Week 4- SCI Treatment Considerations Pt 1 Flashcards
PART 1: INTRO, SKIN INTEGRITY
PART 1: INTRO, SKIN INTEGRITY
- ASIA ______ = Compensation
- ASIA ______ = Compensation and Restoration
- ASIA ______ = Restoration
- ASIA A and B = Compensation
- ASIA C = Compensation and Restoration
- ASIA D = Restoration
Goals of SCI Rehabilitation.
Functional Mobility
- Bed Mobility
- Transfers
- WC Mobility
- Ambulation
- WC Trials
- Equipment Requisition
- Sitting Balance Training
- Skin Management
- Strengthening
- Aerobic Training
- Respiratory
- Home Modifications
- Community Reintegration
Goals For All Levels of SCI Injury:
- Upright tolerance: ___-___ hours/day
- Utilize appropriate seating position and/or mobility devices to support posture and maximize function
- Maintain _____ integrity
- ___________ for all direction of care as needed
- Caregiver becomes independent with all aspects of care as needed
- Maintain healthy habits, minimize body habitus
- MAXIMIZE _____________
- 10-12 hours
- skin integrity
- Independent
- MAXIMIZE INDEPENDENCE
Skin Integrity After SCI:
- Wheelchair Pressure Relief __-__ minutes every ___-___ minutes. (Pushup method only needs to be held 30-90s)
- Bed rolling schedule every ___ hours.
- _____ check daily, may need adaptive equipment.
- 2-4 minutes every 15-20 minutes
- 2 hours
- Skin checks
What are the 2 main reasons SCI patients are at high risk for skin breakdown?
- Less mobile on WC all day.
- Likely lost majority of sensory that lets us know when we’ve been sitting so long.
What are 4 ways a patient can relieve pressure from sitting too long in WC?
- Side bending
- Knee crossover and pull
- Flexion to toes
- Push up method (not recommended)
What is the difference with pressure relief with powerchair users?
-It is easier because the chair does all the work for them.
PART 2: RESPIRATORY CONSIDERATIONS
PART 2: RESPIRATORY CONSIDERATIONS
What is the number 1 cause of death after a SCI?
-Pneumonia
What things do we examine in regards to our respiratory function? (5)
- RR, breathing pattern, chest excursion
- Cough
- Posture
- Breath support w/ speech
- May need Pulmonary Function Testing
An effective _______ is crucial for a patients ability to clear secretions.
cough
Functional Cough:
- Sound?
- Number of coughs per exhalation?
- Functional significance?
- Sound = loud and forceful
- Number of coughs per exhalation = 2 or more
- Functional significance = Independent in respiratory secretion clearance.
Weak Functional Cough:
- Sound?
- Number of coughs per exhalation?
- Functional significance?
- Sound = soft, less forceful
- Number of coughs per exhalation = 1 per exhalation
- Functional significance = Independent for clearing throat and small amount of secretions. Assistance needed for clearing large amount of secretions.
Nonfunctional Cough:
- Sound?
- Number of coughs per exhalation?
- Functional significance?
- Sound = sigh or throat clearing
- Number of coughs per exhalation = no true cough; attempt
- Functional significance = Assistance needed for airway clearance.
Why is a posture examination in their WC important?
-To make sure components being added to chair are not impeding but rather promoting activity of respiratory muscles.
What is a way to measure breath support with speech?
-Inhale and have them count out load to see how loud/strongly they can speak.
What are the main ways to increase respiratory strength and endurance? (3)
- Diaphragmatic Breathing
- Upper Chest Strengthening
- Respiratory Inspiratory Muscle Trainers
Diaphragmatic Breathing:
- Ideal for _______ breathing.
- “______ breathing”
- How can we help a patient with this when in supine?
- Instructing the patient to sniff can encourage diaphragmatic breathing.
- quiet breathing
- “belly breathing
- Place a large, light object (ex: box of tissues) on abdomen and instruct patient to watch themselves breathe. (Progression = active resistance on abdomen)
Upper Chest Strengthening:
- ↑ inspired air to enhance coughing, improve breath support for speech, or during ↑’d activity.
- How can we help a patient with this?
- Quick stretch to ______, _________, and _________ by pushing the upper chest in and caudally just before asking patient to inhale.
- Therapist places hands on upper chest and ask patient to push against them while breathing deeply.
- SMC, Pec major, and Scalenes
Respiratory Inspiratory Muscle Trainers:
- Useful alternative to diaphragmatic breathing and upper chest strengthening.
- Shown to improve strength & endurance in muscles of ventilation, improved PFT results, encourages slower and deeper breathing, reduces use of __________ muscles, and increases activity tolerance.
-accessory
Other Respiratory Interventions. (8)
- Eccentric Control of Exhalation
- Chest Wall Mobility
- Posture Considerations
- Glossopharyngeal Breathing (tetra)
- Abdominal Binders (tetra)
- Assisted Cough Techniques
- Self Cough Techniques
- Vent Weaning (tetra)
- ________ control of exhalation is required for normal speech production.
- How do we instruct a patient to perform this?
- Goal = __-__ seconds before inhalation
- Can further promote by adding _____________ or __________.
- Eccentric
- Patient inhales maximally and then counts or says, “ah” or “oh” for as long as possible before taking another breath.
- 10-12 seconds
- manual vibration or resistance
- Very often we see chest wall _________ problems due to pain and other injuries from accidents.
- What are some things we can do to increase this?
- mobility
- Deep breathing exercises, passive stretching, joint mobilizations, intermittent positive-pressure breathing.
Anterior pelvic tilt, erect trunk, adducted scapulae, and neutral head and back alignment are all _________ considerations for enhanced respiration.
-postural
____________ breathing involves the use of the tongue and pharyngeal muscles to help with respiration. Involves forcing air in the lungs through a series of “_____”.
-Can also help with what?
- Glossopharyngeal (tetra), “gulps”
- chest wall mobility
- ________________ can also be used with higher paraplegic injuries to contain abdominal contents in sitting and better position diaphragm.
- Why?
- Abdominal binders (tetra)
- Patients with paralysis of abdominal muscles are higher paras or tetras and can see a difference in ability to breathe in lying down vs sitting up due to mechanical shift of contents in abdomen.
- _________ cough techniques are crucial in preventing complications like pneumina.
- When is it used?
- What is the technique?
- Assisted Cough Techniques
- When patient does not have a normal functional cough.
- 2 coughs per 1 breath while pressing into patients abdomen.
List the steps to performing a self-cough technique.
- Breathe in as deeply as possible. (If possible, combine with trunk and neck extension as well as shoulder flexion or scapular adduction.
- Hold breathe deeply.
- Cough. (If possible, combine forced exhalation with trunk and neck flexion as well as shoulder extension or scapular abduction. (If patient can control it they can even fall into a folded position))
If adequate UE strength and balance, can self-apply Heimlich-like maneuver to stomach
Vent Weaning (Tetra):
- ___ or lower can usually regain capacity to breathe independently. What are some factors that will reduce this potential?
- Even if unable to complete wean from vent, can still make goal towards developing capacity to breathe independently for brief periods of time. What can this assist with?
- Gradual reduction of patients dependence on ventilator. (Progressive Ventilator Free Breathing)
- C3 or lower. Respiratory or other medical complications, pre-existing respiratory conditions, >50 years old, VC<1000, max negative inspiratory pressure <30cm H2O, hx of smoking.
- Reduces safety concerns from electronic failure and can help with ease of transfers, bathing, or trach care.
PART 3: ROM
PART 3: ROM
Why is it common to see ROM impairments and soft tissue contractures? (2)
- UMN Injury, lose descending drive from cortex because it cant get past spinal cord injury to muscles to modulate tone.
- From injury itself we will see mismatch in working muscles vs non-working muscles. (Ex; C5 tetras will have biceps but no triceps)
What are some prevention strategies to maintain ROM?
- Daily ROM exercises, proper positioning, WB activities
- Adequate spasticity management
- Splinting
_______ cast is used for legs to make it removable when we want to perform functional activities.
-Bivalve casts
What are (3) ways we will manage contractures if our main conservative measures do not work?
- Serial Casting
- Medication
- Surgical Interventions
- What is serial casting?
- What is the worst thing about serial casting?
- It can be used for both _________ and ____________ of contractures.
- With patients with spasticity (without clonus), this can help prevent what would otherwise be an inevitable contracture formation.
- Bring shortened muscle into stretch and cast it. Maintained for few days to a week. Gradually increase ROM.
- Can interfere with functional mobility.
- treatment and prevention
- What are the two main medications used in the management of contractures?
- Which can be used in conjunction with serial casting?
- Baclofen and Botox Injections
- Botox Injections
What surgical interventions may be used to manage contractures? (3)
- Joint manipulation under anesthesia
- Arthroscopic vs open release
- Rotational osteotomy (physically move things around in joint, commonly done at femur)
Particular Considerations:
- With weakened or paralyzed elbow extensors, shortening of elbow _______ is a common problem.
- __________ and other scapular muscles should be monitored closely for contractures. (decreased muscle length significantly impacts force production)
- Patients with incomplete tetraplegia or complete/incomplete paraplegia who are walking candidates require _______ ROM throughout the entire LEs. What are some common troublemakers here?
- flexors
- Rotator cuff
- normal ROM, common trouble makers are hip flexors, hamstrings, and DFs
Adaptive Shortening:
- What is adaptive shortening?
- With intact innervation of ___ = wrist extension preserved. This means we can use the wrist to achieve _______ which can help with what task?
- Patients with __ or __ SCIs must avoid overstretching their finger flexors during activities and functional tasks to maintain tenodesis capabilities.
- With specific levels of SCI, allowing adaptive shortening of particular muscles is recommended to enhance the achievement of certain functional skills.
- C6, Tenodesis which can allow passive shortening of finger flexors to help with grasping activities.
- C6 or C7
Adaptive Lengthening:
- Combination of lengthened ________ + adaptive shortening of ____________ can provide stability in short- and long-sitting positions.
- Need to maintain ____-____ SLR without overstretching back muscles.
- lengthened hamstring + shortened back extensors
- 110-120 degrees SLR
PART 4: STRENGTHENING
PART 4: STRENGTHENING
UE and LE Strengthening:
- Should we target key muscles with MMT testing?
- Monitor patients closely for _______ response when initiating new strengthening activities. (Blunted responses with autonomic dysfunction)
- Combination of _____-_____ exercises as well as ______ movements.
- Are closed-chain or open-chain more beneficial?
- No, further MMT should be completed for all intact spinal nerve roots.
- hemodynamic
- multi-joint as well as isolated movements
- Both open and closed chain are beneficial (If MMT ≥3/5, try to find positions/techniques to prioritize closed-chain, functional based activities.)
Injury prevention is key, what is a common site of MSK breakdown with these patients?
- Shoulder common site and are extremely important to functional independence!
- STOMPS Trial (2011)
UE Restoration and Maintenance:
- UEs become primary mode of locomotion, this means increased load, especially on the shoulder joints. It is the number 1 site for orthopedic pain and injury following SCI.
- We should focus on strengthening what key muscles to prevent injury to UE? (5)
- Also focus on teaching strategies to _______ UE use.
- Big focus on shoulder ergonomics: WC MOBILITY
- Serratus anterior, Lats, Pec major, Rotator cuff, Tricep
- minimize
Why is core strengthening important?
-Important for balance, stability during functional movement, and respiratory function.
What are some helpful equipment used to help strengthening with SCI? (6)
- Powder board
- Skates
- Air splints
- Inclined board
- Mobile arm support
- Thera-Band
Supine Benefits:
- ______-_______ position for many UE/LE muscles.
- Easy to facilitate _____ ______.
Supine Considerations:
-Can be compromising position for _________ muscles. May need to consider propping on wedge or pillows to improve _________ function during exercises.
- Gravity-eliminated
- rest breaks
- respiratory
- respiratory
Side Lying Benefits:
- ______-_______ position for many UE/LE muscles.
- Can be more comfortable than supine if vertebral _________ present.
Side Lying Considerations:
- Need to be aware of not over-_______ trunk which can compromise respiration.
- Difficult to incorporate LE _______-_____ exercises.
- More so able to implement some functional-based tasks.
- Gravity-eliminated
- fractures
- over-flexing
- closed-chain
Prone Benefits:
- Great way to extend back, hip flexors, even knee flexors.
- Allows for full pressure relief of _______.
- Can progress position in variety of ways (prone on elbows, prone with elbows extended).
- Can allow for neck _________ strengthening.
Prone Considerations:
- Be cognizant of _____ ROM - need to be able to move freely to allow for comfort and breathing.
- If neck ROM limitations - may consider use of towel rolls to prop chest and head.
- Primarily a position used to target ___s when considering strengthening interventions.
- buttocks
- extension
- neck ROM
- UEs
Quadruped Benefits:
- Great functional position, closed-chain UE/LE.
- Challenges ________ muscle.
- Incorporates _______ muscles and _______stabilizers.
- Can allow for neck _________ strengthening.
Quadruped Considerations:
- Challenging position - but variety of ways therapist can assist and facilitate to allow even patients with tetraplegia to achieve this position!
- Consider use of equipment to help maintain position.
- proximal
- trunk muscles and pelvic stabilizers
- neck extension
High Kneeling Benefits:
- If intact, great position for glutes, pelvic muscles, low back stabilizers.
- If higher level, targets intact ______ muscles and can incorporate balance strategies.
High Kneeling Considerations:
-Be careful of leg position, be sure pelvis, hips are neutral to avoid inappropriate load through hip/knee joints.
-trunk
Sitting Benefits:
- _____ stabilization.
- _______-chain UE exercises.
Sitting Considerations:
-Great position to incorporate ____-____ balance activity while strengthening targeted muscles.
- core stabilization
- closed-chain
-dual-task
(Assisted) Sitting:
- Great functional position, closed-chain UE/LE.
- Challenges _________ muscles.
- Incorporates trunk muscles and pelvic stabilizers.
- Can allow for neck extension strengthening.
(Assisted) Standing:
- Challenging position - but variety of ways therapist can assist and facilitate to allow even patients with tetraplegia to achieve this position.
- -Consider use of equipment to help maintain position.
-proximal
Upright Tolerance:
- _____ is a VERY COMMON problem in acute stages.
- What are the S/Sx of this?
- Orthostatic Hypotension
- hypotension + tachycardia, dizziness, pale skin, sweating, slurred speech, fogginess, blurred vision, nausea and/or vomiting
What are some strategies to manage and progress upright tolerance?
- Slow transitions
- Compression garments (abdominal binders, TED stockings, ACE wraps)
- Equipment (tilt’n space w/c, tilt table, ERIGO, active standing frame)
Regardless of level on injury or prognosis, incorporating standing into your POC has a multitude of benefits. List some. (8)
- Socialization
- Mood
- Respiratory and Cardiovascular function
- Aids in digestion
- Bone health
- ROM maintenance
- Strengthening
- Skin integrity
Assisted Standing Considerations:
- Monitor _______ closely during each session.
- Incorporate _______ or ____ strengthening into session as tolerated.
- Incorporate _______ or small range LE strengthening as able and as device allows.
- Consider use of _____ while in standing.
-Goals are typically __________-based (“Pt can tolerate 10 minutes of assisted standing frame with stable hemodynamics and minimal report of fatigue”) but can incorporate strengthening goals as well!
- vitals
- trunk or UE strengthening
- isometric
- FES
-tolerance-based
PART 5: BALANCE
PART 5: BALANCE
What 3 things are we focusing on in regards to balance with tetraplegic injuries?
- Achieving Balance
- Maintaining Balance
- Reaction to LOB
Tetra UE Prop Positions for Sitting Balance:
- What are the (3) primary positions for UE support when in short or long sitting from easiest to hardest?
- What are some important ROM to achieve these positions?
- This is often a part of ____-______ for patients with mid-low level tetraplegic.
- Posterior Prop, Lateral Prop, Anterior Prop
- Shoulder extension, abduction, and ER
- goal-setting
- _______ are an important muscle when relying on closed-chain BUE support in sitting.
- What is a compensation for weakness of this muscle?
- Triceps
- If triceps are impaired (C6 injury), can still achieve closed-chain UE support if anterior deltoid and shoulder ER are functional.
C6/C7 needed to maintain finger flexion whenever WBing through UEs during sitting balance task, why?
-To protect tenodesis grasp.
Reactionary Techniques (Tetra Static Sitting):
Normal:
- Small perturbations = ______, _____/____ muscles
- Large perturbations = reaching reaction with UEs
With Loss of trunk and variable UE strength:
- Small perturbations = _____/_____, upper ______ and upper ______ muscles
- Large perturbations = difficult to be successful
What is the “sweet spot”?
- trunk, pelvic/hip
- head/neck, upper shoulder and upper trunk
- Sweep Spot = Every patient has a “sweet spot” that their COM lands perfectly over their BOS and they can briefly hold balance without UE support despite inadequate trunk strength.
Dynamic Balance Considerations for Paraplegic Injuries:
- _______ Balance + ______ Control + _____ and _____ Strengthening.
- Focus on quickening _________ strategies.
- Higher paraplegia may benefit from head/neck reactionary techniques for smaller LOBs.
- Dynamic Balance + Trunk Control + UE and Core Strengthening.
- reactionary
__________ positions are key positions to promote strength, balance, and functional independence.
-Therapeutic Positions
What are the (4) main therapeutic positions?
- Long Sit
- Short Sit
- Ring Sit
- Prone
