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Systems T3 > SCI TREATMENT CONSIDERATIONS > Flashcards

SCI TREATMENT CONSIDERATIONS Flashcards

1
Q

What are the 12 key treatment considerations for individuals with SCI?

A
  1. Working with Spasticity
  2. Skin Breakdown & Care
  3. Autonomic Dysreflexia/Hyperreflexia
  4. Osteoporosis & Fractures
  5. Heterotopic Ossification
  6. Pneumonia, Atelectasis & Aspiration
  7. Cardiovascular Disease
  8. Deep Vein Thrombosis (DVT)
  9. Syringomyelia
  10. Neuropathic Pain
  11. General Wheelchair Use
  12. General Safety Issues
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2
Q

What is spasticity?

A

An exaggeration of normal reflexes due to a lack of inhibitory control from the brain.

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3
Q

How does the brain normally regulate reflexes?

A

The brain’s reflex center assesses incoming stimuli and, if the stimulus is not dangerous, overrides spinal reflexes using inhibitory neurons to dampen muscle contraction.

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4
Q

What is spastic hypertonia?

A

• A condition in individuals with SCI where structural damage to the spinal cord prevents segmental reflex signals from reaching the brain.
• The brain’s inhibitory signals also fail to reach target tissues.
• This results in muscle spasms, rigidity, myoclonus (shock-like muscle contractions), and dystonia (abnormal muscle tone).

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5
Q

What are common triggers for spasticity in individuals with SCI?

A

• Urinary tract infections (UTI)
• Ingrown toenails
• Constipation
• Tumors
• Guillain-Barré Syndrome (GBS)
• Stretching
• Decubitus ulcers (pressure sores)

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6
Q

In which populations is spastic hypertonia more common?

A

Occurs more frequently in quadriplegia (tetraplegia) and incomplete SCI compared to paraplegia and complete SCI.

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7
Q

What percentage of SCI patients require treatment for severe spasticity?

A

• 42.7% of individuals with SCI require medication or surgical treatment for spasticity within one year of their injury.
• (Data from The National Spinal Cord Injury Statistical Center)

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8
Q

What are the most common types of spasms in individuals with SCI?

A

• Elbow flexor spasms
• Leg extensor spasms (often mistaken for initial motor function return)

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9
Q

What are the complications of spastic hypertonia?

A

• Decreased range of motion (ROM)
• Pain
• Unwanted bladder and bowel release
• Interference with activities (sleeping, changing position, sitting, posture, balance)
• Increased risk of pressure sores

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10
Q

What are some possible advantages of spastic hypertonia?

A

• Muscle spasms can assist with ADLs (e.g., picking up items, emptying bladder, transfers, pressure relief, standing, walking)
• Provides early warning for pain or underlying problems like infection
• Helps maintain muscle size, bone strength, and circulation in legs

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11
Q

How can medications for spasticity be administered?

A

• Orally
• Via a feeding tube
• Transdermal patch
• Intrathecal pumps

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12
Q

What is Baclofen used for, and what are its side effects?

A

Purpose: Acts on the CNS to reduce muscle spasms and pain
Side effects: Dizziness, weakness, fatigue, nausea

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13
Q

What is Valium/Clonazepam used for, and what are its side effects?

A

• Purpose: Acts on CNS, helps with nighttime spasms and sleep disturbances; also acts as a sedative/hypnotic
• Side effects: Dizziness, drowsiness, impaired memory/attention, loss of strength
• Note: May be addictive

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14
Q

What is Dantrium used for, and what are its side effects?

A

• Purpose: Acts on muscles by interfering with contractions to reduce tone, spasms, and pain (not selective to spastic muscles)
• Side effects: Weakness in all muscles (including respiratory muscles), dizziness, drowsiness, diarrhea, fatigue

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15
Q

What is Zanaflex used for?

A

Acts on CNS, short-acting, taken when relief from spastic hypertonia is most important

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16
Q

Baclofen Pump

A

• A surgically implanted device that delivers Baclofen directly into the fluid surrounding the spinal cord
• Inhibits reflex signals in the spinal cord, stopping muscle spasms

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17
Q

What are key features of the Baclofen pump?

A

• Size: Round metal disc (~1 inch thick, 3 inches in diameter), placed under the skin near the waistline
• Refilling: Medication is refilled via a needle inserted into the pump’s filling port
• Dosage: Uses a much smaller dose compared to oral administration
• Types:
- Programmable: A motor moves medicine from the reservoir through the catheter
- External: Treatment team can adjust dose, rate, timing
• Replacement: Pump needs to be replaced every 5-7 years (battery)

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18
Q

What are other treatment methods for spasticity besides medication?

A

• Daily ROM exercises and stretching
• Botox injections (chemodenervation)
• Surgeries:
- Contracture release
- Tendon transfer
- Osteotomy: Bone wedge removed to reposition/reshape joint or for arthrodesis (fusion)
- Dorsal root rhizotomy: Rarely used; involves severing, burning, or chemically destroying nerve roots

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19
Q

What are decubitus ulcers (pressure sores), and why are they a major concern for SCI patients?

A

• Caused by excessive pressure and shearing forces, mainly over bony prominences (ischial tuberosities, greater trochanters)
• Prevalence:
- Up to 80% of SCI patients will experience a pressure sore
- 30% of these individuals will have more than one

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20
Q

How often should pressure releases be performed in SCI patients with limited/no movement or sensory deficit?

A

Every 15 minutes

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21
Q

What are the major risk factors for decubitus ulcers in SCI patients?

A
  1. Muscle tone changes
  2. Altered/lost sensation
  3. Autonomic blood supply control changes
  4. Loss of skin elasticity, making it highly sensitive to pressure
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22
Q

What additional factors contribute to the development of decubitus ulcers?

A

• Limited ROM
• Prolonged ischemia
• Moisture (sweat, bladder/bowel incontinence)
• Spasticity
• Diabetes
• Edema
• Obesity/anorexia
• Temperature-related injuries (hydrotherapy, sunburn, frostbite)
• Anemia
• Smoking & alcohol use
• Stress
• Respiratory dysfunction
• Peripheral vascular disease (PVD)

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23
Q

What are the complications of spastic hypertonia?

A

• Decreased ROM
• Pain
• Unwanted bladder and bowel release
• Interference with daily activities (sleeping, changing position, sitting, posture, balance)
• Increased risk of pressure sores

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24
Q

What are the possible advantages of spastic hypertonia?

A

Muscle spasms can assist with ADLs (e.g., gripping light objects, emptying the bladder, transfers, pressure relief, standing, walking)
Provides early warning of pain or infections
Helps maintain muscle size, bone strength, and circulation in the legs

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25
Q

How can medications for spasticity be administered?

A

• Orally
• Via a feeding tube
• Transdermal patch
• Intrathecal pumps

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26
Q

What are the effects and side effects of Baclofen?

A

• Effects: Acts on CNS, reduces muscle spasms and pain
• Side effects: Dizziness, weakness, fatigue, nausea

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27
Q

What are the effects and side effects of Valium (Diazepam) and Clonazepam?

A

• Effects: Acts on CNS, useful for nighttime spasms and sleep disturbances, acts as sedative/hypnotic
• Side effects: Dizziness, drowsiness, impaired memory/attention, loss of strength, may be addictive

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28
Q

What are the effects and side effects of Dantrium?

A

• Effects: Acts on muscle (interferes with contraction), reduces tone, spasms, and pain
• Side effects: Weakness in all muscles (including respiratory), dizziness, drowsiness, diarrhea, fatigue

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29
Q

What is the function of Zanaflex?

A

Short-acting medication acting on CNS
Taken when relief of spastic hypertonia is most needed

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30
Q

What is a Baclofen pump, and how does it work?

A

• A surgically implanted pump that delivers Baclofen directly into the spinal cord fluid
• Inhibits reflex signals in the spinal cord to stop muscle spasms

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31
Q

Where is a Baclofen pump placed, and how is it refilled?

A

• Placement: Under the skin of the abdomen near the waistline
• Refilling: A needle is inserted through the skin into a filling port in the pump

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32
Q

What are the advantages of a Baclofen pump over oral administration?

A

• Requires a smaller drug dose since it is delivered directly to the spinal cord
• More effective with fewer systemic side effects

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33
Q

How often must a Baclofen pump be refilled and replaced?

A

• Refilled every 2-3 months
• Replaced every 5-7 years (battery replacement)

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34
Q

What are alternative methods for treating spasticity?

A

• Daily ROM exercises & stretching
• Botox injections (chemodenervation)
• Surgeries:
- Contracture release
- Tendon transfer
- Osteotomy (removes a wedge of bone to reposition a joint)
- Arthrodesis (joint fusion)
• Dorsal root rhizotomy (rare, destroys nerve roots to reduce spasticity)

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35
Q

What are the causes of pressure sores in SCI patients?

A

Excessive pressure or shearing forces, especially over bony prominences (ischial tuberosities, greater trochanters)

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36
Q

How often should pressure releases be performed in SCI patients?

A

Every 15 minutes if the patient has limited/no voluntary movement or sensory deficits

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37
Q

What percentage of SCI patients experience pressure sores?

A

Up to 80% will experience a pressure sore
30% have more than one

38
Q

What are the major risk factors for developing pressure sores in SCI patients?

A

• Significant changes in muscle tone
• Altered/lost sensation
• Changes in autonomic control of blood supply to skin & subcutaneous tissue
• Loss of normal tissue elasticity

39
Q

What additional factors contribute to pressure sores?

A

• Limited ROM
• Prolonged ischemia
• Moisture (sweat, bladder/bowel incontinence)
• Spasticity
• Diabetes
• Edema
• Obesity/anorexia
• Temperature extremes (sunburn, frostbite)
• Anemia
• Smoking, alcohol abuse
• Stress
• Respiratory dysfunction
• Peripheral vascular disease (PVD

40
Q

What are the four stages of pressure sores?

A

• Stage 1: Red/discolored skin that does not fade within 30 minutes after pressure removal
• Stage 2: Broken epidermis, forming a shallow sore, may have drainage
• Stage 3: Extends into the dermis or subcutaneous fat tissue
• Stage 4: Extends into muscle and bone, may have dead tissue and drainage; surgery may be required

41
Q

What are the red flags for worsening pressure sores?

A

• Increased size or drainage
• Increased redness or black areas around sore
• Edema, suppuration, fever

42
Q

What should therapists consider when treating SCI patients?

A

• Do not leave skin oily or wet (breaks down faster)
• Monitor incontinence (major skin integrity concern)
• Be aware of skin shearing (e.g., sliding in wheelchair/bed)
• Cushion bony areas prone to movement during spastic reactions
• Watch for complications: Septicemia, amputation, autonomic dysreflexia
• Scar tissue breaks down faster – apply pressure in increments, check response

43
Q

What is autonomic dysreflexia (AD)?

A

A medical emergency caused by an uncontrolled sympathetic nervous system reflex in SCI patients at or above T6

44
Q

When does AD occur, and who is at risk?

A

• Occurs after spinal shock resolves when reflexes return
• Most unpredictable in first year post-SCI
• Affects 4 males:1 female
• Seen in 48-90% of SCI patients with injuries above T6

45
Q

What are common triggers for AD?

A

• Bladder issues (most common, e.g., full bladder, catheter blockage, UTI)
• Bowel issues (constipation, impaction, digital stimulation, enema)
• Skin irritations (wounds, pressure sores, burns, insect bites, ingrown toenails, tight clothing)
• Other triggers: Sexual activity, gastric ulcers, extreme temperatures, menstruation, pregnancy, labor, ROM/stretching

46
Q

What symptoms appear above the SCI level?

A

• Bradycardia (slow HR)
• Upper body flushing, blotchiness
• Blurred vision, nasal congestion
• Headache, nausea, chills, sweating, piloerection

47
Q

What are the potential severe outcomes of prolonged AD?

A

• Intracranial stroke
• Retinal hemorrhage
• Myocardial infarction (MI)
• Seizures

48
Q

What is the first step in managing an AD crisis?

A

Find and eliminate the nociceptive source!

49
Q

What are common bladder/bowel issues that can trigger AD?

A

• Full drainage bag
• Kinked tubing
• Drainage bag raised higher than the bladder
• Clogged catheter

50
Q

What clothing and positioning factors should be checked during an AD crisis?

A

• Loosen tight clothing, abdominal bands, or straps
• Check wheelchair, bed, or seat cushion for sharp objects
• Remove pressure from clothing on lower extremities

51
Q

What medications or substances may cause symptoms similar to AD?

A

• Erectile dysfunction medications (ask if taken in the last few hours)

52
Q

What medications can help if AD occurs frequently?

A

Transdermal nitroglycerine

53
Q

What are key signs of AD in terms of blood pressure?

A

• A rise of 20-40 mmHg in systolic BP from baseline
• Baseline systolic BP for most at-risk individuals: 90-110 mmHg

54
Q

What are additional ways to lower blood pressure in AD?

A

• Medication
• Upright positioning
• Removal of supportive hose

55
Q

How can you identify a patient with a history of AD?

A

They often carry a medical alert card

56
Q

Why do most SCI patients develop osteoporosis (OP)?

A

Due to loss of muscle activity and weight-bearing

57
Q

How can SCI patients delay bone density loss?

A

• Increase load on bones (standing during transfers, using a walking frame)
• Spasticity may help maintain bone density

58
Q

What are the main risks associated with osteoporosis in SCI patients?

A

• Pathological fractures
• Poor bone healing

59
Q

What additional factors can increase the risk of osteoporosis?

A

Certain medications

60
Q

What is heterotopic ossification (HO)?

A

Calcification of muscles, joints, and connective tissue outside of the normal skeleton

61
Q

Where is HO most commonly found?

A

Coxafemoral (hip) or tibiofemoral (knee) joints

62
Q

What are the consequences of HO?

A

• Progressive joint stiffening
• Risk of joint fusion

63
Q

How long does it take for heterotopic bone to mature?

A

12-18 months

64
Q

What interventions help maintain ROM in HO?

A

• ROM exercises
• Functional activities

65
Q

What treatment may be required for severe HO?

A

Surgical release

66
Q

Why are patients with SCI above T4 at risk for respiratory issues?

A

Due to restrictive lung disease (limited respiratory function)

67
Q

Which muscle weaknesses contribute to respiratory dysfunction in SCI?

A

• Diaphragm
• Intercostal muscles
• Abdominal muscles

68
Q

What are the consequences of weak respiratory muscles in SCI?

A

• Ineffective coughing
• Poor lung clearance
• Increased risk of pneumonia, aspiration, and other lung conditions

69
Q

When does respiratory dysfunction become progressively worse in SCI patients?

A

5-10 years after injury

70
Q

How often should pulmonary function be tested in SCI patients?

A

Annually after 5-10 years post-SCI

71
Q

What are key preventative measures for respiratory complications in SCI?

A

• Postural drainage & percussion
• Assisted coughing

72
Q

Why are SCI patients at higher risk for cardiovascular disease?

A

They tend to live more sedentary lives

73
Q

What is important in cardiovascular assessment for SCI patients?

A

• Regular assessment of cardiovascular function
• Exercise programs adapted for upper extremities

74
Q

Why does SCI affect circulatory and thermoregulatory function?

A

• Autonomic spinal reflexes return, but ascending/descending signals are blocked
• Loss of higher-level modulation of spinal and autonomic reflexes

75
Q

How does SCI above T6 impact cardiovascular function?

A

• Impaired sympathetic control of the heart and vasomotor tone
• Blood pooling in extremities → Increased risk of postural hypotension, peripheral edema, DVT

76
Q

Why is DVT common in SCI patients?

A

Blood stasis due to loss of neurological control of blood vessels

77
Q

What is a common early-stage rehab complication in SCI patients?

A

Lower leg DVT

78
Q

How can DVT be prevented in SCI patients?

A

• Pneumatic compression stockings
• Blood thinners (Heparin, Coumadin)

79
Q

What is syringomyelia?

A

Post-traumatic enlargement of the central canal of the spinal cord

80
Q

What percentage of SCI patients develop syringomyelia?

A

1-3%

81
Q

What is a major risk of syringomyelia?

A

Progressive loss of function above the original injury

82
Q

What is the treatment for syringomyelia?

A

Surgical drainage & placement of a drainage tube

83
Q

What types of pain are common after an SCI?

A

• Nerve root pain (sharp, electric shock feeling)
• Musculoskeletal pain
• Phantom limb pain (occasionally)

84
Q

What are signs of neuropathic pain below the injury level?

A

• Radiating pain
• Allodynia
• Hyperpathia

85
Q

What are treatment options for neuropathic pain in SCI?

A

• Medication
• Nerve block procedures

86
Q

What are common overuse injuries in wheelchair users?

A

• Blisters
• Tendonitis
• Pressure sores
• Nerve compression

87
Q

What precautions should be taken with catheters in wheelchair users?

A

Do not position urine bag above kidney level

88
Q

How should spastic and flaccid tissue be handled in SCI patients?

A

• Spasticity: Stroke softly, hold gently
• Flaccid tissue: Modify pressure accordingly

89
Q

Why is hydrotherapy a concern in SCI patients?

A

Vasomotor paralysis or paresis can cause full/partial vasodilation

90
Q

Why is maintaining ROM important in SCI patients?

A

To prevent joint subluxation and contractures

91
Q

Should all contractures be removed in SCI patients?

A

No! Functional contractures (e.g., fingers for gripping a spoon, sitting posture) may be beneficial

92
Q

What medications require caution in SCI patients?

A

• Spasticity meds
• Blood pressure meds
• Diuretics
• Anticoagulants
• Corticosteroids

Systems T3 (26 decks)

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