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SCI Part II EXAM 1 Flashcards

1
Q

Laundry list of 2* Complications of SCI

A
  • press sores
  • HO
  • Osteoporosis
  • syringomyelia
  • autonomic dysreflexia
  • RSD
  • OH
  • altered thermoreg
  • DVT/PE
  • pain
  • Resp dysf.
  • contractures
  • spasticity
  • B&B dysf.
  • altered sexual function
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2
Q

Single greatest factor leading to INC in hospital LOS and $$$

A

Pressure sores aka Decubitus Ulcer

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3
Q

Pressure Sores…. aka what?

due to what?

A
  • Decubitus ulcers
  • combo of anasthesia w/ pressure/and shearing forces
  • ****MAJOR SOURCE MORBIDITY AND MORTALITY
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4
Q

Pressure Sores

What can cause them?

A
  • Poor B&B control
    • skin maceration (like pruny fingers)
  • Hypertonia
    • shearing– skin breakdown
  • trauma
    • # tapeburns
  • Nutritional deficiencies or comorbidities delay healing

***See O’Sullivan table 20.3***

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5
Q

Pressure sores… what is @ risk?

A

ANY WBing part of body

* calcaneous

* lat. malleolus

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6
Q

Pressure sores…. the best tx is…

A

PREVENTION

*pos changes q hour

NOTE: q= every

* Sitting pressure releases q 15mins

*need entire rehab team on this!!!!!

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7
Q

Heterotopic Ossification (HO)

What is it?

A
  • Abnormal dev. of BONE below lvl of SC lesion
    • ​usually in soft tissues
      • ​surrounding joints
        • ​w/ SCI–> hips/knee
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8
Q

HO is….

A

Extraarticular

Extracapsular

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9
Q

HO typ. occurs where?

A

@ hips/knees

MAY also occur shoulders, elbows, paravertebral area

*functional limits 20% pts

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10
Q

Predisposing Factors for HO

A
  • COMPLETE lesions
  • pressure sores
  • hypERtonicity
  • C/S–mid T/S lesions
    • *Males 2x likely to dev. HO
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11
Q

Early s/s of HO may mimic what?

A
  • Thrombophlebitis
    • ​warm, erythema, swelling, reduced ROM
  • NO X-ray findings
  • elevated Alkaline Phosphates significant clinical finding
    • ​***New bony growth blood marker***
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12
Q

HO and ROM

acute vs. later phases

A
  • Early research discourages ROM—> proven wrong!!!
    • Acute phase== rest/gentle PROM
    • Acute phase OVER== PROM and mobilization
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13
Q

HO @ its WORST….

A

Prevents safe and normal siting posture, transfers, interferes w/ preserved ROM and worsens hygiene problems due to B&B issues

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14
Q

Pharmacologic interventions HO

A
  • Prophylaxis—-beforehand
    • ​Indomethacin (NSAID) OR refecoxib (COX-3 inhibitor)
      • ​reduce risk of developing HO
    • radiation tx’s
  • For Tx:
    • ​Etidronate—- halts progression after dx
      • early admin is key!!!
    • radiation— slow/stop HO progress.
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15
Q

Osteoporosis due to changes in……..

A

Ca metabolism

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16
Q

INC risk of THIS w/ Osteoporosis

also INC risk of _____ and ________

A
  • INC risk patho fx
    • no support
    • no trauma
    • just happens
  • INC risk renal stones
    • INC conc. of Ca in urinary system
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17
Q

Osteoporosis commonly tx’d w/

A

Biphosphates

Ex’s: Fosamax or Didronel

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18
Q

EARLY TX for Osteoporosis

A

Wt. Bearing Ex!!!!

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19
Q

Osteoporosis due to what?

Tx?

A
  • due to immobility and disuse from lack of WBing BUT
  • WBing w/out mm contraction USELESS
    • ​Spasticity can prevent this
  • Tx to INC mm contraction prevents this
    • FES reasonable tx
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20
Q

Syringomyelia aka

A

Posttraumatic Cystic Myelopathy

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21
Q

What is Syringomyelia aka Posttraumatic Cystic Myelopathy?

A
  • Dev. of fluid filled cyst in SC—-typ near lvl of injury
    • ​sx’s WORSE as cyst ENLARGES
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22
Q

Syringomyelia aka Posttraumatic Cystic Myelopathy s/s:

A
  • Sx’s include:
    • PAIN
      • local/radicular
        • diff vs. deafferent dysesthesia
    • sensory changes
    • weakness/mm atrophy
    • hypOreflexia
  • NOTE: develops in 3% all SCI pts
    • ​8% incidence in comp. tetraplegia pts
      • ​can occur ANYTIME post injury
        • ​mo’s—-decades
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23
Q

Dx of Syringomyelia?

A

History THEN MRI

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24
Q

Tx Syringomyelia:

A
  • Surgical
    • laminectomy/drainage
    • syringoperitoneal OR syringosubarachnoid shunting
  • outcomes mixed
    • some surgeons NO operate if only sensory symptoms w/out motor changes
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25
Q

What should you remember about Autonomic Dysreflexia/Hyperreflexia???

A

IT IS A MEDICAL EMERGENCY!!!!!!!!!!!!!!!

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26
Q

Autonomic Dysreflexia is a syndrome that affects indiv’s w/ what kind of SCI?

A

T6 or higher SCI******

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27
Q

Autonomic Dysreflexia occurance?

A
  • Affects indiv’s w/ T6 or higher SCI
    • occurs due to uncontrolled autonomic outflow
      • ​Causes:
        • ​SEVERE HTN
        • HR changes
        • severe sweating and flushing
        • severe HA
        • piloerection (gooseys)
        • shivering
    • Consequences can be lethal!!!
  • AUTONOMIC DYSREFLEXIA IS A MEDICAL EMERGENCY
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28
Q

MASSIVE, uncompensated, CV rxn of the sympathetic NS to a noxious stimulus below the lvl of the SCI lesion resulting in marked HTN

A

Autonomic Dysreflexia

*They have sensory loss, so cannot feel noxious stim but still get the signals that it’s there

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29
Q

What is going on w/ Autonomic Dysreflexia

why can pt not feel the normal signals?

A

Normal signs from the carotid sinus and to lower peripheral resistance are unable to pass the injured area of the SC

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30
Q

Persistence of HTN assoc’d w/ Autonomic Dysreflexia can be Fatal

causing….

A

Stroke

Cardiac Arrest

Seizures

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31
Q

Autonomic Dysreflexia

What to do if it’s happening?

A
  • have the pt Sit UP
    • ​Remember….they have HIGH BP so this will REDUCE BP
  • Search for the offending noxious stimulus
    • ​The trigger
      • ​pain stimulus below SCI person cannot perceive
        • blocked catheter (often)
        • bedsore
        • restrictive clothes
  • Take (and note) BP
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32
Q

Why should we TAKE and NOTE BP in someone w/ Autonomic Dysreflexia?

A

People w/ SCI can have normal systolic pressures of 90-100

so a BP of 140/80 could indicate significant HTN for them!

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33
Q

Autonomic Dysreflexia

What to do if you try to remove the stimulus but this does not work?

A
  • IF BP does NOT come down after this….
    • catheterization
  • IF still no drop in BP
    • medical or surgical intervention
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34
Q

Address Autonomic Dysreflexia IMMEDIATELY

A

MEDICAL EMERGENCY!!!!

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35
Q

Complex Regional Pain Syndrome (CRPS) OR aka

A

Reflex Sympathetic Dystrophy (RSD)

**P. nerve injuries mostly**

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36
Q

CRPS or RSD occurance

A

small # SCI pts

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37
Q

CRPS or RSD likelihood?

A

INC’s in neurological lvl is at or near lvl of injury

**HIGHER injury==more likely

MAY cause INC in abnormal sensory discharge/responsiveness

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38
Q

CRPS/RSD

where is pain?

what is spared?

A
  • Typified by PAIN @ fingers or hand WITH shoulder or scapular pain
  • Forearm or elbow spared
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39
Q

CRPS or RSD

Sympathetic vasomotor changes

A

Red, taut, glossy skin and trophic nailbed changes

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40
Q

CRPS or RSD pain cycle

A

leads to cycle of immobilization and stiffness

demineralization of bone

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41
Q

When will we normally see OH? (Orthostatic HypOtension)

What pos changes?

A

Supine –> sit

Sit—> stand

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42
Q

OH results from loss of what?

A

Loss of SNS influences that control vasoconstriction

Basically….not enough volume of blood to maintain BP

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43
Q

____________ combined w/ __________ and _________ leads to __________ w/ OH

A

LE vasodilation combined w/ loss of mm pump and prolonged bed rest leads to venous stasis (stoppage or pooling of blood)

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44
Q

What interventions can we use for OH?

A

Pressure garments like TEDS and Abdominal binders

Teach the Valsalve Maneuver

**ALL preventative measures**

45
Q

OH and early PT tx

A
  • resumption of upright is very difficult in early tx
    • judicious BP monitoring
    • patience!!!
  • Graded standing via tilt table ==== PT intervention of choice!!!
    • ​@ 80deg they’ll feel “upright”
    • @ 90deg falling forward feeling
46
Q

Altered thermoreg is limited thermoreg where?

A

BELOW LESION LVL

47
Q

Why does altered thermoreg happen?

A

Connect. b/w ANS and SC interrupted

*normal thermoreg may not happen*

48
Q

Altered thermoreg s/s

A
  • Pt unable to sweat when warm or shiver when cold
    • ​HIGHER the lesion===GREATER proportion of body that is unable to maintain safe temp!
49
Q

Being mindful of altered thermoreg

A

*People w/ SCI should ICE after strenuous act. to cool down

OR

dress warmly in cool weather

50
Q

DVT and PE

What are they?

A
  • DVT
    • clot in the venous system or blockage
  • PE
    • clot that breaks loose and travels into the pulmonary aa circulation into lungs
  • LIFE THREATENING
51
Q

DVT/PE risks

A

INC risk due to DEC LE mvmt

Loss of LE mm pump (gravity pulls blood DOWN)

52
Q

Pharmacologic prevention and Tx DVT/PE

A
  1. Coumadin–anticoagulant
  2. Heparin– intravenous
53
Q

DVT/PE prevention

A

Compression garments (TEDS or intermittent SCDs)

SCDs==> Sequential Compressive Device—these have timers and inflate to squeeze the limbs (mimic mm pumps)

**PT for daily mobilization**

54
Q

MAJOR problem experienced by those w/ SCI

55
Q

PAIN assoc’d w/ SCI can come from a variety of causes

what are they?

A
  • Overuse
  • Mm imbalances
  • Reverse action use***GOOGLE
  • Trauma
  • Radicular pain
  • Dysesthesias (prickling, burning)
  • Phantom pain**
    • feeling of limb being in place after amputation
56
Q

Lesions above ________ result in paralysis of the diaphragm

A

lesions above C4

*this means person w/ C1-C3 tetraplegia req’s artificial ventilation***

57
Q

Lesion of ________ spares diaphragm

58
Q

C5-T12 lesion spares diaphragm BUT limits what?

A

Limits use of intercostals and accessory mm’s

*still leads to Resp Dysfunction

59
Q

Compensations for Resp Dysfunction occur over time

BUT

A

Diminished functional resp capacities present

60
Q

People w/ lesion above ________ have abdominal weakness and limited expiratory capacity

61
Q

People w/ lesion ABOVE T10 have _______________

results in what?

A

Abdominal weakness and limited expiratory capacity

This results in diminished cough and inability to expel lung secretions

#PNA

62
Q

Flexibility is the cornerstone to…..

A

Mobility!!!

63
Q

Marked loss of FLEX

A

Contractures

64
Q

Contractures occur due to:

A
  • Occur due to:
    • lack of mm opposition
    • hypERtonicity
    • lack of norm. positioning

Significantly limit ability to participate in OR perform ADLs

Tenodesis!!! —> passive insufficiency where multi joint long finger flexors are pulled tight when wrist moves into pos of ext

65
Q

Spasticity is ________

A

Velocity dependent

*velocity dependent INC in resp. to PROM

66
Q

Spasticity and using PROM

A

PROM can prevent secondary complications

UNLIKELY that any type of handling tech. can “cure’ spasticity

may DEC it temp.

67
Q

Spasticity Tx: medical

A
  • Medical Tx:
    • antispasmatics
      • ​Baclofen
      • Klonopin
      • Tizanidine
68
Q

Spasticity Tx: surgical

A
  • Surgical Tx:
    • IT (intrathecal) Baclofen
    • Phenol block
      • dorsal spinal N. root injection
      • Botox (botulinium toxin)
        • ​paralytic INTO muscle and paralyzes that muscle
          • Temporary (few mos)
          • reduces resting tension
          • if pt does receive this…we can mobilize and stretch to restore ROM
69
Q

Role of Urinary System?

A

make urine in kidneys

store it in bladder

remove it from bladder via urethra

NOTE: bladder composed of smooth mm and can stretch to accommodate 500cc (2cups)

70
Q

Successful mgmt bladder comps ====

A

PRIMARY reason for DEC morbidity and mortality in people w/ SCI

71
Q

What controls flow of urine from bladder?

A
  • Sphincter mm’s
    • sphincters relax—> urine flows
72
Q

Bladder innervated….

A

Sacral N. segments

*Detrusor muscle

73
Q

2 Syndromes assoc’d w/ bladder

A
  1. Spastic or reflex bladder==hyperreflex
  2. Flaccid bladder== hyporeflex
74
Q

Spastic Bladder

A
  • Detrusor hypERsensitivity
  • usually occurs w/ SCI @ or above T12
  • external catheter req’d
75
Q

Detrusor hypersensitivity aka Spastic bladder

what happens?

A
  • Bladder empties as a reflex to a certain lvl of filling
  • Rxn may be triggered by exercise OR removal OR kinking of indwelling catheter
76
Q

Spastic bladder

A

@ or ABOVE T12 SCI

77
Q

Flaccid Bladder

A
  • Sphincter remains CLOSED and bladder fills w/out emptying==distended
  • occurs w/ lesions BELOW T12
  • Tx either by indwelling (stays in place) OR intermittent (changed t/o day) catheter
78
Q

Flaccid bladder: sphincter remains closed

what happens?

A

urine backs up into kidneys==urosepsis

79
Q

Flaccid bladder occurs

80
Q

Loss of neurologic control of the intestinal tract causing loss of control of defication

A

Neurogenic bowel

81
Q

Neurogenic bowel

lose control of intestinal tract==lose control of defication===

A

DEC gastric motility and loss of voluntary control anal sphincters

82
Q

After all is said and done….

w/ neurogenic bowel what is the result?

A

Stool retention

83
Q

Stool retention as a result of neurogenic bowel interventions:

A
  • Includes:
    • digital stimulation (exactly what it sounds like)
    • suppositories
    • enemas
    • manual disimpaction
      • manually remove feces
  • PT and B&B
    • transfers, balance, limb mvmt
84
Q

Sexual disturbances in SCI

A

physiologic dysf.

S and M disturbance

psychologic and sociologic distress

85
Q

Why should PTs understand issues related to sex and sexuality???

A

Rapport

VERY close proximity w/ pts

they are COMFORTABLE w/ you

86
Q

Sexuality in men after SCI

these 3 things are different phenomena

A
  1. Erection
  2. Ejaculation
  3. Orgasm

**depending on type of lesion, all three may be affected in some way

87
Q

Organs of MALE repro. and sexual anatomy supplied by:

88
Q

Somatic supply controlling ejaculation in men comes from:

A

S2-S4 to the pudendal nerve

89
Q

Normal Erections have 2 separate components:

A
  1. Psychogenic
  2. Reflexogenic
90
Q

Psychogenic Erections

A
  • erotic ideation—> Endocrine function
  • Structures involved supplied by T10-L2
  • NOT EXP’D BY INDIV’S W/ LMN LESIONS***
91
Q

Reflexogenic Erections

*UMN thing

A
  • result of internal or external stim of genitals
  • MOST common in men w/ lesions ABOVE T12
  • Structures involved arise from S2-S4
    • ​Erectile reflex center***
92
Q

Somatic supply controlling ejaculation comes from….

A

S2-S4 segments to the pudendal nerve

93
Q

Ejaculation 3 stages:

A
  1. emission of seminal fluid from urethra
  2. closing of bladder sphincter
  3. antegrade ejaculation
94
Q

Three stages of ejaculation coordinated by

A

diff. nerves and mm’s

*far less common occurence than erection

retrograde ejaculation may occur (goes back into urethra into bladder)

95
Q

Sterility after SCI: due to

A
  • Ejaculatory dysf.
  • genital duct blockage
    • ​recurrent UTI and non-drainage of repro tract
      • DEC spermatogenesis due to INC testicular temp
        • issues maint. temp
  • repro often artificial insemination
96
Q

50% of men w/ SCI report they can have orgasms

A

Hallelujah!!!!

*unrelated to lvl of injury

97
Q

These control vaginal secretions and clitoral tumescence

A

Parasympathetic nerves

S2-S4

98
Q

Control the smooth muscle of the Fallopian Tubes and Uterus

A

Sympathetic Splanchnic nerves

T5-T12

99
Q

Innervates Pelvic floor musculature

A

Somatic pudendal nerves

S2-S4

100
Q

What is the PRIMARY sexual impairment in women w/ SCI

A

Lack of lubrication!!

buy some lube!!!

NOTE: intercourse can contribute to INC UTI’s

*post-coital catheterization

101
Q

This is very common in women post-SCI

*relates to sexuality

A

disruption of menstrual and ovulatory cycles

NOTE: generally resumes to prior status w/in a yr.

102
Q

Long term repro capacity in women w/ SCI

A
  • NOT impaired, but complications
    • Autonomic dysreflexia—EMERGENCY!!!
    • thromboembolism–DVT
    • resp. diff’s
      • if lesion is cervical OR high thoracic
  • risks can be mg’d and not insurmountable barrier to preg.
103
Q

Risks assoc’d w/ Sexuality and SCI

A
  • pregnancy possible regardless of whether male or female
  • STD’s
  • realities of the disability….
    • fall off bed
    • skin breakdown from vigorous love making
    • pathologic fx’s
104
Q

Counseling for Sexuality and SCI

A

see slide 52

105
Q

Current concepts in SCI rehab

A
  • FES—mm stim for functional mvmts
  • BWS TM/Gait training
    • ​robotics
106
Q

Use of electrical stim to aid in physical functioning of persons w/ phys disablity

and 2 types

A

FES

  1. FES-based cycle ergometry or FES-based orthotics
  2. Implanted FES units for UE’s and LE’s
107
Q

BWSTT/BWSGT 3 types

A
  1. Litegait—PT assists in moving legs
  2. Lokomat—robot legs kindof
  3. Alter G–high tech

*pt needs to be able to move limbs

108
Q

Robotic ADs

MedCon Rehab II (5 decks)

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