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Semester 5 PMNM Exam 8 > Spinal Cord Injury 2 > Flashcards

Spinal Cord Injury 2 Flashcards

1
Q

Rehab considerations

A 
Level of injury
Complete or Incomplete
Shortened length of hosp. stays
Pts prior level of function
MOTIVATION!
Age
Physical condition
Family support
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2
Q

Length of stay

A

Acute - 11 days

Rehab - 36 days

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3
Q

Examination

A

ASIA scale

Supplement with other assessment tools

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4
Q

Examination - ASIA scale

A

International standardization

Ensure consistency in measurement technique, data and communication

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5
Q

Examination - ASIA scale - major drawback

A

Only clinically “essential data” is considered

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6
Q

ASIA definitions - Neurological Level

A

Thoe most caudal segment with normal sensory and motor function on both sides of the body

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7
Q

ASIA definitions - Skeletal level

A

The level at which the greatest vertebral damage is found by radiographic examination

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8
Q

ASIA definitions - Motor level

A

The lowest key mm that has grade 3 or more as muscle power and all mm receiving innervations from above that level are normal

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9
Q

ASIA definitions - Complete injury

A

No sensory or motor function in the lowest sacral segment

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10
Q

ASIA definitions - Incomplete injury

A

Partial preservation of sensory and/or motor functions below the neurological level and the sacral segment

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11
Q

ASIA definitions - Zone of partial preservation

A

Includes the dermatomes and myotomes that remain innervated caudal to the level of injury in complete injuries ONLY

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12
Q

ASIA Grade A

A

Complete - no sensory or motor function is preserved in the sacral segment S4-S5

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13
Q

ASIA Grade B

A

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

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14
Q

ASIA Grade C

A

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

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15
Q

ASIA Grade D

A

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

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16
Q

ASIA Grade E

A

Normal

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17
Q

Neuro complications

A 
Dec motor func
Dec sens func
Altered mm tone
Altered temp reg
Resp problems
B/B dysfunction
Sexual dysfunction
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18
Q

Neuro complications - Decreased motor function

A

Maintain ROM
Maintain mm mass
Understand functional capabilities that are feasible

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19
Q

Neuro complications - Decreased sensory function

A 
Decubitis ulcers
In the hospital - pt turned every 2 hours
WC cushions
Pressure relief techniques
Safe techniques with transfers
Education
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20
Q

Neuro complications - altered mm tone

A

Spinal shock
Spasticity (2/3 of all SCI - more prevalent in C and T)
Disabling
Affects QOL and can lead to fucntional dependence

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21
Q

Neuro complications - altered mm tone - Spastic hypertonia (UMN)

A

Spasticity, mm spasm, hypertonia, increase DTR, clonus

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22
Q

Neuro complications - altered mm tone - Management

A 
Weight bearing
PROM 
Medications
Baclofen pump
Botox injection
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23
Q

Neuo complications - respiratory function C1 -3

A

Weak mm in addition to those seen in paraplegia (pecs, sa, scalenes, traps, SCM, diaphragm)
All planes of ventilation are limited

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24
Q

Neuo complications - respiratory function C1 -3 - results in

A

significant dec in tidal volume and vital capacity

95% require mechanical vent

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25
Q

Neuo complications - respiratory function C4

A

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

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26
Q

Neuo complications - respiratory function C4 - results in

A

dec tidal volume

May require mechanical vent

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27
Q

Neuo complications - respiratory function C5 - 8

A

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

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28
Q

Neuo complications - respiratory function C5 - 8 - results in

A

Dec VC
Dec FEV
Dec cough effetiveness
Paradoxical breathing

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29
Q

Neuo complications - respiratory function T1-T5

A

Weak/absent abdominals, intercostals, erector spinae

Limited planes of vent - dec in ant/lat exp

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30
Q

Neuo complications - respiratory function T1-T5 - results in

A

Slight-mogerate dec in vital capacity
Dec effective cough
May show paradoxical breathing

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31
Q

Pulmonary intervention

A

Suctioning and chest PT
Breathing ex
Incentive spirometer
Quad cough

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32
Q

Pulmonary intervention - if pt becomes breathless

A

lay them down so gravity is not effecting them as much

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33
Q

Pulmonary intervention - quad cough

A

Assisted cough for weak abs
Lay pt down
Assist with expiration - place hand below xiphoid process

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34
Q

Neuro complications - Altered temp regulation

A

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

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35
Q

Neuro complications - Altered temp regulation SS

A

HA
Nasal congestion
Tiredness
Reduced concentration

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36
Q

Neuro complications - Altered temp regulation - tx

A

Sponging with cold water
Drink lots of water
Education

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37
Q

Neuro complications - bladder dysfunction - two levels of control

A

Spinal reflex center of micturition - conus medullaries S2 - 4
Pontine micturition center - integreate the reflex, coordinated contraction of detrusor mm and sphinter relaxation

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38
Q

Neuro complications - bladder dysfunction - two types of bladder dysfunctions

A

spastic

flaccid

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39
Q

Neuro complications - bladder dysfunction - spastic bladder -

A

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

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40
Q

Neuro complications - bladder dysfunction - flaccid bladder

A

areflexic bladder (LMN bladder)
Lesion of conus/cauda equina - reflex center absent
Urinary retention
Emptying by vasalva, manual compression, self cath

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41
Q

Neuro complications - bladder dysfunction - catheterization program

A

Prevent UTIs, hydronephrosis, renal and bladder calcuili
Indwelling
Intermittent

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42
Q

Neuro complications - bladder dysfunction - catheterization program - Indwelling

A

Infection
Often unsatisfactory
Condom/Suprapubic catheter

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43
Q

Neuro complications - bladder dysfunction - catheterization program - Intermittent

A

Self cath
Emphasis on clean rather than sterile
Timed voiding program - autonomous bladder
Residual volume drainage - automatic bladder

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44
Q

Neuro complications - bowel dysfunction - control levels

A

Reflexic/Spastic

Areflexic/Flaccid

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45
Q

Neuro complications - bowel dysfunction - control levels - Reflexic/Spastic

A

Internal and sphincter relaxes reflexively when rectum is distended
SCI above S2

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46
Q

Neuro complications - bowel dysfunction - control levels - Areflexic/Flaccid

A

Incontinence due to flaccid sphincters; feces may become impacted
SCI S2-4 or cauda equina/peripheral nerves

47
Q

Management of bowel dysfunction

A 
Prevent constipation and impaction
Promote regular BMS
- Manual removal of stool
- Digital stimulation
- Suppository
- Abdominal massage
- High fiber diet
- Meds, stool softener, laxative
48
Q

Sexual dysfunction

A 
Impaired sensation
Impaired genital function
Physical movements are difficult
Fear of incontinence
Anxiety
49
Q

Sexual dysfunction - male erection

A 
Psychogenic reflex (thoughts): T12 –L3 and S2-S4
Reflexogenic (genital stimulation): intact reflex arc in S2-S4
50
Q

Sexual dysfunction - male ejaculation

A

Greater ability in LMN lesions (S2-4) and in incomplete injuries
Difficult in lesions above T12

51
Q

Sexual dysfunction - male orgasm

A

Cerebral event
Varies with level and extent of injury
More likely with incomplete injury and those below T12

52
Q

Sexual dysfunction - female UMN lesion

A

reflex arc intact so sexual arousal components (vaginal lubrication, clitoral erection) will occur. Psychogenic response is lost

53
Q

Sexual dysfunction - female LMN lesion

A

psychogenic responses will be preserved but reflex responses lost

54
Q

Fertility - men

A

Decreased fertility (erectile dysfunction/ impaired ejaculation/ low sperm count/ low motility)
Retrograde ejaculation
Physical aids for erectile dysfunction
Electro-ejaculation or by penile vibration

55
Q

Fertility - Women

A

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

56
Q

Secondary complications

A 
Joint contracture
OP
Heterotopic ossification
Orthostatic hypo
DVT
Decubitis ulcers
UTI/Kidney infection
Pulmonary infections
57
Q

Osteoporosis

A

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

58
Q

OP - management

A

Ca supplements
Weightbearing
Vibration

59
Q

Heterotopic ossification

A

Abnormal bone formation in soft tissue around joints
Range from 10-53%
Associated with trauma, UTI, pressure sores

60
Q

Heterotopic ossification SS

A

Swelling
warmth
Dec ROM
Low grade fever

61
Q

Heterotopic ossification - PT consideration

A

ROM can be continued (gentle)
Avoid resistance or strenuous exercise
Active movements in pain free ROM

62
Q

Heterotopic ossification - medical interventions

A

Anti-inflammatory meds may prevent
Pulse low intensity electromagnetic field may prevent
Surgery may eventually be needed

63
Q

DVT -

A

Most common in the acute phase

Can become pulmonary embolus- cause of death

64
Q

DVT - reduce risk by

A

Early mobilization
Compression hose
Thromboprophylaxis (anticoagulants)
Vena cava filter placement if anticoagulation therapy failed or is contraindicated

65
Q

DVT - if suspected

A

Stop mobilization
Exercise is withheld for 72 hours till medical therapy
Medical referral
Doppler clearance / start of medication

66
Q

BP considerations

A

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

67
Q

BP considerations - lower due to

A

lack of regulation of BP by sympathetic nervous system

lack of mm contractions

68
Q

Autonomic dysreflexia - tx

A

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

69
Q

PT management - goal

A

Achieve max functional independence

70
Q

PT management - tx plan needs to

A

Promote max physiologic capacity
Provide compensation for deficits
Provide education of bx changes and comp strategies

71
Q

PT exam

A 
Sensory testing
MMT
ROM/tightness
Resp system
Integumentary system
ASIA scale
72
Q

Standardized measures - acute/sub acute (3-6 months)

A 
FIM
Spinal cord independence measure
Walking index for SCI
Sickness impact profile 68
Modified ashworth scal
73
Q

Standardized measures chronic

A

Craig handicap assessment and reporting technqiue
Sickness impact profile 68
Wheelchair skills test
World health organization QOL - BREF

74
Q

MMT considerations

A

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’

75
Q

Common mm substitutions

A

1 Tenodesis = for finger flexors
2 Supination+ gravity = wrist extension
3 Shoulder external rotation + supination + gravity = elbow extension

76
Q

Common mm substitutions - push ups in wc - SA and Delt

A

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

77
Q

Common mm substitutions - push ups in wc - Trap

A

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.

78
Q

ROM considerations

A

Maintenance of ROM - passive ROM, functional positioning, splinting if needed, education
‘Normal’ may not be the goal

79
Q

ROM considerations - neck

A

Avoid overstretching cervical extensors and use of thick pillows under the head in supine
Forward neck posture interferes with balance and respiration

80
Q

ROM considerations - trunk

A

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

81
Q

ROM considerations - Hamstring

A

SLR 110
Required for long sitting and ambulation with braces
DO NOT start long sit without SLR of 110 (will overstretch lumbar fascia)

82
Q

ROM considerations - Ankle DF

A

0 ankle DF
Passive stability with feet flat on floor
Required for ambulation

83
Q

ROM considerations - shoulder

A

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

84
Q

ROM considerations - elbow

A

Full elbow extension (especially if weak Triceps or spastic Biceps) & forearm supination-pronation
Required for all ADL skills

85
Q

ROM considerations - wrist

A

Attain 90° of extension

Required for stability, linear weight bearingq

86
Q

ROm cosniderations - fingers

A

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

87
Q

Mat mobility skills

A

Orthotic spinal stabilization
Rolling
Supine/side lying to sitting and reverse
Long sitting with scooting

88
Q

WC posture - poor seated posture

A 
Improper weight bearing
Sacral sitting
Lumbar kyphosis (&amp; all the resultant effects)
Less effective wheelchair mobility
Poor social interaction
Poor self image
89
Q

WC Rx - support surface

A 
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
90
Q

Info for WC Rx

A 
Goals of the patient
Environment in which wheelchair used
Changing conditions- wt, recovery
Assistance required for transfers/propelling
Insurance
Physical characteristics of the owner
91
Q

WC skills

A

Transfers
Pressure relief techniques
Wheelies- curb jumping
Maneuvering- doors, ramps, stairs, escalators

92
Q

WC recommendations - C1-4

A

power wheelchair with mouth-stick activities

93
Q

WC recommendations C 5

A

electric wheelchair with hand controls; manual wheelchair with quad peg for short distances (indoors)

94
Q

WC recommendations C6 and below

A

manual wc

95
Q

SCI gait

A

Energey cost of locomotion is huge!

96
Q

SCI gait - purpose

A

Functional gait
Stretching of muscles
Weight bearing
Good emotional boost

97
Q

SCI gait - pre gait activiteis

A 
Orthosis
Standing balance in parallel bars
Strengthening
Pelvic control
Push-ups
98
Q

SCI gait training

A 
Swing to/ through gait
Gait training on crutches
Transfer from wheelchair to crutches
Recovery from a fall with crutches
Stair case climbing with crutches
99
Q

Psycho-social considerations

A

Each pt is unique and reacts differently

Many stressors are present

100
Q

Psycho-social considerations - consider referral to counseling for

A

vocational rehab
b/b programs
sexual function
child bearing

101
Q

Stages of emotional recovery

A

Shock – Denial – Grief – Anger – Acceptance/adaptive reconciliation - Goal directed behavior

102
Q

Stages of emotional recovery - our role as PT

A

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

103
Q

Functional outcomes - factors that influence the expected functional outcomes

A 
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
104
Q

Ped - SCI most common

A

Paraplegia common 0-12
Quad common 13-21
with complete/incomplete more similar

105
Q

Ped - Scoliosis

A

Neuromuscular scoliosis- occurs frequently. <12 y/o then 3.7 times more likely need spinal fusion

106
Q

Ped - hip sublux

A

Hip subluxation-occurs in 100% of children injured <5 y/o and 94% injured <10 y/o.

107
Q

Ped - autonomic dysreflexia

A

Unable to detect autonomic dysreflexia or other symptoms (fever, change in spasticity, headache, sweating)

108
Q

Ped - patho/anatomic differences

A

SCI w/o radiographic abnormality - 64%

Delayed onset of SCI for 30 min to 4 days post injury

109
Q

Ped exam - considerations

A

Age - present and at time of injury
Development and maturation of child
Other injuries or cog delay

110
Q

Ped exam - musculoskeletal

A

Consider skeletal maturity and alignment, Pain: Wong-Baker FACES Pain Scale

111
Q

Ped exam - neuro

A

functional strength testing for younger child; Pediatric Balance Scale; Functional Reach; Ashworth

112
Q

Ped exam - acitvity and participation measures

A

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)

113
Q

Ped interventions

A 
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
114
Q

Psychosocial aspects of ped SCI

A

Fear of returning to play and friends
Lack of understanding this is a permanent condition
Loss of independence in teens
Parent guilt

Semester 5 PMNM Exam 8 (8 decks)

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