SCI- MED AND PT MANAGMENT Flashcards
What is the most common way to obtain a traumatic SCI?
motor vehicle accident
central cord syndrome- common with older adult falls
What is the mean age of SCI?
43 YEARS
-group of older adults and younger
78% male
What percent of SCI are in ppl > 60 years?
11.5%
What is the most common type of SCI?
incomplete tetraplegia
ISNCSCI testing (“ASIA Testing”)
COMPONENTS
-light touch sensation
-pin prick sensation
-anorectal exam —> allows us to determine incomplete or complete
-UE and LE motor testing
Light touch sensory testing-ISNCSCI
Dermatomes- C2-S4/5
0- Absent - patient does not correctly and reliably report being touched
1- Impaired - feels touch but diff from face
2- Normal - feels touch and feels same as face
NT- not testable - Key sensory point unavailable or patient unable to distinguish
accurate testing on face
pin prick sensation- ISNCSCI
Dermatomes- C2-S4/5
0- Absent - patient does not correctly and reliably report being touched by either end of pin OR does not reliably distinguish between sharp and dull ends of the pin
1- Impaired - distinguishes between sharp and dull but reports intensity is different from face (greater or lesser)
2- Normal - distinguishes sharp or dull sensation correctly and describes it as same as their face
NT- not testable - Key sensory point unavailable or patient unable to distinguish
accurate testing on face
Upper extremity myotomes
- C5: Elbow Flexors
- C6: Wrist Extensors
- C7: Elbow Extensors
- C8: Finger Flexors
- T1: 5th Finger Abductor
Lower extremity myotomes
- L2: Hip Flexors
- L3: Knee Extensors
- L4: Ankle Dorsiflexors
- L5: Great Toe Extensors
- S1: Ankle Plantar Flexors
When is an upper and lower extremity motor exam typically performed per ISNCSCI?
often 72 hours after injury
-performed in supine (gravity eliminated)
Anorectal Exam
Deep Anal Pressure (DAP)
*May be the only evidence of an INCOMPLETE SCI
- Insert gloved, lubricated finger into anus
- The patient is asked to describe any sensory awareness
including feeling of touch or pressure - Recorded as present or absent
Voluntary anal contraction- anorectal exam
- After testing DAP, ask the patient to attempt to contract around your finger as though preventing a bowel movement
- A circumferential tightening of the anal sphincter around your finger is positive
- Pressure at the tip of your finger is the result of “bearing down” with the diaphragm or abdominals and is recorded as negative.
AIS A on INSCSCI
COMPLETE
- No sensory or motor function is preserved in sacral segments S4-S5 –> no anal sensory or motor contraction
- No anal sensory or motor contraction
- Trick: NOOOON
—> N: no voluntary anal contraction
0- light touch R
0-pin prick R
0-light touch L
0-pin prick L
No- deep anal pressure
AIS B
INCOMPLETE
-sensory, but not motor function is preserved below the neurological level
-must include sacral segments S4-5
-NO NOOOON
B = Incomplete: Sensory, but not motor, function is preserved below the neurologic level and extends through sacral segments S4-S5
AIS C
INCOMPLETE
- Sensory or motor function is preserved in S4/5 segments
- Must have either voluntary anal contraction OR
Sacral sensation PLUS motor sparing of the
motor function 3 levels below the motor level - More than half the muscles grades below the single neurologic level are <3.
Explain sparing with spinal cord injury:
C4 AIS A
–> patient can still have biceps control and wrist extensor control despite C4 level of injury
AIS D
INCOMPLETE
- Everything for AIS C
- AND at least half of the muscle grades below the single neurologic level at >/= 3.
** muscles are stronger than AIS C
AIS E
INCOMPLETE
- Sensory and Motor function are normal
- Persistent hyperreflexia does not negate
this classification
-the patient had prior SCI-related deficits
*Individuals without a spinal cord injury do not receive an AIS Grade.
What factors have an impact on functional recovery following SCI?
age
timing of surgical decompression
penetrating injuries
What is the relationship between age and prognosis with SCI?
50-65 difficult to determine prognosis
under 50 - better prognosis
over 65- worse prognosis
What is the rate of SCI recovery?
-most rapid in the first 3 months
-majority of recovery first 6-9 months
-late recovery up to 2-5 years
-most plateau 12-18 months
-early improvement–> greater recovery
What type of SCI has the lowest conversion rate to an incomplete?
High thoracic AIS A
-due to innate bony stability of the thoracic spine
What type of SCI has the highest rate of conversion?
lumbar AIS A
-the highest rate of conversion likely due to cauda equina and possible peripheral nerve injury
rate of conversion of SCI from greatest to least
lumbar>cervical>low thoracic> high thoracic
AIS A characteristics:
CERVICAL
* Most (67-80%) cervical
complete regaining of motor function
at least one level at 1 month
* 90% of muscles with a 1 or 2
grade at initial testing recover to
greater than or equal to 3/5 by
one year
* Chance of LE recovery very low
if still motor/sensory complete at
1 month
THORACIC
-very low recovery in thoracic injuries T9 and above at one year
-more recovery possible in T10-T12
AIS B Characteristics- motor complete, sensory incomplete
- Individuals with sensory sparing in a COMBINATION of modalities with
the greatest chance of recovery (light touch, pin prick, deep anal pressure)
-if pin prick spared> prognosis than light touch alone
-PP sparing in >50% of LE dermatomes (L2-S1) at 72 hours was predictive of ambulation
AIS C and D characteristics- motor and sensory incomplete
-if only VAC is preserved (motor), functional recovery minimal at 1 year
-if VAC plus DAP+LT+PP at S4-5 spared–> 80% chance of recovery to functional recovery to AIS D
Positive factors for SCI on imaging
T2 sagittal level
BASIC score: 5 factors from MRI correlated with the ISNCSCI exam and conversion rates
POSITIVE FACTORS:
-edema
-lesion spanning <3 levels
-BASIC score of 2
Negative factors for SCI imaging
hemorrhage
lesion spanning > 3 levels
BASIC imaging score of 4
What predictor is helpful for the prognosis of AIS B and C?
S1 pinprick sensation
What is prevented by the ICU/ acute care team in a hospital for patients with SCI?
-respiratory
-skin breakdown
-autonomic function
-bowel and bladder complications
-shoulder pain
-joint contractures
Characteristics of a UMN injury:
-CNS affected
-preserved reflexes- hyperreflexia
-spasticity
-neurogenic bowel and bladder–> spastic sphincters
-preserved reflexive penile erection
LMN injury
-PNS affected
-loss of reflexes
-flaccidity
-flaccid bowel and bladder- flaccid sphincters
-no reflexive erection in males
Common medical comorbidities in acute SCI
-pressure injury
-orthostatic hypotension
-autonomic dysreflexia
-deep vein thrombosis
-pulmonary embolism
-HO
-orthopedic injuries (cervical instability/fracture, vertebrae fracture (requires bracing))
-respiratory dysfunction
-sexual dysfunction
-neurogenic bowel/bladder
Pressure ulcers and skin protection
Why are SCI patients more susceptible?
- Decreased vascular supply (even WITHOUT pressure)
- Impaired autonomic system
- Impaired temperature control
-early detection is VERY important
-can happen very fast
-push to see if blanching occurs- early in the process
-not blanching- more severe
SKIN PROTECTION:
-turn in bed every 2 hours
-weight shift in w/c every 20 min for 2 min
-recommended to turn at least once at night
-check sacrum, ischial, heels, shoulder blades, back of head
**make sure patients are not mobilized into chairs and left there for too long
Review supine padding and side-lying padding examples on PPT
do it
Why is it important to avoid cardiac chairs?
not enough padding
must be adequately padded if using and watch sacral pressure
Characteristics of autonomic dysfunction (co-morbidity of SCI)
neurogenic shock
-orthostatic hypotension, loss of spinal reflexes in UMN injuries
cardio complications
-bradycardia, bradyarrhythmias, orthostatic hypotension, increased vasovagal reflex,
vasodilatation and stasis
temperature regulation
-reduced sensory input to thermoregulating centers and loss of sympathetic control of temp and sweat regulation below level of injury (LOI)
altered sweat secretion
-can be excessive, absent, or simply diminished
-reflex sweating- exclusively occurs below the LOI
Orthostatic hypotension following SCI and treatment
-dec more than 20 mmHg systolic or more than 10 mmHg diastolic
CAUSES:
-↓vasoconstriction, ↓ venous return, Dehydration
PRESENTATION:
-Palor, diaphoresis, dizziness, nausea, light-headedness, blurry vision, “shortness of breath”, loss of consciousness
DIFF DX:
-vestibular dysfunction
-low oxygen saturation
-stress/anxiety
TREATMENT:
* Abdominal binder, medications
(Proamitine/midodrine, Florinef,
NaCL tablets), caffeine, Ace
wraps – Tubigrip/Dermafit
* Initial mobilization to a wheelchair.
* Caution: hospital bedside chairs or raising HOB -> sacral/ coccygeal pressure ulcers!
* Hydrate!! - to increase blood volume
Autonomic Dysreflexia (AD)
- Increase in BP (>20 - 40 mm Hg above baseline) usually associated with bradycardia
CAUSES:
-noxious stimulus below LOI
—full bladder, impacted/irritated bowel, pain (cannot feel)
-vasodilation above the level of injury only
-vasoconstriction below LOI
PRESENTATION:
-flushing/blotchy red rash
-sudden headache
-diaphoresis
-chills
-nasal congestion
-blurred vision
-anxiety
-nausea
TREATMENT:
-needs to be treated emergently
-sit the person UPRIGHT to reduce BP
- find the cause
How does automatic dysreflexia occur with SCI?
NORMAL:
-afferent stimulus triggers peripheral sympathetic response–> vasoconstriction–> BP rises –> inhibitory signals sent down from the brain to reduce vasoconstriction
WITH SCI:
-can’t sent inhibitory signals from the brain through spinal cord to reduce vasoconstriction
Cardio issues with SCI
DVT
-40-100% of new injuries
-prophylaxis with Heparin, Coumadin, Lovenox
PE
-2-5% of new injuries
-leading cause of sudden death in acute SCI
**6-12 MONTHS OF ANTICOAGULATION MEDS REQUIRED - POST SCI
HO and neurogenic heterotopic ossification following SCI
-bone growth in or near joint after SCI and traumatic brain injury
-most common near hips (most common), knees, elbows
-20-50% of SCI
-most common 4-12 weeks after injury (as early as 2-3 weeks)
CAUSE:
-due to whole-body trauma and immobilization (neurologically driven)
PRESENTATION:
-decreased ROM unilaterally
-edema
-warmth
-low-grade fever, especially at night
-can have palpable mass beneath inguinal ligament or laterally near greater trochanter or femoral head
Diagnosis of HO:
1.) Asymmetrical PROM - decreased hip flexion and internal rotation; pain
2.) Bone scan- detects early phase 2-4 weeks after onset
3.) xray- can only detect progressive HO (3-6 months after formation)
4.) Serum alkaline phosphatase- elevates 2-3 weeks after bone formation but also durign fx healing; not well-correlated
Medications for HO
Bisphosphonates
NSAIDs (Indicin) - may be prophylactic in acute stages
Low field radiation
Surgical Resection - often unsuccessful due to highly vascularized tissue–> regrowth
What drug is now banned by FDA for HO?
DIDRONEL
-if taken for 2 months or less can cause rebound ossification
Respiratory dysfunction following SCI:
-PRIMARY CAUSE OF DEATH AFTER SCI
TREATMENT:
-clear secretions
-maximize inspiration:
–stacking breaths
–inspiratory muscle trainers
–incorporate ventilatory strategies into mobility
-maximize cough/expiration
–assisted or self-assisted cough
–abdominal FES
Diaphragm and its effect on respiratory function after SCI:
INNERVATION: phrenic nerve C3-C5
-contributes to 65% of vital capacity
-an abdominal binder or supine
positioning can help to increase VC by 16 to 28%
DPS- diaphragmatic pacer system:
-stimulates the phrenic nerve and allows partial or full time weaning from the ventilator
Sexual dysfunction and SCI
DEPENDS ON:
-complete or incomplete
-muscle movement and mobility
-sensation and hypersensitivity
-medical complications
-fatigue, energy levels
-interest and desire
CONSIDERATIONS:
-AD
-spasticity
-positioning
-skin integrity
-neurogenic bowel/bladder
-orthostatic hypotension
-pain- somatic and neuropathic
- women can have full-term pregnancies with SCI
Neurogenic bowel and bladder with SCI
UMN
-spastic sphincter> retention of urine
-high amount of bladder pressure -> AD
-incomplete bladder drainage > UTI
-deterioration in renal function
LMN
-flaccid sphincters > leaking
INTERMITTENT CATHETERIZATION
-will need intermittent catheterization –> maintain low urine volumes and pressures to avoid urinary tract damage -400-600 cc
-clean technique taught to patients and caregivers –> Compliance is higher
-LMN injuries, may need to cath more frequently due to leaking
Suprapubic catheter
-Constant drainage of bladder through
indwelling catheter directly into
bladder via stoma located above
pubic bone
-Decreased infection risk from foley
catheter, allows improved peri-care
and confidence with potential sexual
functioning (decreased risk of UTI)
-reversible
Bowel management after SCI:
UMN
-spastic sphincters can lead to stool retention, impaction, AD
-daily bowel program: digital stimulation, suppository, upright, regular schedule
-diet: aim to keep stool loose
LMN
-flaccid sphincters –> harder to hold in
-BID or TID bowel program: no dig stimulation, suppository, upright, regular schedule (30 min after meals)
-diet: keep stool slightly formed
The ideal bowel program:
– Less than 90 minutes
– Every day or every other day
– No routine use of suppositories
– Less than 3 incontinence episodes
per year
– Low incidence of constipation
*MOST SIGNIFICANT CONCERN AFTER SCI
What is a colostomy?
-can be easier and faster to empty than bowel program BUT external to the body
- Surgical procedure to re-route
colon to the external stoma and
attached bag - Eliminates the need for daily bowel
program - Can be easier for the caregiver
management - Significant surgery and recovery,
but can be reversed surgically
Where should the tip of a wheelchair user’s middle finger be in relation to the axel of the wheelchair?
tip of middle finger near center axel
What levels of SCI are you more unlikely to teach a supine-to-sit transfer/
above C7 injury
Exercise recommendations after SCI
2-3 days per week of strength training
150 per week moderate to high-intensity cardio exercise
Postural asymmetry can lead to _______ if not managed well
respiratory compromise
How can bone mineral density loss with aging be mitigated with SCI?
PT can provide education, training, and equipment evaluation for a safe, regular supported standing program to slow bone mineral density loss
