Week 6 Flashcards
1
Q
What is the order of importance from the recovery standpoint in a person with tetraplegia?
A
- Hands
- Bowel/Bladder
- Sexual Function
- Walking
2
Q
What is the order of importance from the recovery standpoint in a person with paraplegia?
A
- Bowel/Bladder
- Sexual Function
- Walking
3
Q
How does the brain change/cortical reorganization post SCI?
A
- Learned non-use happens in the 1st 72 hrs of injury
- Decreased cortical representation
- Posterior shift in cortical map representation
- Decreased cortical motor excitabilitity
- Impaired cortical drive: altered muscle recruitment patterns, especially in the hands
- Decreased intracortical inhibition: decreased spine inhibition, especially in the hand intrinsic muscles
- Impaired somatosensation: decreased afferent input
4
Q
What are the characteristics for UE recovery post SCI?
A
• Better in incomplete Bs, Cs, and Ds
• “Motor incompletes” have greatest potential for recovery
• Central Cord and Brown Sequard Syndromes have best
prognosis (caveat with Central Cord, intrinsic hand function is last)
• With complete injuries, may regain sensory/motor function at least one level below level of injury
5
Q
What is the most common site of pain in patients with SCI?
A
Shoulder
6
Q
What are the most common shoulder presentations in patients with an SCI?
A
- Rotator cuff tear
- Tendinitis
- Most of wheelchair users have carpal tunnel syndrome
7
Q
The intensity of shoulder pain is inversely related to ____
A
The intensity of shoulder pain is inversely related to quality of life & physical activity
8
Q
What are the things we need to be thinking about in terms of evaluation in patients with an UE dysfunction in a SCI?
A
- Pain
- Posture/Position
- Palpation
- Joint Mobility
- ROM
9
Q
Why does shoulder subluxation in patients with a SCI generally occur?
A
Due to paralysis of stabilizers
10
Q
What can shoulder subluxation in patients with a SCI lead to over the first two weeks?
A
Overstretching of capsular
support
11
Q
How do we test for shoulder subluxation in patients with a SCI?
A
Sulcus Sign: longitudinal traction applied at 20-50 degrees abduction and neutral rotation
• 1+ Sulcus: less than 1 cm
• 2+ Sulcus: 1-2 cm
• 3+ Sulcus: > 2 cm
12
Q
What is shoulder impingement in patients with a SCI?
A
Entrapment of SIT(no S), biceps, and bursa between the acromial arch and humeral head
13
Q
What are the presentations of patients with a shoulder impingement in patients with a SCI?
A
- Abnormal Firing/ Muscle Activation (Hypertonicity)
- Poor Shoulder Positioning
- Often occurs with Subacromial Bursitis
- Excessively Anteriorly displaced humeral head
- Tight Posterior and/or Inferior Capsules
14
Q
What causes biceps tendonitis in patients with a SCI?
A
- Pain causing excessive firing
* Overstretching of the tendon from lack of shoulder stability
15
Q
What can add stress in patients with biceps tendonitis in patients with a SCI?
A
Abnormal muscle activation like a flexor synergy
16
Q
What are the presentations of patients with a biceps tendonitis in patients with a SCI?
A
Hypertonicity of shoulder complex
17
Q
What causes adhesive capsulitis in patients with a SCI?
A
- Pain limiting mobility causes the capsule to tighten
* Can also occur from a gross increase in tone (hypertonicity)
18
Q
What are the presentations in a person with adhesive capsulitisin patients with a SCI?
A
• Decrease in AROM and PROM
- Flexion, Abduction, External Rotation*, Internal Rotation
• Develop generalized weakness and atrophy
• Not as easy to manage as an orthopedic AC
19
Q
What is a neuropathy?
A
Gross lack of sensation
20
Q
What causes a neuropathy?
A
Due to paresis and lack of stability, brachial plexus can become compromised with abnormal pain response
21
Q
_____ can cause damage to the vasculature of the upper arm in a neuropathy
A
Paresis can cause damage to the vasculature of the upper arm in a neuropathy
22
Q
What are some interventions that can be used in patient with an UE dysfunction?
A
- Functional Electrical Stimulation
- Kinesiotape
23
Q
What are the shoulder pain risk factors in SCI?
A
- Duration of Injury: Worse at 12-15 years after injury
- Age: Older vs Younger
- Higher BMI: 0.5% increase = 20N (5lb)
- Gender: Females > Males
- Wheelchair Propulsion Style: Excessive Reaching on anterior capsule vs Neutral Position
- Pressure Relief: Depression Lift
- Activity Level: Active Lifestyle, Independent
24
Q
What is the proper hand position in wheelchair mobility?
A
We want the AC joint to be right over the axis of the wheels. Leads to minimal stress on the anterior capsule
25
What do we see when a patient is too far forward in their wheelchair?
An excessive amount of backward reaching, which increases the amount of anterior stretch
26
What do we use to assess shoulder pain in patients in a wheelchair?
Wheelchair User’s Shoulder Pain Index (WUSPI)
27
What are the characteristics of the WUSPI?
* 15-item self report index for functional activities (w/c mobility, transfers, self care)
* VAS Scored 0 to 10 for each item: 0 – 150. 0=no pain, 10= worst pain
* Two items: Difficulty and Pain
* High test-retest reliability
* Valid: demo an increase in shoulder pain with a decrease in shoulder ROM
28
What are the functional interventions to do for patients with shoulder pain?
* Activity Based and Task-specific Training
* Electrical Stimulation and with motor performance
* Resistance Training
29
What should the focus of the task- specific training for patients with shoulder pain be?
* Increasing synaptic strength
* High repetition
* High intensity
* Task specific
* Optimal sensory input
* Rhythmic?
* Tools to help accomplish this?
30
What are the recommendations highlighted in Strengthening and Optimal Movements for Painful Shoulders (STOMPS)?
1. Exercises to be performed 3x / week
2. Allow one day rest between each exercise day
3. May alternate exercises on days
4. Use a calendar to show you have done the exercises
31
What are the parameters for stretching in the STOMPS Warm-up Phase?
* Hold each stretch for 15 seconds
* Repeat each stretch 3-5 times
* Do not bounce or apply forceful pull on the muscles or joints
1. Biceps and Pec Stretch
2. Post Capsule Stretch (Across the body)
3. Upper Trap/ Levator Stretch
32
What are the parameters for active movements in the STOMPS Warm-up Phase?
4. Lateral Raise with thumb up
5. Active IR/ER
6. Scapular Squeeze
7. Arm Diagonals (Crossbody Chops)
33
What are the resistance exercises highlighted in STOMPS?
* Rest for 1-2 minutes between sets
* Use weight as long as you can control the proper motion
1. “Thumb Up”
* 3 sets of 15 repetitions
2. Shoulder ER w/ TB
* 3 sets of 8 repetitions
3. Scapular Squeeze w/ TB
* 3 sets of 15 repetitions
4. Crossbody Chops w/ TB
* 3 sets of 8 repetitions
34
Which is better for patients with shoulder pain as a result of an SCI, exercise or exercise and EMG?
Exercise and EMG
35
What are the challenges with exercises in patients with SCI?
```
Exercise Modifications
• Wheelchairs vs Standing
Patient Positioning
• Prone, Supine, Basic Transfers
Holding onto Equipment
• Grip Gloves, Ace Wraps, TB Ties
Basic Machines
• Not always practical
```
36
What are the joint mobility and passive ROM considerations to keep in mind in patients with UE dysfunction due to an SCI?
• Remember cervical and first rib mobility
• Clavicular
• Glenohumeral
• Elbow
• Up to 70% of persons with tetraplegia and 29% of those with paraplegia had limited ROM of shoulder during or in the first year after IP rehab .
- Shoulder flexion most affected
37
What are the consequences of a bowel/bladder dysfunction after a neurological injury?
```
• High intravesical pressure lead to reflux into urethra
• Hydronephrosis
• Increased risk of:
- Kidney infections
- Kidney stones
- Elevated risk of bladder Ca
• Constipation, impaction, decreased appetite
• Ileus: bowel obstruction
• Diverticulosis
• AD
• Skin breakdown
• Psychosocial
```
38
What is a diverticulosis?
A condition of having diverticula(little outpocketings of the colonic mucosa and submucosa) in the colon, because of weaknesses in the muscle layers of the colon wall
39
What are the characteristics of normal bladder function?
* Have sensation when bladder is full
* Can “hold” when needed
* Can empty bladder completely and with control
40
What are the levels of bladder function control?
* Sacral SC
* Pons
* Extrapontine regions of brain
41
What is normal bladder function dependent upon?
Neurological control of the detrusor muscle, the external sphincter, and peri-urethral pelvic floor muscles, which involves both autonomic and somatic innervations
42
What does sympathetic nerves do in normal bladder function?
It relaxes the detrusor and contracts the neck of the bladder
43
What does parasympathetic nerves do in normal bladder function?
It contracts the detrusor
44
What is the presentation of a bladder after a complete SCI?
Loss of voluntary control and sensory awareness; sacral reflexes may/may not be functional
45
What is the presentation of a bladder after an incomplete SCI?
Function depends on integrity of sacral reflex arc and cortical connection
46
What happens in the bladder during spinal shock?
Flaccid during spinal shock; and can last up to 6-8 wks
47
What are the options of what can happen to a person's bladder after spinal shock?
- Areflexive Bladder
| - Reflexive Bladder
48
When is a bladder permanently areflexive?
If sacral reflex arc lost (S4, 5 or
| cauda equina). Lower motor issue
49
What are the characteristics of an areflexive bladder?
* Loss of parasympathetic stimulation. Info from brainstem can't come down
* Detrusor remains flaccid
* Causes urinary retention
* Can have incontinence
* Retention and distention leads to UTI
* Typically see with injuries at or below T12
50
What is a reflexive bladder?
One where there is an intact sacral reflex arc and an intact S2-4
51
What are the characteristics of a reflexive bladder?
• Bladder empties reflexively once filled to level where
sufficient stretch on wall is present
• Can also be triggered via stimulus
• Typical in pts with c- or t- spine injuries (above T12)
• Detrusor-Sphincter Dyssynergia
52
What are some of the ways to trigger emptying in a reflexive bladder?
- Pressing/stroking of the abdomen
- Sensory stim
- Stroking of the inner thigh
- Credae maneuver (pressure over the abdomen and moving downward)
53
What is Detrusor-Sphincter Dyssynergia?
Involuntary external sphincter contraction with concurrent detrusor contraction, which results in a high intravescular pressure and a high post void residual, which leads to UTIs, septsis, urine back up, urinary stones
54
What is the goal of bladder management?
- Complete or near complete bladder emptying
- Voiding at appropriate times
- Avoidance of incontinence
55
What are some of the way to manage a dysfunctional bladder?
• Catheterization
- Indwelling vs. intermittent
• Training
- Regular emptying, followed by cath; restriction of fluid
- Crede, tapping abdomen, other sensory triggers (reflexive)
56
What are the characteristics of an indwelling catheters that we see in acute care?
• Includes a Foley Catheter and Suprapubic Catheter
• Indwelling portion with external bag
• Internal portion needs changing 1 x /month; empty
external bag when full
57
What are the advantages of an indwelling catheter: foley?
* Low maintenance
| * Ease of use for patient and caregiver
58
What are the disadvantages of an indwelling catheter: foley?
* Increased risk of UTI
* Interference of bag
* Increased incidence of bladder Ca
* Skin issue (mostly males)
* Sexuality issues
* Social issues
59
What are the characteristics of an Indwelling catheter: Suprapubic?
• Surgically placed between umbilicus and pubic bone,
inserted in bladder
• Changed every 4 wks
• External bag
60
What are the advantages of an Indwelling catheter: Suprapubic?
* Larger bore, less occlusion
* Easier to manage and change
* No interference with sexual activity
* Less skin breakdown
61
What are the disadvantages of an Indwelling catheter: Suprapubic?
* Same risk of UTIs
* Potential infection post surgery
* Increased incidence of bladder Ca
62
What are the characteristics of an External Condom Catheter?
• Condom like latex sheath applied to penis, connect to
external bag
• Need urodynamic studies before using
• Can be a temporary intervention in bladder
management training
• Has to be able to voluntarily urinate and completely
63
What are the advantages of an External Condom Catheter?
* Increased independence
| * Less invasive
64
What are the disadvantages of an External Condom Catheter?
* Catheter can be pulled off
* Skin breakdown
* Greater incidence of leakage
65
What are the OT/PT interventions for patients with bladder dysfunctions?
* Potential goals for those with C6 injury or below
* Ability to determine when external bag needs emptying
* Management of external bag valve
* Urinal management
* Leg management
* Don/doff condom cath
66
What are the characteristics of an Intermittent Catheterization Program (ICP)?
```
• Need established program
- Cath every 4 hours
- May limit fluid intake
• Clean versus Sterile Technique
- Most people use the clean technique
```
67
What are the advantages of an Intermittent Catheterization Program (ICP)?
* Decreased risk of infection
* Does not interfere with sexual function
* More conducive to active lifestyle
68
What are the disadvantages of an Intermittent Catheterization Program (ICP)?
* Level of independence
* Restricted intake volumes
* Compliance
69
What are the OT/PT interventions for a patient with an Intermittent Catheterization Program (ICP)?
* Clothing management
* Management of legs, positioning
* Use of adaptive equipment
* Set up of equipment for cathing
* Cathing technique
70
What is normal bowel function?
• Normally, feel fullness, hold and empty
• Control from:
- Intrinsic
- Autonomic: GI function with the rest of the body. Parasympathetic input excites the intestines
- Somatic: controls external anal sphincter and pelvic floor muscles
71
What are the presentations dysfunctional bowel function?
* No anal sensation; absent anal contraction or weakness
* Neurogenic pathology
* UMN = reflexive bowel
* LMN = areflexive (flaccid) bowel
72
What is the presentation of bowel function, post SCI?
Decrease or loss of peristalsis and defecation reflexes with
| spinal shock
73
What is the presentation of bowel function in a complete SCI?
Loss of both voluntary control and sensory awareness
74
What is the presentation of bowel function in an incomplete SCI?
Depends on integrity of sacral reflex arc and connection to brain
75
SCI disrupts autonomic and somatic input resulting in...?
* Colonic transit is slowed
* Voluntary control of defecation lost
* Reflexive defecation may be lost depending on the injury
76
What are the characteristics the intrinsic defecation reflex?
- Mediated by intrinsic system
- Stimulated by filling of the rectum, which causes a relaxation of the internal anal sphincter and intensification of the peristalsis
77
What are the characteristics the parasympathetic defecation reflex?
- Needed for normal defecation
- Comes from the sacral spine reflex
- Causes relaxation of the internal sphincter and intensification of the peristalsis
78
What happens when feces enters the rectum?
The internal sphincter relaxes, and you get simultaneous contraction of the external anal sphincter to prevent unwanted defecation
79
What are the characteristics of a reflexive bowel?
* S2-4 and corresponding peripheral nerves intact
* Sphincter has resting tone, relaxes reflexively with rectal distention; reflex defecation occurs
* Complete emptying may not occur
80
What are the characteristics of an areflexive bowel?
• Intrinsic defecation reflex intact, but parasympathetic
defecation reflex lost.
• Sacral reflex arc is interrupted, either at the level of the spinal cord injury or peripheral nerve damage
• Bowel will not empty reflexively
• Impaction of feces in the rectum can occur
• External sphincter and pelvic floor muscles remain flaccid, so may or may not have incontinence
• May or may not have sensation of fullness
81
What are some bowel management methods?
```
• Has to occur at regular intervals
• Goal is to establish predictable, controlled schedule
• Bowel conditioning
• Reflexive
- Stimulate reflexive defecation
• Areflexive
- Manual removal of stool
```
82
What are the OT/PT Interventions in the management of bowel dysfunctions?
```
• Getting appropriate adaptive equipment and training
in use of this
• Balance activities to facilitate reach
• Toilet transfer training
• Watch for complications
```
83
What innervates bowel and bladder function?
Sacral segments (S2-4)
84
What is the bowel and bladder presentation in a SCI above T12 (UMN)?
Reflexive (spastic) B&B
85
What is the bowel and bladder presentation in a SCI below T12 (UMN)?
Areflexive (flaccid) B&B
86
What spinal level is responsible for ejaculation in males?
T11-T12
87
What spinal level is responsible for erections in males?
S2
88
What are the things that need to be working normally in males in order to have normal sexual function?
```
A. Erection
B. Arousal
C. Orgasm
D. Ejaculation
E. Fertility/Fatherhood
```
89
What is a psychogenic erection?
```
Psychological arousal (erotic thoughts or other sensory experiences like sights,
sounds, smells
```
90
What spinal area is responsible for a psychogenic erection?
T11 to L2
91
Why may a person not be able to have a psychogenic erection?
If complete injury is above T11 to L2 level
92
What is a reflexogenic erection?
Direct stroking/caressing to the penis or erogenous zones
93
What spinal area is responsible for a reflexogenic erection?
S2 to S4
94
What is a spontaneous erection?
Internal stimulation; usually when bladder is full
95
What spinal area is responsible for a spontaneous erection?
S2 to S4
96
What kind of erection can a person with a complete UMN lesion above T11 have?
Reflexogenic erections
97
What kind of erection can a person with a complete LMN lesion have?
Psychogenic erections (assuming preserved function in T11-L2)
98
What kind of erection can a person with an incomplete UMN lesions sparing T11-L2 have?
Reflexogenic and psychogenic
| erections
99
What kind of erection can a person with an incomplete LMN lesions have?
Psychogenic erections
100
What are natural ways to make erection stronger or last longer?
1. Presence of spasticity during intercourse
| 2. Kegel exercise
101
What are some sexual aids and options to elicit an erection?
1. Oral medication ( i.e. Viagra, Cialis)
2. MUSE (medicated Urethral System erection)
3. Papaverine Injection
4. Vacuum pump: manual pump vs battery operated
5. Penile ring/condom
6. Penile surgical implant: semi rigid, inflatable rods and self-contained unit
102
What are the areas of sexual arousal in a person?
1. Mouth and lips
2. Neck and Shoulder
3. Stomach
4. Feet/toes
5. Ears
6. Breast
7. Buttock
8. Penis/scrotum area (male); Clitoris (female)
103
What is the research between orgasms and SCIs?
Questionnaire Studies have shown 50% of males and females with SCI to have a capacity to achieve orgasm and
this has not been found to be related to the degree of injury. This has been confirmed via laboratory –based research
104
What is a paraorgasm?
“Built- up intense sensation”
| that is similar to orgasm
105
What is the research between an ejaculation and SCIs?
Ejaculation is markedly decreased after SCI, most likely due to the fact that it involves a more complex coordination between neurologic impulses from the sympathetic, parasympathetic and somatic nervous system for ejaculation to occur
• Rate of ejaculation men with complete upper motor neuron injuries can be as low as 4%.
• Chance of ejaculation better when capacity of psychogenic erection is intact
106
What is a retrograde ejaculation?
Something that happens in a SCI in which the ejaculated
| semen goes back to into the bladder instead of ejecting from the penis
107
What are the characteristics pf alternative ways to elicit an ejaculation: Penile Vibratory Stimulation (PVS)?
- Specifically engineered for ejaculation of men with SCI
- Delivered an amplitude of 2.5 mm when pressed below the head of the penis. This amplitude has a higher success rate compared with lower
amplitude
- Requires prescription from MD
- Two kinds: personal and clinical
108
What are the characteristics pf alternative ways to elicit an ejaculation: Electro Ejaculation (EEJ)?
- Performed under anesthesia to retrieve semen for purpose of artificial insemination
- Probe containing electrodes is placed into the rectum and electrical stimulation is delivered
- Only to be used if PVS fails
* PVS is less invasive, preferred most by patients and results in better semen quality than electro-ejaculation (Brackett et al., 1997)
109
What are the factors contribute to sperm quality?
1. Motility- are the sperm “strong swimmers”?
2. Speed - rapid linear progression
3. Morphology- tadpole shape; abnormally shaped sperm
cannot fertilize an egg
4. Sperm Count- over 40 million sperm in a single ejaculation; < 40 million decreased fertility
5. Concentration- # of sperm in a ml. of semen; normal
concentration is 20 million per ml of sperm
110
What are the most important factors when assessing the fertilizing capability of sperm?
Motility, speed and morphology appear to be the most important factors when assessing the fertilizing capability of sperm. Despite low sperm count, many men with high quality (viable and highly mobile) sperm may still be fertile
111
What are the issues concerning Female SCI population?
```
A. Menstruation
B. Vaginal Lubrication
C. Arousal
D. Orgasm
E. Birth Control
F. Fertility/pregnancy
G. Labor and delivery
```
112
What are the characteristics of a SCI and menstruation?
* Amenorrhea or absence of menstruation is common for 3 to 6 months after SCI.
* Pregnancy can still occur even with absence of menstruation.
* OB-Gyn needs to be consulted for appropriate birth control.
* Both Tampons and Sanitary napkin can be used depending on ease and comfort
* PMS can trigger Autonomic Dysreflexia for females with SCI at T6 and above
* At menopause, female with SCI may be at higher risk for bone thinning
113
What are the characteristics of a SCI and vaginal lubrication?
* Women with SCI complete above T12 level, reflexogenic lubrication may occur
* Women with SCI complete below T12, psychogenic lubrication may occur
* Women with complete SCI and upper motor neuron injuries affecting sacral segment will maintain capacity for reflex lubrication and lose the capacity for psychogenic lubrication
114
What are the characteristics of a SCI and arousal/orgasms in females?
* Regardless of the injury level, it was observed that differences in response depends on the sensory preservation at T11-L2. Women with greatest ability to perceive surface stimulation have the greatest ability for psychogenic vaginal vasocongestion.
* This finding is supportive of the sympathetic nervous system being in control of psychogenic genital vasocongestion due to the sympathetic cell bodies located at the intermediolateral cell column at T11-L2.
115
What are the characteristics of a SCI and arousal/orgasms in females cont'd?
• Research also disputes the hypotheses that sexual arousal in women is mediated by parasympathetic fibers (S2- S4 segments).
• Research suggests that female psychogenic genital vasocongestion is a primary function of the sympathetic nervous system.
• Ability of human females with Complete and Incomplete SCI to achieve orgasm has also been documented.
• It was proposed that sensation associated with orgasm are at least in part of afferent autonomic innervation, which remains even in the
presence of complete SCI.
116
What are the different types of birth control a woman can use?
1. Oral contraceptives
2. Condom helps prevent STDs/AIDS
3. Sponges
4. Vaginal suppositories
5. Norplant (contraceptive implant/ form of synthetic progesterone)- good for
5 years
6. IUD
7. Progesterone shot- every 3 months
* Norplant and Progesterone shots do not contain estrogen so there is no
increased risk of blood in the veins of leg
8. Tubal Ligation
9. Rhythm method
117
What are the factors to be considered when choosing a method of birth control?
1. Safety (e.g. IUD, Rhythm method)
2. Convenience
3. Expense
4. Effectiveness (e.g Pills, diaphragm)
5. Values
6. Physical ability
7. Shared responsibilities
118
What are the characteristics of a SCI and fertility/pregnancy in females?
SCI should not change your ability to conceive but definitely imposes a lot of physical
challenges.
119
What are some problems that a patient with an SCI may occur during pregnancy?
1. Increased spasms
2. Increased chance of pressure sores because of weight gain
3. Swelling of legs and feet
4. Increased fatigue
5. Anemia
6. Increased chance of blood clots
7. UTI or accidents from the baby pressing the bladder
8. Difficulty transferring towards the end of pregnancy
9. Increased back pain due to increase lordosis
10. Autonomic Dysreflexia (T6 and above injuries) when the baby’s head begins to press on the pelvic bones
11. Increased risk for carpal tunnel syndrome
12. Premature or low birth weight
13. Preeclampsia
14. Early labor (even as early as 28 weeks)
15. Pulmonary difficulty (C4 and above/ vent dependent)
16. Orthostatic hypotension
120
What are the characteristics of a SCI and labor and delivery in females?
• Communication with Obstetrician is ESSENTIAL
• Pregnant women with SCI are at risk for unattended delivery due to unrecognized contractions. Recommend in patient admission as early as
28 weeks if there is a presence of cervical dilation
• Vaginal delivery vs Caesarean
• T6 and above, higher risk for autonomic dysreflexia due to uterine contraction
• Induction by Ptocin/Oxytocin, the risk is even greater.
• Appropriate antihypertensive therapy should be available at the patient’s bedside during labor
121
What is the role of a PT in a person with a sexual dysfunction?
• LISTEN
• Provide basic information (know your boundaries)
• Direct patient to the right professional
• Help patient analyze the activities that contribute to
their noted problems
• Discuss available positioning techniques
• Follow up with patient
122
What are the characteristics of the management of a SCI and labor and delivery in females?
• Some recommend continuous monitoring during labor by
electrocardiogram, pulse oximetry and arterial line especially if the patient has a baseline pulmonary insufficiency
• Effective management includes epidural anesthesia early in labor to prevent AD; vacuum extraction is helpful in the expulsion stage
• Episiotomy is usually not needed due to relaxed pelvic
floor
123
What are the stages of grief?
- Denial
- Anger
- Bargaining
- Depression
- Acceptance
124
What is the interpretation of the denial stage of grief for a SCI?
Hope of recovery and return to
| Premorbid functioning
125
What is the interpretation of the anger stage of grief for a SCI?
Increased awareness, external
| expression of emotion
126
What is the function of the denial stage of grief for a SCI?
Maintain premorbid identity
127
What is the function of the anger stage of grief for a SCI?
Control situation or destiny
128
What is the interpretation of the bargaining stage of grief for a SCI?
Hope of improvement
129
What is the function of the bargaining stage of grief for a SCI?
Maintain motivation for
| treatment
130
What is the interpretation of the depression stage of grief for a SCI?
Uncertainty of the future; defeat
131
What is the function of the depression stage of grief for a SCI?
Grieving of losses; preparing
| for future
132
What is the interpretation of the acceptance stage of grief for a SCI?
Willingness to do things differently
133
What is the function of the acceptance stage of grief for a SCI?
Regain quality of life
134
What is included in the model of reactions of disability?
* Shock
* Anxiety
* Denial
* Depression
* Internalized anger
* Externalized hostility
* Acknowledgement of disability
* Adjustment to disability
135
What are the characteristics of suicide and a SCI?
• Much greater risk in persons with SCI
• 5 times higher than general population
• Higher among those with less disability
• Among top 4 leading causes of death
• Most among those less than 39 y/o
• One VA study found rate 10 x that of uninjured peers
in subjects with paraplegia
136
What are the characteristics of quality of life and a SCI?
• Good predictor of survival 15 yrs post injury
• Markedly lower than able bodied folks
• Lower QOL associated with medical complications
such as pressure sores, AD, respiratory dysfunction
• Lower quality of life associated with lower
participation
• Also associations between educational level, social
support, financial security
137
What are the characteristics of chronic pain and a SCI?
• Reported prevalence ranges from 11-94%
• Spinal cord related pain in 64.9% of 1,295 war-related
SCI survivors
• Highest percentage of pain in persons with lumbar
level SCI
• Neuropathic type pain
• More common in incomplete injuries
138
What are the predictors of high life satisfaction?
Sex and functional independence
139
In what systems do we see premature aging in a patient with chronic disabling neuro condition?
* Cardiovascular*
* Endocrine*
* Immune
* Musculoskeletal*
* Respiratory
* Integumentary
* Genitourinary
* Gastrointestinal
* Nervous
140
What are the characteristics of social isolation and disability?
```
• Limited mobility may equal limited social interaction
• Feeds depression
• Therapy can’t be only source of social life
• Encourage social interaction
- Support groups
- Peer mentoring
- Volunteer activities
- Return to work
- Return to social circles
```
141
What are the challenges and barriers in patient with an UE dysfunction following a brain injury?
* Pain
* Spasticity
* Hypotonia
* Lack of motivation
* Positioning challenges
* Weightbearing challenges
* Neglect/inattenton
* Reflex Sympathetic dystrophy (RSD)/ Complex Regional Pain Syndrome (CRPS)
* Ataxia
* Complexity of UE
* Relative instability
142
What is Reflex Sympathetic dystrophy (RSD)/ Complex Regional Pain Syndrome (CRPS)?
When a person has some sort of trauma r no known onset, go through autonomic changes in the limb including trophic changes in the skin, decrease circulation and a painful and hypersensitive limb, making rehab difficult
143
What makes the complexity of the UE?
```
Instability of shoulder girdle
• The joints
• Connections to the body
• Muscular support
• Forces to overcome
```
144
What are the forces to overcome of the shoulder girdle?
* Weight of arm
* Gravity
* Lever arm
* Object
145
What are the common abnormal postures and movements of the GH joint?
* Anterior and/or inferior subluxation
* Excessive internal rotation and adduction
* Tight and/or hypertonic pecs and lats (and other IRs)
146
What are the common abnormal postures and movements of the elbow?
Hypertonic elbow flexors
147
What are the common abnormal postures and movements of the Wrist, forearm, and fingers?
Flexed, pronated
148
What makes the complexity of the wrist and hand?
* So many joints and bones
* So many movements
* Dependency on the shoulder girdle
* Alterations in muscle tone
149
What are characteristics of the level of precision needed for fine motor as it contributes to the complexity of the UE?
* Graded force and activation
* Dependent on many, many systems
* Typically requires reach
150
What does the majority of pain in a hemiplegic shoulder result from?
• Immobility (flaccidity or stiffness)-therefore maintain ROM
• Imbalance (combination high/low tone)-therefore regulate mm tone
• Impingement (trauma between 2 structures)-therefore align
structures
151
What is the suggested main cause of shoulder pain?
Flaccidity
152
What does flaccidity cause?
Causes weight of unsupported arm to stretch capsule and ligaments, resulting in subluxation and pain
153
____ is the main cause of shoulder pain following stroke
*Adhesive capsulitis* is the main cause of shoulder pain following stroke.
Followed by subluxation, RTC tears
154
What is the relationship between subluxation and pain?
- Shoulder pain more significant in Left Hemiplegia
- Severe inferior sublux had tendency to show medial
displacement of humeral head
- Correlations between pain and ROM, especially ER
- Adhesive changes seen in most subjects
155
What are the factors contributing to subluxation in patients with hemiplegia following a BI?
• Downward rotation of the scapula, causing angulation
of the glenoid fossa. (esp in acute phase)
• Weakened rotator cuff muscles
• Loss of joint capsule integrity, specifically the superior
fibers.
• Weight of unsupported UE
• Brachial Plexus injury
156
What are the treatment goals for the Hemiplegic shoulder in patient with hemiplegia following a BI?
• Maintain pain free ROM without trauma/proper
handling
• Facilitate stabilizing muscles in trunk & shoulder girdle
• Maintain proper alignment of scapula, humerus & trunk
• Normalize muscle tone
• Weightbearing
157
What are the characteristics of inferior subluxation in patients with hemiplegia following a BI?
```
• Hypotonia
• Presents more in acute cases
• Postural considerations
–Kyphosis
–Rounded shoulders-scapular
depression, downward rotation of glenoid fossa
–Abduction of humerus
–Scoliosis toward paretic side
• Brachial plexus injury
```
158
What are the characteristics of anterior subluxation in patient with hemiplegia following a BI?
```
• Hypertonic
• Muscle imbalance
– IRs v. ERs
– Add v. Abd
– Flexors v. Extensors
• Scoliosis increased with
tight lats & pelvic elevation from quadratus lumborum
```
159
What are some ways to manage a subluxation in a patient with hemiplegia following a BI?
* E-stim
* Supports
* Positioning
* Strengthening
160
What are the characteristics of a GivMohr Sling?
* Reduced vertical subluxation without overcorrecting
* Rolyan cuff did not significantly reduce vertical subluxation
* No change in horizontal subluxation
161
What happens in our patients have being flaccid after a BI?
Develop hypertonicity in the arms
162
Whar are the characteristics of adhesive capsulitis in patients with a BI?
• Pain, stiffness, and limited ROM
• Capsular pattern: ER limitations > Abduction limitations > IR limitations
• Cyclical problem
• Best treatment is prevention
• Once present: mobilizations, stretches, modalities,
pharmacological management
• May resolve, may require surgical management (not recommended)
163
What are the signs and symptoms of impingement in patient with a BI?
• Painful arc & “toothache” type discomfort
• Pain on resisted muscle testing
• Local tenderness over specific cuff muscle
• Subluxation
• Nocturnal pain
• Pain referred to upper lateral brachium
• Greater restriction in IR-1
st, 2nd elevation, 3rd ER
• (+) impingement testing
164
What is the treatment for impingement in patients with a BI?
• Stretching where tight
• Posterior capsular mobs
• Improve scapular posture to optimize length tension
ratios for the rotator cuff
• Strengthening the scapular stabilizers & rotator cuff
mm (ER & abductors-rotator cuff mm hold humeral
head down)
165
What are the best practice recommendations in patients with an UE dysfunction as a result of a BI?
• Education in proper handling
• Support at all times for flaccid shoulder
- w/c support, pillows
- Shoulder protracted, arm forward, slight abduction and neutral rotation
- Brace or sling as patient begins gait
- FES
• Analgesics and antispasmodics for spastic shoulder
166
What are the dos and don'ts in protecting the hemiplegic shoulder?
- DO NOT pull affected shoulder for turning or repositioning
- DO support scapula & pelvis for turning or repositioning.
- DO NOT elevate arm with hand rotated toward middle or down.
- DO elevate arm with thumb pointing up toward ceiling
- DO NOT support from weak arm to stand or walk
- DO support at pelvis to stand or walk
- DO NOT pull from affected arm to assist with sit to stand transitions or to reposition.
- DO assist for standing at pelvis.
167
What are the keys to repetitive task practice in the rehab of a patient with UE dysfunction?
• Identification of 5-6 tasks pt most wants to carry out
• Task and movement analysis
- ID primary impairments
- ID movement components that need remedy
- Determine level of challenge
• Use home exercise program to transition to home UE use
• Motor Activity Log or other tools to increase pt’s awareness and track progress
• Usually done 3x a week for 10 wks
168
What are the characteristics of mental practice in the rehab of a patient with UE dysfunction?
* Repetitive cognitive rehearsal of physical movements in absence of physical, voluntary attempts
* Shown to trigger the same neural areas and musculature as physical practice
* Most effective when combined with task specific practice of same skill
* Accelerates motor learning and improved movement
169
What is Constraint Induced Movement Therapy (CIMT)?
Combination of repetitive task practice (RPT), behavioral training techniques, and
restraint of less affected UE. Focuses on the forced use paradigm, with patients performing meaningful functional activities
170
What are the standard requirements for Constraint Induced Movement Therapy (CIMT)?
* 10 degrees active wrist extension
| * 10 degrees extension of thumb and at least 2 fingers
171
What are the standard protocol for Constraint Induced Movement Therapy (CIMT)?
* 2 weeks treatment period
* Restraint of less affected limb for 90% of waking hours
* 6 hours of RTP
172
What is the research evidence behind Constraint Induced Movement Therapy (CIMT)?
Numerous studies show CIMT to be more effective than usual care, even in chronic populations
173
What is the protocol for the modified Constraint Induced Movement Therapy (CIMT)?
* 30 min treatment sessions
* 3 times per week
* 10 week treatment period
174
What are the key components of the Constraint Induced Movement Therapy (CIMT) and the modified version?
* Restraint
* RTP
* Behavioral techniques such as shaping
175
What is the research evidence behind the modified Constraint Induced Movement Therapy (CIMT)?
As efficacious as CIMT, with better clinical utility
176
What are the characteristics of bilateral arm training as an intervention for UE dysfunction?
• Everyday tasks often involve bilateral UE use
• Training a unilateral task doesn’t improve use in bilateral tasks
• Coupling effects when arms are moved together; can be exploited for training benefit
of paretic arm
• Results in increased facilitation of both hemispheres and reduced intracortical
inhibition
• Does not seem beneficial in all patients… attention needs to be matching training approach to specific pt characteristics
177
What are the training mechanisms of bilateral arm training as an intervention for UE dysfunction?
* Repetitive training with hand fixed
* Isolated muscle repetitive tasks training
* Whole arm function training
178
What muscles are usually targeted when using FES on a hemiplegic patient?
- Deltoid and pecs
- Supraspinatus
- If the patient isn't in IR: mid deltoid and supraspinatus
- Arm in IR: posterior deltoid
- Most common is supraspinatus and mid deltoid
179
During FES of the shoulder, we want to avoid using it over what muscle?
The Upper trap
180
What is the evidence of the use of FES?
• FES in addition to conventional superior to
conventional alone
• More successful in Acute to subacute stroke (less than 6 months)
• Review is strongly supportive of short-term effects,
but inconclusive for long term effects
• FES does not have significant effect on upper arm motor function early after stroke (impairments improved, not necessarily function)
• In chronic stroke, 2/3 studies found effect (EMG activity and abduction force, but no functional improvement)
• Lateralization of activity dependent on severity of impairment… patients with some finger extension shift towards focused activity in ipsilesional site; those without finger extension showed enhanced
involvement of contralateral site
181
What are the characteristics of mirror therapy as an intervention for a hemiplegic patient?
• Used to improve motor function
• Mirror placed in patient’s midsagittal plane
• Reflects movements of nonparetic side as if it were
affected side
• Improved sensory and motor function and stimulated
recovery from neglect
• Evidence supports use as additional intervention
• Form of motor imagery
• Use mirror to create reflective
illusion of affected limb
• Go through a series of motions multiple times
182
How do you treat the flaccid UE?
- Maintain good flexibility(ROM) even if it is passively
- Weight bearing activities to try to increase stabilization and activation around the shoulder girdle
- Bilateral activities
183
How do you treat the more chronic UE?
- Maintain/regain ROM
- Weight bearing activities
- Finding positions that allow gravity to assist
- Focusing on movements that are against the person's natural position
184
What are some Activities to Facilitate Increased UE Activation in Acute Setting?
* Weightbearing stability development
* Weightbearing mobility
* Active Assist
* Bimanual activities
* Movements with weight of arm supported
* Isometric/stability first, then mobility
185
What are some ways to progress the dysfunctional UE?
* Weightbearing/closed-chain to non-weightbearing/open-chain
* Gross motor to fine motor
* Isometric to eccentric to concentric
* Short lever arm to long lever arm
* Gravity assisted to gravity eliminated to against gravity
* Automatic to cognitive
* Open hand to grasp
* Grade grasp: large to small, non-weighted to weighted, firm to compliant, without arm movement to grasp with arm movement
186
What are some thoughts to keep in mind while rehabing patients with an UE dysfunction?
* Motivation and expectancies
* Salience and autonomy
* Awareness, attention, education
* Anticipate problems
* Understand patterns of recovery and treat appropriately
* Support and positioning
* Develop stability while maintaining mobility
* Limit/control degrees of freedom
* Match demand to capacity
187
There is ____ support for efficacy of strength training in
| persons with neurological disorders, even in presence of spasticity
There is *strong* support for efficacy of strength training in
persons with neurological disorders, even in presence of spasticity
188
What is strengthening really about in weak patients with a neuromotor disorder?
• Changes in cortical excitability
• Fewer motor neurons area activated post training due
to enhanced efficacy of synapses
• Changes in motor unit recruitment and increases in
neural drive
• IMPROVING MOTOR UNIT RECRUITMENT
• Longer treatment duration may be warranted
189
What are the key components of strengthening in weak patients with a neuromotor disorder?
• Customized strengthening intervention
- Characteristics of patient (dx, age, comorbids, functional
level, balance ability, level of motor control recovery or
stage of disease progression)
• Ongoing evaluation and progression
- Continual challenge to neuromuscular system to adapt and facilitate optimal recovery
190
What is included in the 5D Differences in “strength” presentation based on Practice Patterns?
Nonprogressive disorders of CNS
• Directly related to specific site and severity of BI; correlate with
functional status; remediation improves function
191
What is included in the 5E Differences in “strength” presentation based on Practice Patterns?
Progressive disorders of the CNS. MS, parkinsons....
| • Progressive decline in strength
192
What is included in the 5G Differences in “strength” presentation based on Practice Patterns?
Acute or chronic polyneuropathies. GBS, CIDP....
| • Weakness is primary clinical issue; careful recovery phase
193
What is included in the 5H Differences in “strength” presentation based on Practice Patterns?
Nonprogressive disorders of the spinal cord. Traumatic injuries
• Weakness or total paralysis that correlates with site and extent of damage; recovery depends on degree of sparing and neuroplasticity at SC
194
What do we see in patients post stroke?
* Force production or impairment of motor control
* Weakness primarily on paretic side contralateral to lesion**with some ipsilateral weakness
* Primarily distal, flex/ext affected equally
* Reduced force generation plus slowness in force production, excessive sense of effort, rapid onset of fatigue
* Cause: central activation deficits(primary problem), transsynaptic degeneration and secondary changes in muscle
195
What do we see in patients with an Acquired BI?
• Variable impairments depending on focal or diffuse
injury
• Weakness compounded by other injuries
• Could be unilateral or bilateral
• Primarily central neural activation deficits with impaired ability to active motor units
• May also have disuse atrophy
196
What do we see in patients with MS?
• Scattered axonal degeneration and reduced or
blocked nerve conduction
• Disruption of supraspinal and/or spinal pathways to
motor unit pool
• Weakness and muscle fatigue
• Reduced and slowed force production
197
What are the characteristics of Strength Training Post Stroke?
• Effective in improving strength, less robust evidence
of link to improved function
• What makes for most transfer of increased strength to
increased function?: Task specificity and intensity
• Modes: PRE, circuit training, isokinetic(not very common), functional/ task specific
• Low to high intensities (mod-high should be the aim)
198
What are the characteristics of Strength Training in MS
• Strength plus aerobic training improved fitness, function,
and QOL
• Carry over to function
• No increase in exacerbations, minimal risk of adverse side
effects
• Resistive training at least 2x/wk at moderate intensity and task specific training – mild to moderate MS
• Strengthening to maintain strength and prevent decline in
those with moderate to severe
199
What are the medical management options for GBS?
```
• DVT prophylaxis
• Appropriate mgmt of symptoms
• Immunotherapy
- Plasma exchange
- IVIG
```
200
What are the PT interventions for GBS?
• PROM and positioning to maintain flexibility, prevent
skin breakdown, facilitate respiratory management
• No AROM during ascending phase (no more progression of weakness)
• AAROM to AROM after paralysis begins to descend
• Pain control: positioning
• Functional training, energy conservation
201
What are the treatment options for CIDP?
```
• Responsive to IVIG and plasma exchange
• Responds to corticosteroids
• Rehab initially, as well as ongoing
- Strengthening
- Energy conservation
- Orthotics and ADs
```
202
What are the treatment options for CMT?
* Strengthening what remains
* Appropriate stretching
* Orthotic management
* Activity specific training
203
What are the general rule for the exercise prescription in PPS?
• Muscles that test at a 3 or below should not be exercised other than gentle stretching and should be protected during exercise.
• Muscles that test at a 3+ to 4 can be exercised cautiously.
• Muscles that test at a 4+ to 5 can be exercised moderately to
vigorously, provided no signs of overuse present.
204
What are the 20% rule for the exercise prescription in PPS?
* Establish maximum capacity for any one exercise.
* Begin your program at 20% of that capacity.
* Do this level 3-4 times/week for 1 month.
* Increase by 10% each month if no new problems.
205
What are the other interventions for patients with PPS?
* Self management
* Lifestyle changes for reduction of metabolic load
* Education about the polio-PPS process
* Alleviate and prevent pain
* Minimize postural and gait deviations
* Maintain/increase function
206
What are the effects of assistive devices and orthotics in patients with PPS?
* Can help to decrease load
* Make mechanics more normal
* Very fine line for correcting mechanics
* LISTEN TO YOUR PATIENT
207
What are ALS Medical Management options?
```
• One drug approved: Riluzole
• Respiratory failure
- Non-invasive Positive Pressure Ventiliation
- Tracheostomy
• Safety
• Bulbar dysfunction
- Change diet
- Feeding tube
```
208
What are some "good" exercises for patients with PPS or siila?
- Aquatics
- Sit and be fit
- No long lever
- Upper extremity
- Isolated muscle exercises with no weight
- Modified yoga
- Potential stationary bike
209
What are some "bad" exercises for patients with PPS or other neurodysfunction?
- High reps
- Things that involve alot of "pounding" like treadmills and such
- Vigorous
210
What are the spasticity management options for ALS treatment?
* Medication
| * Standard interventions
211
What are the pseudobulbar affect options for ALS treatment?
Medication
212
What are the weakness treatment options for ALS treatment?
* Submax strengthening for muscles not yet affected
| * Adaptations, supports, w/c, assistive technology
213
What are the miscellaneous treatment options for ALS treatment?
Education, planning
214
What are some preparatory interventions for patients with weakness in neuromotor disorders?
* NMES
* EMGBFB
* PNF
* PRE
* Isokinetic exercise
* Task-specific strength training
215
What are some exercise principles in patient with neuromotor disorders?
• Overload
- Subacute and chronic stroke tolerated 80% 1RM
- Recommendations for 60-75% 1RM with 10-15 reps
- Maybe submax for early rehab
• Specificity of training- type and speed of muscle contraction, length of muscle during training
• Cross-training – introduce variability
• Reversibility – detraining effects unless strength is
maintained
216
What are the characteristics of the type of contraction in strength training in neuromotor disorders?
• Isometric – initially, build force-generating capacity;
increase strength in postural mm; Valsalva caution
• Eccentric – more efficient, require fewer MUs; effective in early strength training; caution in GBS, PPS, other neuromuscular disease (do this 2nd)
• Concentric – eccentric before concentric increases
force of concentric; increase speed to focus on power
217
What are the characteristics of PRE in patients with neuromotor disorders?
• Cuff weights, elastic bands, weighted bars, weight
machines, etc…
• 1RM versus 10RM
• Slow to moderate speed
• Attend to quality, stabilization (find right position for best)
• PRE is best for those with at least 3+/5
218
What are the characteristics of aquatics in patients with neuromotor disorders?
* Supported environment, reduced weightbearing
* Can offer resistance
* Effect of water temperature
* Positives and negative(still not functional, possible open wounds, safety issues, fearful patients)
219
What are the characteristics of exercise machines in patients with neuromotor disorders?
* Accessibility and safety
* Teach safety and set-up
* Monitor
220
What are the characteristics of functional task-oriented strengthening in patients with neuromotor disorders?
• Addresses multiple system impairments and promotes
transfer to functional skills
• Focus on the task or specific movements required for
the task
• Think about manipulation of the 3 factors:
- Individual
- Task
- Environment
221
What do we do for patient with very weak muscles?
* Sensory Stim
* NMES
* Biofeedback
* Combo of EMG triggered NMES
