SCI Rehab - Salles Flashcards
What are the non-key muscles for ASIA scoring?
C5 Shoulder flexion, extension, abd, add, internal and ext rotation
Elbow supination
C6 elbow pronation, wrist flexion
C7 finger flexion and poximal joint extension, thumb flexion, extension, abduction in plane of thumb
C8 Finger flexion at MCP joint, thumb opposition adduction and abduction perpendicular to palm
T1 finger abduction of the index finger
L2 Hip aduction
L3 Hip ext rotation
L4 Hip extension, abduction, IR; Knee flexion, Annkle inversion and eversion, Toe MP and IP extension
L5 hallux and toe: DIP and PIP flexion and abduction
S1 hallux adduction
ASIA testing in which time frame is felt to be most predictive of recovery?
72 hours to one week
ASIA exam has poor utility in:
poor utility < 5.
Frequency of ASIA testing is recommended at: (3)
- 4-6 weeks
- 6 months
- 1-2 years post injury
Prognostication factors of functional outcome: 9
Preexisting medical conditions
Concomitant injuries
Secondary complications
Cognitive impairments
Age
Body habitus
Availability of financial resources and insurance coverage
Psychological, social and cultural factors
Dependent on the physical exam and neurological level of injury
FIM: describe
Not sensitive or specific to SCI especially in tetraplegics
Total of 126 point
Composed of 18 items, 13 motor and 5 cognitive
Uses a seven level ordinal scale to measure function
FIM measuring scale 1-7
7-Complete Independence No helper or device 6-Modified Independence May need a device, extra time or safety issue 5-Supervision Standby assist, setup 4-Minimal assist Patient=75%+ 3-Moderate assist Patient=50-74% 2-Maximal assist Patient=25-49% 1-Total assist Patient =less than 25%
What is the Spinal Cord INjury Measure III (SCIM III)
19 items assess 3 domains Self care (six items and scores range from 0-20) Respiration and Sphincter management (4 items and scores range from 0-40) Mobility ( 9 items and scores range from 0-40) Total SCIM range of 0-100 Assessment completed by observation and questioning of the patient
What is the walking index for SCI - Version II (WISCI-II)
21-item scale (0–20) categorizes walking function based on level of physical assistance required and use of braces and assistive devices required to walk 10 m on a level surface
NLI C1-4 Respiratory
Expected outcome
Equipment
EE: vent or diaphragmatic pacer (C1-3), inability to clear secretions
EQ: ventilator, suction equip, backup generator, nebulizer
NLE C1-4 Bowe expected outcomes and equipment
EE: dep for dig stimulation, suppository and hygiene
Eq: padded reclining commode chair with head control; roll-in shower
NLE C1-4 Bladder Expected outcomes and equipment
EE dep with CIC, SPT, or foley
Eq: foley, external cath, urine drainage bag
NLI C1-4 Bed mobility Expected outcomes, Equipment
Eo: independent with direcing care but dep with rolling
Eq: full electric hospital bed, pressure relieving mattress
NLI C1-4 Transfers EO EQ
independent with directing care but dep for transfers
hoyer lift with sling, sliding board
NLI C1-4 WC mobility
independent with power, dependent with manual
needs: power recline and tilt, head support, head, chin or sip and puff, manual tilt and recline
NLI C1-4 Pressure relief
Independent with power, dep with manual WC
needs: jay basic, 2, 3; roho
NLI C1-4 Eating, bathing, dressing
Total assist
Needs: hand held shower, padded reclining shower chair, commode with head support
NLI C1-4 Communication, keyboard use, handwriting, telephone
total assist to independent after set up with equipment
needs: mouth stick,voice activated or infrared head control for computer and ECU, PMV for ventilator tubing for speaker
NLI C1-4 transpotation
total assist
attendant operated van with lift and WC tie downs or accessible public transportation
NLI C5 Respiratory
Low vital capacity and may require assistance to clear secretions
MIE, Quad cough
NLI C5 Bowel/bladder
dependent
Needs: padded reclining commode chair, foley, spt, CIC
NLI C5 Bed mobility
some assist but independent in direction of care and controlling bed
Needs full electric hospital bed, pressure relieving mattress, side rails
NLI C5 Transfers
Dependent but independent in directing transfers
Needs sliding board, hoyer lift with sling
NLI C5 WC propulsion and pressure relief
Ind with power equipment, dependent for outdoors, assist for uneven surfaces
Needs Power w/ tilt and recline with arm drive, ultra-light with handrim modification and postural support
NLI C5 Standing and ambulation
total assist with standing, ambulation dependent on level of incompleteness
needs: hydraulic standing frame, walker
NLI C5 Eating/bathing/dressing
Total assist to cut up food, set up with meal tray, modI with eating AE, some assist with upper body drsesing, total assist with bathing and LE dressing
Needs: wrist splint with U-cuff, bent fork/spoon, nonslip mat, plate guard, and ?? a mobile arm support. Also hand held shower, padded reclining commode ro roll in shower chair with head support
NLI C5 Communication
Set up with equipment
needs AE such as page turner, writing, button pushing, voice activated devices, bluetooth
NLI C5 transportation
Total assist for attendant operated vehicle; some assist with public transportation
Needs modified van with lift
NLI C6-7 respiratory
low endurance and FVC
needs cough assist and quad cough
NLI C6-7 Bowel
Some to total assist
Padded tub bench with cutout or padded shower chair
NLI C6-7 Bladder
some to total assist, may be independent with leg bag emptying;
needs adaptive scissors, foley, spt, CIC
NLI C6-7 Bed mobility
some assist
full electric hospital bed, side rails
NLI C6-7 Transfers
Some assist to independent;
Slidine board
NLI C6-7 WC prop and pressure relief
Power-independent with standar arm drive on all surgaces, Manual: ind indoors and some assist outdoors, ind for pressure relief
Needs power WC with recline +/_ tilt with arm drive control or power assist wheels, manual ultralight rigid or folding fram with handrim mods and postural support, pressure relieving cushion
NLI C6-7 Standing and ambulation
Total assist
hydrailic standing frame
NLI C6-7 Eating/dressing/bathing
Total assist with cutting otherwise independent; ind with UB bathing and dressing, some to total assist for LE
Needs: U-cuff, adaptive utensils, nonslip mat, plate guard, buton hook, loops on zippers/pants, velcro on shoes, padded tub transfer bench, washmit, handheald shower
NLI C6-7 Communication
Ind with or without equipment
Needs page turners,writing, button pushing, voice activated systems/ecu
NLI C6-7 Transporation
INd driving from WC
Needs modified van with lift, hand controls, tie down for WC
NLI for C8 respiatory
Low endurance and vital capacity
Needs: quad coughing, MIE
NLI C8 b/b
ind with dig stim, self cath, supp or enema insertion and personal hygiene
needs: padded commode chair, straight catheters
NLI C8 Bed mobility and positioning
independent
NLI C8 transfers
independent with or without sliding board
Possibly sliding board
NLI C8 WC prop and pressure relief
manual-independent all surfaces
Needs: ultralight righid or folding WC, pressure relieving cushion
NLI C8 standing and ambulation
Standing-some assist to independent, standing frame
NLI C8 Eating/dressing/bathing
independent, some assist to independent with bathing and dressing
Needs: buton hook, loops on zippers, pants, socks; velcro on shoes, padded ransfer tub bench/commode, washmit, handheald shower
NLI C8 communication
independent
Cell phone, ECU for home use, computer/laptop
NLI C8 transportation
independent if able to complete car transfer and load and unload WC, independent driving modified van from captains seat
Needs: car with hand controls, modified van with lift and hand controls
NLI T1-12 Respiratory
low vital capacity for higher level lesions
Quad cough, MIE
NLI T1-12 B/B
Independent with dig stim, supp or enema insertion and personal hygiene, ind with self cath or foley care
Needs: padded commode chair, straight caths, foley, SPT
NLI T1-12 bed mobility
idependent
full to king size bed, pressure relieving mattress/overlay
NLI T1-12 Transfers
independent
sliding board
NLI T1-12 WC prop or pR
manual: independen with all surfaces;
Ultralightweight rigid or folding frame, pressure relieving cushion
NLI T1-12 Standing and ambulation
independent with standing; ambulation only for exercise
Neds: standing frame, KAFO, walker or loftstrand crutches
NLI T1-12 Eating/dressing/bathing
independent
padded tub transfer bench, handheld shower
NLI T1-T12 communication
independent
Cell phone, computer, ECU
NLI T1-12 transportation
independent with car, independent with driving modified van with hand controls
NLI L1-S5 Resp
normal/none
NLI L1-S5 B/B
independent with dig stim, enema, or suppository insertion and perineal hygiene, independent for bladder care
Needs padded toilet seat, straight catheters, foley, SPT
NLI L1-S5 BM and positioning
independent; Full to king standard bed
NLI L1-S5 Transfers
independent with sliding board only if general debility
NLI L1-S5 WC propulsion and PR
Independent on all level surfaces,
Needs Ultra LW rigid or folding chair, pressure relieving cushion
NLI L1-S5 Standing and ambulation
ind with standing, functional if only one KAFO needd;
Needs: standing rame, KAFO +/- AFO, lofstrands or canes as indicated
NLI L1-S5 E/BD
independent; padded tub transfer bench
NLI L1-S5 transporation
Ind with driving care; car with hand controls, depending on the degree of LE function
______ at 4 weeks post injury and baseline lower extremity pinprick have been associated with an improved prognosis for walking
- Sacral pinprick preservation
Initial presence of motor function below ____ also remains a positive predictor for walking
The presence of ____ is less predictive of walking compared to sacral sensation to LT or PP at S4-5 and voluntary anal contraction
the NLI
deep anal pressure
prognostic indicators of ambulation following SCI: 6
Severity of injury LE motor function/score Spasticity Balance Proprioception Age
roel of imaging for prognosis and recovery: MRI (5)
To date had contributed more than any other imaging modality in acute SCI
Its use is controversial in the setting of trauma and in the absence of neurological deficit
Helpful in excluding occult ligamentous or soft tissue injury, vertebral thrombosis and for confirmation of bone injury age
Useful in patients that are uncooperative, obtunded or malingering
It does not differentiate between edema from axonal injury
Spinal cord hemorrhage:
- most common within the _____
- The anatomic location of hemorrhage corresponds closely with the ____
- Detection of > ____ mm in length is typically assoicated with complete injury.
- overall associated with ____ prognosis
- central gray matter
- NLI
- > 10mm
- poor
Spinal cord edema
- Seen as: _____
- usually involves
- _____ always co-exists with spinal cord edema bu the opposie is not always true
- The length of spinal cord edema is ____ dependent
- _____ alone connotes a more favorable prognosis compared to hemorrhage
- high intensity signal on T2 weighted images.
- variable length above and below the level of the injury
- post-traumatic hemorrhage
- time dependent aftera cute injury
- cord edema
Incomplete paraplegia:
- LEMS > ____ a one month lads to 100% community ambulator in one year
- overall, ___% become community ambulators
- motor recovery takes longer than sensory: time span?
- Muscle groups with 1-2/5 strength at one month will have ____ at one year
- 12 months vs 3 months
- > 3/5 strength
- > 10
- 76%
complete paraplegia:
- Motor and sensory recovery occur at _____
- Most recovery of function occurs within _____ months with plateau at ____
- Above ____ level show no LE recovery
- _____ show hip an knee recovery but not foot.
- Presence of _____ function increases likelihood of hip flexion recovery.
- ____% are community ambulators
- Same rate
- 9-12 months, 12-18months
- T9
- T9-L2
- lower abdominal motor function
- 5%
Incomplete tetra:
- motor recovery takes longer than sensory: time span?
- Most recovery within _____
- Muscles groups with 1-2/5 strength at one month will likely have ____ strength at one year.
- ____% are community ambulators but depends on boh UEMS, LEMS and age
- 6 months vs 3 months
- first year
- > 3/5
- 46%
complete tetras
- ____% of those with complete SCI will convert to incomplete injuries
- Motor and sensory occur at ____ rate
- Muscle groups with 1-2/5 strength at one month will have ____ strength at one year (97%)
- Rarely regain: ______
- most recovery in ____ months
- 10-20%
- same rate
- > 3/5 strength
- LE motor function
- 6-9 months
Incidence of DVT in SCI reported to be as high as ____% for those without ppx and ___% for PE
40%, 5%
Highest risk for DVT in SCI withing the first _____ post injury with peak occurence between ______
2 weeks post injury; between days 7-10 days
Clinical findings of DVT in SCI 5
To date had contributed more than any other imaging modality in acute SCI
Its use is controversial in the setting of trauma and in the absence of neurological deficit
Helpful in excluding occult ligamentous or soft tissue injury, vertebral thrombosis and for confirmation of bone injury age
Useful in patients that are uncooperative, obtunded or malingering
It does not differentiate between edema from axonal injury
Clinical findings of PE in SCI 8
Tachycardia Tachypnea Hypoxia Change in mental status Pleural friction rub or pleural effusion Fever Cyanosis Rales
three diagnostic tests for DVT in SCI
Doppler US-preferred method, non invasive and 98-100% sensitive
V/Q scan-indicated only if suspect PE
CT PE protocol-has replaced V/Q scan and allows to determine presence of PE/upper leg DVT
mechanical ppx for DVT in SCI 3
Compression hose-helps with distributing pressure along the LE and helps venous return and edema but NO change in DVT rate noted
Sequential external pneumatic device-improve LE venous return but ineffective being used alone
Electrical Stimulation-helps with LE stasis but is ineffective alone, may be worn 24 hours a day
Best medication for DVT ppx in SCI; most effective after _____,
LMWH is found to be superior in prevention of thromboembolism after SCI
Most effective if started at 72 hours post injury as long as not active bleeding process present
The use of thrombolytic therapy (TPA, urokinase, streptokinase) has not been established in patients after SCI
Lovenox 30mg BID is only LMWH with Level 1 evidence to support its use after SCI:
_____ weeks in motor complete SCI
______ weeks in patient swith motor complete SCI with long bone fracture or intraabdominal trauma/surgery
minimum of ____ weeks for those individuals with motor incomplete SCI who are ambulators
8 weeks
12 weeks
2 weeks
IVC filters indicated in SCI when?
LMWH is found to be superior in prevention of thromboembolism after SCI
Most effective if started at 72 hours post injury as long as not active bleeding process present
The use of thrombolytic therapy (TPA, urokinase, streptokinase) has not been established in patients after SCI
d/c H2 or PPI in SCI after ____ weeks unless felt to be high risk.
4 weeks
Name the high risk factors for continuing PPI or H2 in SCI after 4 weeks (7)
Mechanical ventilation > 48 hours Coagulopathy Hypoperfusion due to shock or sepsis High dose steroids Spinal Cord or Mod to severe brain injury Use of NSAIDs H/O PUD, gastritis or recent GI Bleed
Orthostatic hypotension in SCI defined as:
Most common in levels above:
Seens as high as ____% in those with tetraplegia and __% in those with paraplegia.
Common presentation: 4
- drop in SBP by 20 pts or DBP by 10 pts when changing position
- T6, 82%, 50%
- dizziness, nausea, double vision, syncope
5 predisposing causes of orthostatic hypotension
Loss of tonic sympathetic control Altered baroreceptor sensitivity Loss of skeletal muscle pumping Cardiovascular deconditioning Hyponatremia Volume depletion
Treatment of orthostatic hypotension after SCI: Medications 5`
Midodrine-a selective alpha adrenergic agent which causes vasoconstriction (level 2 evidence)
Florinef-a mineralcorticoid which stimulates the release of salt into the blood stream causing increase BP by fluid retention (level 4 evidence)
Ephedrine-non selective alpha and beta agonist which causes improvement of blood pressure (level 5 evidence)
L-threo-3,4-dihydroxyphenylserine (L-DOPS)-an exogenous amino acid which is a precursor to noradrenalin (level 5 evidence)
Dihydroergotamine-a ergot alkaloid with selective vasoconstrictive effects both centrally and peripherally (level 5 evidence)
non-pharm treatment of orthostatic hypotension (4)
Balanced fluid and salt intake (level 5 evidence)
Some benefit to use of abdominal binder and TED hose, duration of use not well established (level 2 evidence)
Functional Electric Stimulation-improve LE muscle contraction and facilitates venous blood return (level 2 evidence
Exercise via passive ROM and cycle ergometry helps with venous blood return (level 2 evidence)
HO in SCI
Involves the formation of mature lamellar bone in soft tissue around the paralyzed joint, not connected to the periosteum and becomes encapsulated as it matures which can take 6-18 months
HO in SCI;
- Indicence of ____% after SCI with about ____% becoming significant
- Most often seen in: ______
- Less common in _____ SCI (10-13%)
Incidence of 16-53% after SCI with about 20% with 20% that become clinically significant
Most often seen in the hips, knees, elbows, shoulders, hands and spine after SCI
Less commonly seen in pediatric SCI (10-13%)
typical time of presentation is up to ____ months after SCI for HO.
- Associated with individuals with greater extent of ______
- Pathophys involves _)____
- Increased _____ noted in those with HO
- 6 months
- spasticity
- inflammatory process with increased blood flow in soft tissue
- osteoblast stimulating factor
6 clinical findings of HO in SCI
Gradual Loss of ROM Warmth Pain Swelling Low grade fever In the pediatric population usually only presents as loss of ROM
4 Clinical phases of HO described by nicolas in 1973
Stage 1 - swelling, increased serum alk phos, normal XR
Stage II swelling, increased alk phos, positive xray
Stage III no swelling, increased alk phos, positive xray
Stage IV no swelling, normal alk phos, positive xray
HO around the hip due to SCI and TBI as described by marvogenis ortho traumatology, 2012 (4 types)
a = SCI, b = TBI
Type 1 HO at the anterior hip or the prox end of the femur with or without ankylosis
Type 2 HO at the posterior hip or proximal end of the femur, with or without ankylosis
Type 3 HO at the anterior and medial hip or the proximal end of the femur, with or without ankylosis
Type 4 HO around the hip with or without ankylosis
Clinical markers of HO after SCI 5
SAP-might rise at 2 weeks and then peak at 10 weeks with those with HO
Transient hypocalcemia
Elevated CRP
Elevated Creatnine Kinase Levels
Elevated Prostaglandin E 2 levels in urine
HO
- XRAy will not show HO until _____ weeks.
- _____ needed for early detection
- 5-7 weeks.
- Triple phase bone scan - first 2 phases (blood flow and blood pooling) most sensitive, 3rd phase - most specific to bone turnover and used to determine presence and maturity of HO
NSAIDs ____ in HO
Most studied:
Limited use due to :
Most helpful in preventing HO after acute SCI by reducing inflammatory process and by inhibition of prostaglandins
Indomethacin
3. GI bleed, intolerance, risk of delayed bony fusion of spine post SCI, typically contraindicated due to delaed bone healing and prolongation of usion rate.s
Role of bisphosphonates in HO.
Which is best for HO?
Prevent the formation of hydroxyapatite crystals
Prevent osteoclast attachment to the bone matrix as well as osteoclast recruitment and viability
Etidronate disodium (Didronel)
Most studied in the treatment of HO after SCI
300 mg/day IV for 3 days followed by 20 mg/kg po divided in 2 doses for 6 months
Most common side effect is GI intolerance
Pamidronate might be an alternative in this population but dosing recommendations not yet available
when is surgery indicated for HO? 4
Recurrent skin breakdown
Non healing or recurrent PU
Difficulty with seating and mobility
Loss of function
When may surgery be performed for HO? 2
Surgery to be completed once the HO has matured on triple phase bone scan as well as return to normal SAP
Typically completed at 12-18 months after diagnosis
Will need intraoperative XRT and post operative use of Etidronate to avoid recurrence
