lat dorsi, deltoid, triceps, pecs, traps
♣ Parallel bar lifting, shuffling exercises, wheelchair to bed
Standing frame benefits
• Prevent atrophy of leg muscles, improve ROM, improve circulation, fewer muscles and contractions, maintain bone integrity, reduces swelling in lower extremities, strengthen cardio system and build endurance, prevent pressure sores (decubiti) with changeable positions, improves kidney and bladder functions (reduce infection), improve bowel function and regularity
• Resp muscles
o Phrenic nerve C3-5 Diaphragm (O – rib 6-12 and I – diaphragm)
o C4-C6 scalenus anterior (O – C3-C6 and I – 1st rib)
o C3-C8 scalenus medius (O – C2-C7 and I – 1st rib)
o C6-C8 scalenus posterior (O – C5-7 and 2nd rib)
o T1-T4 Serratus posterior superior (O – C7, T1-3 and I – ribs 2-5)
o T1-T11 Internal intercostals (limited use) (O – ribs and costal cartilages and I – next rib below)
o T1-T11 External intercostals (limited use) (O – ribs and I – rib below)
o T3-T6 Transverse thoracis (limited use) (O – sternum and xiphoid process, ribs 3-6 and I – ribs 3-6)
Lesions
C1-2 = breathing loss
C3 = diaphragm function loss
C4 = decreased biceps and shoulder function
C5 = decreased biceps and shoulder, complete loss of wrists and hands
C6 = loss wrist control, complete loss hand function (HIGHEST LEVEL FOR INDEPENDENCE)
C7-T1 = decreased dexterity in hands and fingers (limited arm use)
T2-T9 = decreased paraspinal and abdominal muscle control
T9-T12 = partial decreased trunk and abdominal muscle control
S1-S5= decreased bowel/bladder control
T10 - L2 = decreased psychogenic erection
S2-S4 = decreased reflex erection
