Spinal Cord Injury 2 Flashcards
Rehab considerations
Level of injury Complete or Incomplete Shortened length of hosp. stays Pts prior level of function MOTIVATION! Age Physical condition Family support
Length of stay
Acute - 11 days
Rehab - 36 days
Examination
ASIA scale
Supplement with other assessment tools
Examination - ASIA scale
International standardization
Ensure consistency in measurement technique, data and communication
Examination - ASIA scale - major drawback
Only clinically “essential data” is considered
ASIA definitions - Neurological Level
Thoe most caudal segment with normal sensory and motor function on both sides of the body
ASIA definitions - Skeletal level
The level at which the greatest vertebral damage is found by radiographic examination
ASIA definitions - Motor level
The lowest key mm that has grade 3 or more as muscle power and all mm receiving innervations from above that level are normal
ASIA definitions - Complete injury
No sensory or motor function in the lowest sacral segment
ASIA definitions - Incomplete injury
Partial preservation of sensory and/or motor functions below the neurological level and the sacral segment
ASIA definitions - Zone of partial preservation
Includes the dermatomes and myotomes that remain innervated caudal to the level of injury in complete injuries ONLY
ASIA Grade A
Complete - no sensory or motor function is preserved in the sacral segment S4-S5
ASIA Grade B
Sensory incomplete - Sensory but not motor function is present below the neurological level and includes the sacral segments S4/5 AND no motor function is preserved more than three levels below the motor level on either side of the body
ASIA Grade C
Motor incomplete - Motor function is preserved below the neurological level and more than half of key mm functions below the neuro level of injury have a muscle grade of less than 3
ASIA Grade D
Motor function is preserved below the neuro level and AT LEAST HALF of key mm function below the NLI have a mm grade 3 or higher
ASIA Grade E
Normal
Neuro complications
Dec motor func Dec sens func Altered mm tone Altered temp reg Resp problems B/B dysfunction Sexual dysfunction
Neuro complications - Decreased motor function
Maintain ROM
Maintain mm mass
Understand functional capabilities that are feasible
Neuro complications - Decreased sensory function
Decubitis ulcers In the hospital - pt turned every 2 hours WC cushions Pressure relief techniques Safe techniques with transfers Education
Neuro complications - altered mm tone
Spinal shock
Spasticity (2/3 of all SCI - more prevalent in C and T)
Disabling
Affects QOL and can lead to fucntional dependence
Neuro complications - altered mm tone - Spastic hypertonia (UMN)
Spasticity, mm spasm, hypertonia, increase DTR, clonus
Neuro complications - altered mm tone - Management
Weight bearing PROM Medications Baclofen pump Botox injection
Neuo complications - respiratory function C1 -3
Weak mm in addition to those seen in paraplegia (pecs, sa, scalenes, traps, SCM, diaphragm)
All planes of ventilation are limited
Neuo complications - respiratory function C1 -3 - results in
significant dec in tidal volume and vital capacity
95% require mechanical vent
Neuo complications - respiratory function C4
Weak mm in addition to those in paraplegia (Scalene, diaphragm, SA, pecs)
Planed of ventilation are limited - marked in ant and lat, slight in inf and sup
Neuo complications - respiratory function C4 - results in
dec tidal volume
May require mechanical vent
Neuo complications - respiratory function C5 - 8
Weak mm in addition to those in para (pecs, SA< scalenes)
Limited in planes of vent - Marked in ant and lat, slight dec in post expansion
Neuo complications - respiratory function C5 - 8 - results in
Dec VC
Dec FEV
Dec cough effetiveness
Paradoxical breathing
Neuo complications - respiratory function T1-T5
Weak/absent abdominals, intercostals, erector spinae
Limited planes of vent - dec in ant/lat exp
Neuo complications - respiratory function T1-T5 - results in
Slight-mogerate dec in vital capacity
Dec effective cough
May show paradoxical breathing
Pulmonary intervention
Suctioning and chest PT
Breathing ex
Incentive spirometer
Quad cough
Pulmonary intervention - if pt becomes breathless
lay them down so gravity is not effecting them as much
Pulmonary intervention - quad cough
Assisted cough for weak abs
Lay pt down
Assist with expiration - place hand below xiphoid process
Neuro complications - Altered temp regulation
No sweating below level of lesion
In summer, body temp continues to rise
In winter, chance or hypothermia
Improper clothing due to loss of sensation
Neuro complications - Altered temp regulation SS
HA
Nasal congestion
Tiredness
Reduced concentration
Neuro complications - Altered temp regulation - tx
Sponging with cold water
Drink lots of water
Education
Neuro complications - bladder dysfunction - two levels of control
Spinal reflex center of micturition - conus medullaries S2 - 4
Pontine micturition center - integreate the reflex, coordinated contraction of detrusor mm and sphinter relaxation
Neuro complications - bladder dysfunction - two types of bladder dysfunctions
spastic
flaccid
Neuro complications - bladder dysfunction - spastic bladder -
Hyperreflexive bladder (UMN bladder)
Lesion above conus - reflex arc for emptying is intact
Detrusor mm contracts reflexivly with pressure build up
Bladder emptying can be spontaneous, triggered by manual stimulation
Urine retention if sphincter unable to relax
Neuro complications - bladder dysfunction - flaccid bladder
areflexic bladder (LMN bladder)
Lesion of conus/cauda equina - reflex center absent
Urinary retention
Emptying by vasalva, manual compression, self cath
Neuro complications - bladder dysfunction - catheterization program
Prevent UTIs, hydronephrosis, renal and bladder calcuili
Indwelling
Intermittent
Neuro complications - bladder dysfunction - catheterization program - Indwelling
Infection
Often unsatisfactory
Condom/Suprapubic catheter
Neuro complications - bladder dysfunction - catheterization program - Intermittent
Self cath
Emphasis on clean rather than sterile
Timed voiding program - autonomous bladder
Residual volume drainage - automatic bladder
Neuro complications - bowel dysfunction - control levels
Reflexic/Spastic
Areflexic/Flaccid
Neuro complications - bowel dysfunction - control levels - Reflexic/Spastic
Internal and sphincter relaxes reflexively when rectum is distended
SCI above S2
Neuro complications - bowel dysfunction - control levels - Areflexic/Flaccid
Incontinence due to flaccid sphincters; feces may become impacted
SCI S2-4 or cauda equina/peripheral nerves
Management of bowel dysfunction
Prevent constipation and impaction Promote regular BMS - Manual removal of stool - Digital stimulation - Suppository - Abdominal massage - High fiber diet - Meds, stool softener, laxative
Sexual dysfunction
Impaired sensation Impaired genital function Physical movements are difficult Fear of incontinence Anxiety
Sexual dysfunction - male erection
Psychogenic reflex (thoughts): T12 –L3 and S2-S4 Reflexogenic (genital stimulation): intact reflex arc in S2-S4
Sexual dysfunction - male ejaculation
Greater ability in LMN lesions (S2-4) and in incomplete injuries
Difficult in lesions above T12
Sexual dysfunction - male orgasm
Cerebral event
Varies with level and extent of injury
More likely with incomplete injury and those below T12
Sexual dysfunction - female UMN lesion
reflex arc intact so sexual arousal components (vaginal lubrication, clitoral erection) will occur. Psychogenic response is lost
Sexual dysfunction - female LMN lesion
psychogenic responses will be preserved but reflex responses lost
Fertility - men
Decreased fertility (erectile dysfunction/ impaired ejaculation/ low sperm count/ low motility)
Retrograde ejaculation
Physical aids for erectile dysfunction
Electro-ejaculation or by penile vibration
Fertility - Women
Fertility unchanged
Menstruation stops post injury, but resumes after 6 mths- 1 yr
Can become pregnant , carry baby full term and deliver vaginally
Risks of pregnancy: Autonomic dysreflexia, DVT, can go into labor without realizing it
Additional concerns: incontinence, spasms, respiratory problems
Secondary complications
Joint contracture OP Heterotopic ossification Orthostatic hypo DVT Decubitis ulcers UTI/Kidney infection Pulmonary infections
Osteoporosis
Imbalance in Ca deposition and re-absorption
Pattern of bone loss different from other conditions leading to OP
Most loss in 1st 6 months
Large amount of Ca in urinary system
Neuropathic loss vs. loss of normal forces of bone
Fracture risk
OP - management
Ca supplements
Weightbearing
Vibration
Heterotopic ossification
Abnormal bone formation in soft tissue around joints
Range from 10-53%
Associated with trauma, UTI, pressure sores
Heterotopic ossification SS
Swelling
warmth
Dec ROM
Low grade fever
Heterotopic ossification - PT consideration
ROM can be continued (gentle)
Avoid resistance or strenuous exercise
Active movements in pain free ROM
Heterotopic ossification - medical interventions
Anti-inflammatory meds may prevent
Pulse low intensity electromagnetic field may prevent
Surgery may eventually be needed
DVT -
Most common in the acute phase
Can become pulmonary embolus- cause of death
DVT - reduce risk by
Early mobilization
Compression hose
Thromboprophylaxis (anticoagulants)
Vena cava filter placement if anticoagulation therapy failed or is contraindicated
DVT - if suspected
Stop mobilization
Exercise is withheld for 72 hours till medical therapy
Medical referral
Doppler clearance / start of medication
BP considerations
Normal BP for patient with tetraplegia is 90/60 mm Hg
Normal BP for patient with paraplegia may also be lower than that seen in individuals without SCI
BP considerations - lower due to
lack of regulation of BP by sympathetic nervous system
lack of mm contractions
Autonomic dysreflexia - tx
If person is supine, immediately sit up the patient!!!
Loosen tight clothing
Survey for trigger sources- get rid of the cause (usually kink cath)
Monitor BP
PT management - goal
Achieve max functional independence
PT management - tx plan needs to
Promote max physiologic capacity
Provide compensation for deficits
Provide education of bx changes and comp strategies
PT exam
Sensory testing MMT ROM/tightness Resp system Integumentary system ASIA scale
Standardized measures - acute/sub acute (3-6 months)
FIM Spinal cord independence measure Walking index for SCI Sickness impact profile 68 Modified ashworth scal
Standardized measures chronic
Craig handicap assessment and reporting technqiue
Sickness impact profile 68
Wheelchair skills test
World health organization QOL - BREF
MMT considerations
Substitutions are done and often missed by the examiner
Fatigue gives the impression of less strength- do not do several repetition or exercise before MMT
Check one level above and one level below the suspected level of ‘normal function’
Common mm substitutions
1 Tenodesis = for finger flexors
2 Supination+ gravity = wrist extension
3 Shoulder external rotation + supination + gravity = elbow extension
Common mm substitutions - push ups in wc - SA and Delt
Serratus anterior = used for sitting push-ups with lower trapezius (scapular protraction= functional lengthening of UE)
Deltoid takes over in the absence of serratus anterior = winging of scapula = reverse action in closed chain = lifting of the buttocks
Common mm substitutions - push ups in wc - Trap
Lower trapezius - reverse action = actively lifts lower trunk
Neck flexors take over in the absence of lower trapezius = drop the head, passive lifting of pelvis through spine and tight connective tissue.
ROM considerations
Maintenance of ROM - passive ROM, functional positioning, splinting if needed, education
‘Normal’ may not be the goal
ROM considerations - neck
Avoid overstretching cervical extensors and use of thick pillows under the head in supine
Forward neck posture interferes with balance and respiration
ROM considerations - trunk
Avoid overstretching back extensors
Tight lumbar fascia provides passive trunk stability
Tight low back helps with rolling and transfers
Loose low back causes kyphotic posture- interferes with respiration and also causes sacral sitting
ROM considerations - Hamstring
SLR 110
Required for long sitting and ambulation with braces
DO NOT start long sit without SLR of 110 (will overstretch lumbar fascia)
ROM considerations - Ankle DF
0 ankle DF
Passive stability with feet flat on floor
Required for ambulation
ROM considerations - shoulder
Stretch pectorals and encourage hyperextension (not in injuries higher than C4)
Sitting support (UE swung behind for support)
Supine on elbows- assist to sitting position
Hooking onto wheelchair handles
External rotation ROM important
ROM considerations - elbow
Full elbow extension (especially if weak Triceps or spastic Biceps) & forearm supination-pronation
Required for all ADL skills
ROM considerations - wrist
Attain 90° of extension
Required for stability, linear weight bearingq
ROm cosniderations - fingers
Avoid stretching finger flexors with wrist extension
Fingers should flex with wrist extension and extend with wrist flexion = mild tightness
Avoid overstretching the thumb web space
Mat mobility skills
Orthotic spinal stabilization
Rolling
Supine/side lying to sitting and reverse
Long sitting with scooting
WC posture - poor seated posture
Improper weight bearing Sacral sitting Lumbar kyphosis (& all the resultant effects) Less effective wheelchair mobility Poor social interaction Poor self image
WC Rx - support surface
Relieve shear forces as patient moves Conform to bone prominences Not have resistance and allow body immersion Adequate support to entire surface Provide adequate comfort Prevent skin breakdown Pressure maps
Info for WC Rx
Goals of the patient Environment in which wheelchair used Changing conditions- wt, recovery Assistance required for transfers/propelling Insurance Physical characteristics of the owner
WC skills
Transfers
Pressure relief techniques
Wheelies- curb jumping
Maneuvering- doors, ramps, stairs, escalators
WC recommendations - C1-4
power wheelchair with mouth-stick activities
WC recommendations C 5
electric wheelchair with hand controls; manual wheelchair with quad peg for short distances (indoors)
WC recommendations C6 and below
manual wc
SCI gait
Energey cost of locomotion is huge!
SCI gait - purpose
Functional gait
Stretching of muscles
Weight bearing
Good emotional boost
SCI gait - pre gait activiteis
Orthosis Standing balance in parallel bars Strengthening Pelvic control Push-ups
SCI gait training
Swing to/ through gait Gait training on crutches Transfer from wheelchair to crutches Recovery from a fall with crutches Stair case climbing with crutches
Psycho-social considerations
Each pt is unique and reacts differently
Many stressors are present
Psycho-social considerations - consider referral to counseling for
vocational rehab
b/b programs
sexual function
child bearing
Stages of emotional recovery
Shock – Denial – Grief – Anger – Acceptance/adaptive reconciliation - Goal directed behavior
Stages of emotional recovery - our role as PT
Listen to what the patient is saying verbally and non-verbally
Be receptive to questions and concerns
Be honest about what you do not know (and are willing to find out)
Educate family
Tailor goals after discussing with patient
Functional outcomes - factors that influence the expected functional outcomes
Level and extent of injury Psychological state (motivated/ anxious) Body type (weight/ height) Pre-existing medical conditions (DM/ HT) Associated injuries (wounds/ fractures/ infections) Secondary complications Resources (support systems) Environment
Ped - SCI most common
Paraplegia common 0-12
Quad common 13-21
with complete/incomplete more similar
Ped - Scoliosis
Neuromuscular scoliosis- occurs frequently. <12 y/o then 3.7 times more likely need spinal fusion
Ped - hip sublux
Hip subluxation-occurs in 100% of children injured <5 y/o and 94% injured <10 y/o.
Ped - autonomic dysreflexia
Unable to detect autonomic dysreflexia or other symptoms (fever, change in spasticity, headache, sweating)
Ped - patho/anatomic differences
SCI w/o radiographic abnormality - 64%
Delayed onset of SCI for 30 min to 4 days post injury
Ped exam - considerations
Age - present and at time of injury
Development and maturation of child
Other injuries or cog delay
Ped exam - musculoskeletal
Consider skeletal maturity and alignment, Pain: Wong-Baker FACES Pain Scale
Ped exam - neuro
functional strength testing for younger child; Pediatric Balance Scale; Functional Reach; Ashworth
Ped exam - acitvity and participation measures
May use Adult Spinal Cord Independence Measure (SCIM)
Pediatric Wee-FIM
Pediatric Evaluation and Disability Inventory (PEDI)
Pediatric Powered Wheelchair Screening Test
Pediatric AOL
School Function Assessment (SFA)
Ped interventions
Learning new skills vs relearning Must be age appropriate Readiness of independence Function in school and community Consider sexuality and reproductive health Periodic re-evaluations with growth and readiness to learn Transfers Floor play Orthotics WC Endurance
Psychosocial aspects of ped SCI
Fear of returning to play and friends
Lack of understanding this is a permanent condition
Loss of independence in teens
Parent guilt
