Spinal Cord Injury Flashcards
complications with SC injury
•autonomic dysreflexia cardiovascular impairment •including postural hypotension •impaired temp control •pulmonary impairment • bowel and bladder dysfunction
most common PI areas with SC patients
- ischium
- sacrum
- trochanter
- bony areas of feet
- heels
PI and SCI
- Decreased mobility, activity, sensation, spasticity B+B incontinence, nutritional deficiencies contribute to pressure injuries
- Patients should be checked with the Braden scale and palpation for increased skin temp due to hyperemia should be checked as well as areas under orthotic contact points. (p. 871)
- In bed patients should be re-positioned every 2 hours
- Patients should perform a pressure relief maneuver every 15 minutes in the wheelchair by doing a push up, leaning sideways or leaning forward
- All pressure relief maneuvers should be held for at least 2 minutes to be effective (p. 874-875)
Pressure relief maneuvers
- If using a forward lean pressure relief weight shift, the lean should be greater than 45 degrees
- Patients who cannot perform pressure relief may be assisted or wheelchair tilted back- if tilted back it should be at least 65 degrees to remove pressure from ischial tuberosities
Heterotopic ossification
- bone growth in soft tissues usually near the joints (esp. hips and knees) below the level of the lesion
- Factors associated with heterotopic ossification include: complete injury, trauma, severe spasticity, UTI, pressure injuries, and vigorous PROM that causes trauma.
- Early symptoms include swelling , joint and muscle pain, decreased ROM, erythema, and local warmth near the joint.
- Management includes: pharmacologic such as bisphosphonates and NSAIDS, PT- maintaining ROM, pulsed low- intensity electromagnetic field and surgical excision if there is resultant extreme limitations of activities.
SCI pt bone mineral and fx risk
- SCI patients experience rapid bone mineral loss in the first 4-6 months after injury and continues to decrease up to 3 years post injury
- Risk factors for fracture include: female, lower BMI, complete injury, paraplegia vs. tetraplegia, longer time since injury.
- Falls or a forced maneuver during transfer, ADL, such as dressing and stretching are common activities that precipitate fracture.
- Interventions: pharmacological- bisphosphonates, electrical stimulation, weight bearing activities with standing frame or orthotics and assistive devices.
Contracture prevention
•A consistent program of ROM exercise, positioning and splinting are important to maintain joint motion and prevent contracture (p. 867-868)
Contracture risk with SCI patients
Factors that place SCI patients at high risk for developing contractures: lack of active muscle function, eliminating the normal reciprocal stretching of a muscle group and surrounding structures, spasticity, positioning in a wheelchair for prolonged periods of time and abnormal muscle tone.
Early mobility interventions post SCI
- gradual return to vertical
- s/s of OH: dizziness, nausea, ringing in the ears, loss of vision or conciousness
- Use of abdominal binder and elastic stockings
- Patient should be brought to supine position or trunk reclined with LE’s elevated if any s/s of OH is experienced
- ROM and strengthening
Avoid stress on unstable site in the lumbar region
To avoid stress on an unstable site in the lumbar region, SLR may be restricted to no more than 60 degrees and hip flexion (during combined hip and knee flexion) limited to no greater than 90 degrees
With an unstable cervical spine motion may be limited
With an unstable cervical spine, motion of the head and neck may be contraindicated and shoulder flexion and abduction limited to no more than 90 degrees.
HS functional length
Some muscles require such as hamstrings eventually require a fully lengthened range for an SLR of 100 degrees for functional activities such as long sitting and LE dressing; but the hamstrings should not be overstretched as they provide pelvic stabilization in sitting -> selective stretching
Head-hips relationship
moving the head in one direction in order to cause the movement of hip sin the opposite direction
principles of compensatory strategies in mobility
- head-hips relationship
- momentum
- muscle substitution
- task modification
- working in and out of the task
SCI level requiring power w/c
SCI with C4 lesions and above require power w/c
SCI level that may elect to use a power w/c
SCI with C5 lesion may elect to use a power W/C esp. for community mobility
level of SCI able to propel a manual w/c
A SCI with a C5 or C6 level injury may be able to independently propel a manual W/C but may not have the strength or endurance for community W/C mobility.
SCI level can independently propel a manual w/c
A SCI with intact triceps (C7) can independently propel a manual wheelchair
two basic frames for manual w/c
1) Folding frame: for those who plan to transfer to a car because they can be folded for storage without having to remove as many parts and provide a smoother ride on uneven surfaces. Disadvantages= heavier and more movable parts causing it to be less energy efficient.
2) Rigid frame: lighter, more energy efficient, may have an adjustable seat to back angle and is more durable than a folding frame.
Disadvantages= More difficult to store in a car- both wheels must be removed.
Wheel locks
High mounted wheel locks are easier to access but can be an obstacle to transfers. Low mounted wheel locks are more difficult to access but are not in the way of transfers
Wheelies and GB
when patients are practicing wheelies, a GB should be looped through the frame of the w/c
other w/c skills SCI patients should learn
Other W/C skills SCI patients should learn include: falling from a W/C, picking up objects off the floor, opening and closing doors, negotiating obstacles, putting wheel locks on and off, removing and returning leg rests, folding the W/C, removing the cushion, moving armrests, and removing and putting the wheels back on
SCI and rolling
- Rolling (pgs 890-891) is a prerequisite skill for other bed mobility tasks- the patient learns to use the head, neck UE’S as well as momentum to move the trunk and/or LE’s
- It is usually easiest to begin rolling from the supine position
- If asymmetric involvement is present rolling should be initiated to the weaker side
- Flexion of the head and neck with rotation assists movement from supine to prone
- Extension of the head and neck with rotation is used to assist movement from prone to supine
- Crossing the ankles facilitates rolling- therapist should cross patients ankles so that the upper limb is in the direction of the roll, i.e. right ankle crossed over left to roll to the left
transfers and SCI
- The head-hips relationship is important . Moving the head and upper trunk in one direction cause the lower trunk and buttocks to move in the opposite direction
- Hand position is important. The hands should be positioned forward of the hips to form a tripod with the buttocks.
- Greater force is generated in the trailing UE (furthest from the surface transferring to.
- If one UE is weaker or more painful, it should be the lead UE.
- The lead UE should be farther from the trunk and buttocks and the trailing UE closer to the trunk/ buttocks
- Emphasis should be placed on lifting and shifting laterally instead of sliding/ scooting to the side to avoid shearing
SCI and pressure
- patients should be checked with the Braden scale and palpation for increased skin temp due to hyperemia should be checked as well as areas under orthotic contact
- in bed patients should be re-positioned every 2 hours
- patients should perform a pressure relief maneuver every 15 minutes in the w/c by doing a push up, leaning sideways, or leaning forwards.
- if using a forward lean then the lean should be >45°
- patients who cannot perform pressure relief may be assisted or w/c tilted back- if tilted back angle should be at least 65° or more to decrease pressure on ischial tuberosities
- all pressure relief maneuvers should be held for at least 2 minutes to be effective
- also check under Halos and orthotics
DVT vs heterotopic ossification
DVT susceptible due to loss of muscle pump and heterotopic ossification are common. Similar s/s (redness, edema) but HO presents with decreased ROM (usually occurs near joints most common at hip and knee)
Heterotopic ossification
osteogenesis in soft tissue (especially hip and knee) below the level of the lesion. Factors associated with HO include: complete injury, trauma, severe spasticity, UTI, and PI + vigorous PROM that results in trauma.
•early s/s include: swelling, joint and muscle pain, decreased ROM, erythema, and local warmth near the joint
•management includes: pharmocological such as biphosphonates and NSAIDS as well as PT treatment such as maintaining ROM, pulsed, low intensity electromagnetic field, and surgical excision if there is resultant extreme limitations of activities
•NSAIDS can help with prevention
secondary possible complications following a SCI
Osteoporosis/skeletal fx/renal calculi
•osteoporosis will be greatest during the first 4 to 6 months then will continue to decrease up to 3 years post injury
• consider osteoporosis during transfers. Some cervical injuries may have osteoporotic UEs
• calcium leaving the bones (due to no muscle pull and decreased WB) can cause kidney stones (renal calculi), which leads to GU problems, which can trigger autonomic dysreflexia
bone mineral loss with SCI and fx risk
SCI patients experience rapid bone mineral loss in the first 4 to 6 months post injury and this will continue to decrease up to 3 years
• risk factors for fx include female, decreased BMI, complete injury, paraplegia vs. tetraplegia, increased time since injury
• falls or a forced maneuver during transfers, ADLs, and stretching are common activities for fx
• Interventions: biphosphonates, e-stim, WB with standing frame and orthotics, and AD
Contractures with SCI
- factors that place SCI patients at increased risk for contractures: lack of active muscle function, eliminating normal reciprocal stretching of a muscle group, spasticity, positioning in a w/c for prolonged time, abnormal muscle tone
- ROM, positioning, and splinting are always helpful options to prevent contractures
Acute SCI medical management
- first responders should ask for s/s of SCI: parasthesisas, lack of movement abilities, decreased sensation, spinal pain, and cognitive function because head injuries often accompany SCI (especially cercical)
- when SCI is suspected both PROM and AROM of spine is dangerous - first responders immobilize
- Halo are often used to limit cervical motion (let RN know id patient is able to move/moving their head)
Stryker frame
the big rotating full body device that decreases risk of skin care
early mobility interventions
- gradual return to vertical- due to venous and abdominal stasis/pooling you will probably see OH
- s/s of OH: dizziness, nausea, ringing in the ears, LOC, or loss of vision
- to help with OH use abdominal binder and stockings, bring the pt to vertical slowly (elevate HOB, tilt table, reclining w/c etc.)
- if pt displays s/s of OH they should be brought back to supine or trunk reclined position with LE’s elevated
SCI ROM and strengthening
- you have to know whether or not the spine is stable and if there are any restrictions in motion
- for cervical know about UE for throracic/lumbar know about LE restrictions
Instability with SCI
- if the fx site is designated as unstable, then ROM. or strengthening exercises are contraindicated
- to avoid stress on an unstable site in the lumbar region, SLR may be restricted to less than 60°, and hip flexion (during combined hip and knee flexion), limited to less than 90°
- with an unstable cervical spine motion of the head and neck may be contraindicated and shoulder flexion and abduction limited to less then 90°
- some joints such as the lower trunk benefit from allowing tightness to develop to increase function i.e. improved sitting posture. Tightness of the long finger flexors provides an improved tenodesis grasp (especially important for C6)
- some muscles such as the HS eventually require a fully lengthened range for a SLR of 100° for functional activities such as long sitting and LE dressing; but the HS should not be overstreched as they provide pelvix stabilization in sitting so perform selective stretching.
Functional expectations
table 20.5
function of C1-C5
- C1 + C2= no diaphragm=ventilator
- C2= little diaphragm but not much
- C4= diaphragm= off ventilator
- C5 may be able to drive
Complete SCI
no motor or sensory function in the lowest sacral segments (S4 and S5), with no sacral sparing (determined by sensory function of S4-S5 dermatome, ability to feel deep anal pressure, or voluntary sphincter contraction)
Incomplete SCI
motor and/or sensory function below the neurological level that includes sensory and/or motor function at S4 and S5 with presence of sacral sparing
Zones of partial preservation
if an individual has motor and/or sensory function below the neurological level but does not have sacral sparing, then the areas of intact motor and/or sensory function below the neurological level are termed zones of partial preservation.
Type A AIS SCI
Complete: no motor or sensory function is preserved in the sacral segments S4 and S5
Type B AIS SCI
Sensory incomplete: sensory but not motor function is preserved below the neurological level and includes the sacral segments S4 and S5 (light touch or pin prick at S4-S5 or deep anal pressure) and no motor function is preserved more than 3 levels below the motor level on either side of the body
Type C AIS SCI
Motor Incomplete: motor function is preserved at the most caudal sacral segments for voluntary anal contraction OR the patient meets the criteria for sensory incomplete status and has some sparing of motor function more than 3 levels below the ipsilateral level on either side of the body (this includes key or non-key muscle functions to determine motor incomplete status) for AIS (ASIA impairment scale) C less than 1/2 of key muscle functions below the single neuro level of injury (NLI) having a muscle grade of more than or equal to 3.
Type D AIS SCI
Motor Incomplete: motor incomplete status as defined above, with more than or equal to 1/2 of key muscle functions below the single NLI having a muscle grade of more than or equal to 3
Type E AIS SCI
Normal: if sensation and motor function as tested with the AIS grade are graded as normal in all segments and the pt had prior deficits. Someone without an initial SCI does not receive an AIS grade
Brown-Sequard syndrome
occurs from hemisection of the SC (damage to one side) and is typically caused by penetration wounds- gunshot or stab wound. The clinical features are asymmetrical. On the ipsilateral side as the lesion, there is paralysis and sensory loss. The ipsilateral loss of proprioception, light touch, and vibratory sense is due to dorsal column damage; paralysis results from lateral corticospinal damage. Damage to the spinothalamic tract results in loss of sense of pain and temp on the contralateral side to the lesion (lateral spinothalamic tract only ascends 2-4 levels on the same side before crossing, while the descending motor tract crosses in the medulla).
• Typically Brown-sequard syndrome patients achieve good functional gains during inpatient rehab.
Anterior cord syndrome
frequently related to flexion cervical injuries with damage to the anterior SC and/or its vascular supply from the anterior spinal artery. Characterized by loss of motor function (corticospinal tract) and loss of sense of pain and temp (spinothalamic tract). Proprioception, light touch, and vibratory sense are generally ok, cause they are mediated by the dorsal columns (vascular supply from posterior spinal arteries). These patients typically require increased length of stay during inpatient rehab compared to other SC injuries
Central cord syndrome
most common SCI syndrome. Generally occurs from hyperextension injuries in cervical region. It has been associated with congenital or degenerative spinal stenosis (narrowing of SC). The resultant (compressive forces give rise to hemorrhage and edema, producing damage to the most central part of the SC. Characteristic increased UE involvement (UE’s more medial in SC tracts) vs. LE. Sensory deficits vary but tend to be less involved than motor with preservation of sacral tracts (lateral), normal sexual and bowel and bladder dunction may remain. Patient’s with central cord syndrome generally recover ability to ambulate. Some distal UE weakness and loss of fine motor control remain.
Cauda Equina
below L1 collection of nerve roots. Cauda equina injuries are typically incomplete. Exhibit areflexive bowel and bladder as well as saddle anesthesia. LE paralysis and/or paresis is variable. LMN injury so potential to regenerate, however, full return is not common because (1) large distance between lesion and point of innervation (nerves retract when severed) (2) axonal regeneration may not occur along the original distribution of the nerve (3) regeneration blocked by scarring (4) end organ may no longer be functioning by the time regeneration occurs (5) rate of regeneration slows then finally stops after approximately 1 year.
Posterior cord syndrome
patients have conscious but not unconscious proprioception i.e they have to look at the part
Autonomic Dysreflexia
•Pathologic autonomic reflex 45% usually above T6
•Initiating stimuli:
- bladder or bowel distension/irritation
- stimuli that would normally be painful below level of injury
- GI irritation
- sexual activity
- labor
- fracture
- e-stim
•S/S: HTN (increased systolic BP 20-30 mmHG), Bradycardia, HA, anxiety, constricted pupils, blurred vision, flushing/pilloerection above the level of the lesion, dry/pale skin below the level of lesion (due to vasoconstriction), nasal congestion, increased spasticity, may be asymptomatic
• more common during chronic stage following SCI 3-6 months post injury
•more common with complete injuries
•TX: get patient upright, loosen tight clothing, check catheter.
OH s/s
•ringing in the ears, blurred vision, lightheadedness, and syncope
TX: abdominal binder, stockings, lay down (opposite tx of autonomic dysreflexia)
Weight shift parameters
- forward lean more than or equal to 45°
- backward lean more than or equal to 65°
- maintain at least 2 minutes
Instability movement precautions
- lumbar instability= SLR less than or equal to 60°, and combined hip and knee flexion not more than 90°
- cervical instability= no head or neck motion, keep shoulder flexion and abduction under 90°
HS mobility
HS should be flexible enough to allow long sitting functional ADLs i.e. 100° of hip flexion ability
Using ND AIS
to document the sensory, motor, and NLI levels, the ASIA impairment scale grade, and/or the zone of partial preservation (ZPP) when they are unable to be determined based on the exam results
functional expectations: C1, C2, C3, C4
Motor Level: face and neck muscles, cranial nerve innervation, diaphragm (partial innervation at C3 and C4)
Available Movements: talking, mastication, slipping, blowing, scapular elevation.
Equipment and Assistance Required:
ADLs:
-dependent
Dependence in ADLs:
-environmental control units (ECU)
- brain- computer interface (BCI)
- adaptive equipment such as head or mouth stick
•Bowel and bladder:
- Full time attendant required, directs care provided by attendants
W/C mobility and pressure relief:
- independent with power w/c, typical components include adaptive controls such as head, chin, tongue, or sip-and-puff control, electronically controlled seating system (tilt and/or recline)
- w/c cushion and head/trunk support
- portable ventilator (depending on innervation of diaphragm)
- dependent with positioning in w/c
Bed Mobility:
- dependent
- adjustable bed with pressure-reducing mattress
- direct care provided by attendants
Transfers:
- dependant, attendants use mechanical lift, directs care provided by attendants
Ambulation & Driving:
- unable
Functional Expectations: C5
Motor Level:
- biceps, brachialis, brachioradialis, deltoid, infraspinatus, rhomboid major and minor, supinator
Available Movements:
elbow flexion, and supination, shoulder ER, shoulder ABD and flexion to approximately 90°
Equipment and functional capabilities:
ADL and feeding:
- some assistance and/or setup required, depending on the activity
Grooming, washing face, and oral hygiene:
-mobile arm supports, deltoid aid, adapted utensils and splinting
Bathing and Dressing:
- dependent, adapted equipment
Bowel and bladder:
- dependent, directs care provided by attendants
W/C mobility and pressure relief:
- independent to some assist with manual w/c on level surfaces, requires plastic-coated hand rims/ extensions
- benefits from power-assist w/c
- independent with power w/c using handheld joystick
- an electronically controlled seating system (tilt and/or recline)
- w/c cushion and trunk support, dependent with positioning in w/c
- manual w/c: independent to some assistance indoors on level surfaces, some/total assistance outdoors
Bed mobility:
- assistance to dependence
- adjustable bed wit pressure-reducing mattress
- bed rails and loops
Transfers:
- dependent, attendants use mechanical lift
- directs care provided by attendants
- may be able to perform with assistance and transfer board
Ambulation: unable
Driving: independent with van with adaptive controls
Functional Expectations: C6
Motor Level: extensor carpi radialis, infraspinatus, latissimus dorsi, pec major (clavicular portion), pronator teres, serratus anterior, teres minor
Available Movements:
shoulder flexion, extension, internal rotation, and adduction, scapular abduction, protraction, and upward rotation, forearm pronation, wrist extension, tenodesis grasp
Equipment and Assistance Required:
ADL and feeding:
-assistance to independent with setup and/or equipment
Grooming, washing face, and oral hygiene:
- universal cuff, adaptive utensils
Dressing and bathing:
- upper body: independent with adaptive equipment
- lower body: assistance with adaptive equipment
Home management:
- part time attendant required
Bowel and bladder:
- may be able to be independent with adaptive equipment, likely to acquire assistance/dependent
W/C mobility and pressure relief:
- independent with manual w/c on level surfaces and independent/some assistance in community
- may require power w/c in community
- requires plastic-coated hand rims/extensions
- may benefit from power-assist w/c
Bed mobility:
-independent to some assistance with adaptive equipment and/or electric bed
Transfers:
- independent to some assistance with uneven transfers
Ambulation: unable
Driving: independent with car/van with adaptive controls
Functional Expectations: C7
Motor Level:
-extensor pollicis longus and brevis, extrinsic finger extensors, flexor carpi radialis, triceps
Available Movements:
- elbow extension, wrist flexion, finger extension
Equipment and Assistance Required:
ADL (dressing, bathing):
-Independent with most ADL with adaptive equipment such as shower chair, hand rails, button hook, and w/c accessible
environment.
Home management:
- likely to require assistance with heavy household tasks
Bowel and bladder care:
- independent with adaptive equipment
W/C mobility and pressure relief:
- independent with manual w/c in home and community with plastic-coated hand rims
- may need some assistance with ramps curbs, and uneven terrain
- independent with pressure relief
Bed mobility:
- independent, may require adaptive equipment
Transfer:
- independent may require assistance between uneven surfaces
Ambulation: unable
Driving: independent in car with adaptive controls
Functional Expectations: C8
Motor Level:
-extrinsic finger flexors, flexor carpi ulnaris, flexor pollicus longus and brevis, intrinsic finger flexors
Available Movements:
- finger flexion
Equipment and Assistance Required:
ADL:
-Independent in all ADLs, may require adaptive equipment
Home Management:
-better able to perform with less need for adaptive equipment due to improved hand function
Bowel and bladder care:
- independent with adaptive equipment
W/C mobility and pressure relief:
- independent with manual w/c in home and community, better able to propel on ramps, curbs, and uneven terrain
- may benefit from power assist
- independent with pressure relief
Bed Mobility:
-independent to some assistance, may require adaptive equipment
Transfers:
- independent, may require assistance between uneven surfaces, may be able to transfer from floor into w/c
Ambulation: unable
Driving: independent with car with adaptive controls
Functional Expectations: T1 to T12
Motor Level:
intercostals, long muscles of the back (sacrospinals and semispinalis), abdominal musculature (T7 and below)
Available Movements:
- improved trunk control with more caudal SCI, increased respiratory reserve, pectoral girdle stabilization for lifting objects
Equipment and Assistance Required:
ADL: independent. Generally tasks become easier and require less adaptive equipment
Bowel and bladder control:
- independent with adaptive equipment
W/C mobility and pressure relief:
- independent with manual w/c in home and community
- independent on ramps, curbs, and uneven terrain
- Independent with pressure relief
Bed mobility:
- independent
Transfers:
- independent
- able to transfer from floor into w/c
Ambulation:
- independent with physiological standing and ambulation for exercise over short distances in the home
- AD: forearm crutches
- Orthoses: hip-knee-ankle-foot orthosis (KAFO)
Driving:
- independent with car with adaptive controls
Functional Expectations: L1,L2,L3
Motor Level:
- gracilis, iliopsoas, quadratus lumborum, rectus femoris, sartorius
Available Movements:
hip flexion, hip adduction, knee extension
Equipment and Assistance Required:
Ambulation:
- independent with short distances in home and possibly community
- may choose to use w/c in the community due to high energy demands of community ambulation
- AD: forearm crutches
- Orthoses: HKAFO, KAFO, AFO (depending on which muscles are innervated
Functional expectations: L4, L5, S1
Motor Level:
-quads, anterior tib, HS, gastroc, glute med and max, extensor digitorum, posterior tibialis, peroneals, flexor digitorum
Available Movements:
- strong hip flexion, strong knee extension, knee flexion, ankle DF and PF, ankle EV and IN
Equipment and Assistance Required:
Ambulation: - independent ambulation in home and community (L4 may elect to use w/c for long distance) - AD: forearm crutches, cane - Orthoses: AFO Less supportive AD and orthoses
