Week 6 Spinal Cord Injury Flashcards
Traumatic – tackling someone and get a traumatic injury, shootings, falling. Something external to the body that compromises blood flow to the cord.
Non-traumatic – cancers, vascular – spinal cord infarct
NO NEED TO KNOW THE NUMBERS ON THIS SLIDE !!!
Most people who have a sci who do qualify for rehab get 4 weeks at tops.
Most traumatic injuries
Falls – have to know if someone is at falls risks. Falls lead to catastrophic injuries such as SCI.
First year of SCI costs the pt about a million dollars.
Reduced life expectancy
Higher medical cost/care
“Paralysis is a problem moving the body due to disease or injury to the nervous system. There are two types: Paraplegia—full or partial paralysis of the lower half of the body. Quadriplegia, sometimes called tetraplegia—paralysis of both legs and both arms.”
“Paraplegia is a paralysis starting in the thoracic (T1-T12), lumbar (L1-L5) or sacral (S1-S5) area, while tetraplegia is caused by damage in the cervical area (C1-C8). Persons with paraplegia possess good functioning of the arms and hands.”
Tetraplegia – involvement of all four limbs (arms and legs)
Incomplete – spinal cord wasn’t completely shut down or cut. Still pathways that are open.
Complete paraplegia – no motor or sensory function below the injured area.
Old school therapists – quadriplegia – synonymous with tetraplegia
The primary ascending tracts:
Dorsal column - conveys (limb movement/proprioception, vibratory sensation, deep touch, and discriminative touch)
Anterolateral system:
spinothalamic, spinoreticular, and spinotectal tracts. Conveys (unconscious proprioception/pain, temperature, and crude touch)
Dorsal and ventral spinocerebellar tracts - conveys (conscious/unconscious) proprioception
The primary descending tracts:
Lateral corticospinal - (Unvoluntary/Voluntary) movement
Anterior corticospinal (Unvoluntary/Voluntary) movement of axial muscles, minimal functional significance due to small size
Medial vestibulospinal (posture and balance/positioning of head and neck)
Lateral and medial vestibulospinal (posture and balance/positioning of head and neck)
Lateral andMedial reticulospinal (positioning of head and neck/posture, balance, automatic gait-related movements)
Rubrospinal - movement of (neck/limbs)
He loves the anatomy
Right side – motor tracts
If you know your anatomy it is easy points on expectations to expect on injuries or syndromes or certain parts of the body that are affected.
proprioception, vibratory sensation, deep touch, and discriminative touch; pain, temperature, and crude touch; unconscious; Voluntary; Voluntary; positioning of head and neck; posture and balance; posture, balance, automatic gait-related movements; limbs;
“In complete spinal cord injuries, the spinal cord is fully severed and function below the injury site is eliminated. In comparison, incomplete SCIs occur when the spinal cord is compressed or injured, but the brain’s ability to send signals below the site of the injury is not completely removed.”
These syndromes guide thinking on potential for the pt to get better, plan of care stuff as well.
Brown-Sequard Injury
Ipsilateral side:
(Motor and sensory loss (DCML)/Loss of pain and temperature)
Contralateral side:
(Motor and sensory loss (DCML)/Loss of pain and temperature)
Begins several dermatomes below – why?
Lateral spinothalamic tracts ascend two to four segments on the same side before crossing and the descending motor tract decussating in the medulla
Facts:
Sparing of dominant (leg/hand) + predictor of increased function
Distal UE sensation/motor (first/last) to return
Rarely a pure injury
75% (will/won’t) ambulate!!!
A complete hemisection of one side of the spinal cord.
A pure knife cut through the spinal cord and this is what they saw in a case study way back when.
Contralateral – lose pain and temp.
On the pink side on the pic – lost motor and sensory function on the brain
Green side – pain and temp loss.
DCML
Corticospinal tract on one side
Spinothalamic crosses and that is why you have the duality of the motor and sensory loss.
DCML crosses, goes up ipsilaterally
Spinothalamic – crosses right away and then goes up the opposite side which is why it is contralateral
Brown Sequard – disc herniation in the neck, isolated gun shot wounds
These individuals will likely ambulate.
Know which side has motor and sensory and which side will lose pain and temp
Motor and sensory loss (DCML); Loss of pain and temperature; hand; last; will
Central Cord Syndrome
(Least/Most) common SCI syndrome
Cervical injuries, (hyperflexion/hyperextension) due to a fall - > 50 years
UE impairment (more/less) than LE impairment - This is similar to the homunculus. The closer you are to the core you get more (UE/LE) loss, more distal you lose more (UE/LE). That is why in the central cord you get more (UE/LE) loss.
Positive Predictors of Recovery: higher level of education, absence of spasticity (older/younger) age Preservation of sacral tracts
Compromises central gray matter
Get UE loss greater than LE.
They’ll have stronger legs than arms.
Central cord – fairly ambulatory, but functional use of their hands really bothers them.
Most; hyperextension more; UE; LE; UE; younger;
Anterior Cord Syndrome
Usually result of (flexion/extension)-based spinal injury (cervical spine)
Cord itself and/or vascular supply is compromised
Loss of (below level of injury): (Motor function and Pain and temperature/light touch, proprioception, and vibration)
Often require longer durations of stay
Flexion based injuries – car accident – really flex neck.
Cardiovascular – anterior infarct of the spinal cord
Corticospinal tract is gone which is loss of motor.
Non red portion of the spinal cord is where the DCML is so it doesn’t affect LT, prop, and vibration
Spinal cord infarcts – due to diabetes – can get anterior cord syndrome
flexion; motor function and pain and temperature;
Cauda Equina Syndrome
“Horse’s tail”
Injury to cord as it exits the spinal column - Below L_
Impairments vary based on nerves injured
Areflexic bowel and bladder
(UMN/LMN) Injury!!
Cauda equina – insult to the spinal nerves below the level of L1.
Below the level of L1, those nerves are part of the LMN system . They will have reflexic bowel and bladder – can’t control when they want to go. Likely flaccid muscle tone, minimal reflexes or a 1 at best.
Impairments based on nerves injured – this area has a lot of adaptability so it is person dependent.
L1; LMN;
Spinal Shock
The absence of muscle tone/reflexes below the neurological level of a pt with SCI - due to initial inactivity of associated (UMNs/LMNs)
Period of time varies in literature: (days to weeks/weeks to months) - Usually 2-3 weeks maximum
Clinical presentation: Flaccid muscle tone Flaccid bladder, sphincters Absent DTRs Absent erection in males
Consideration: careful with (AROM/PROM)
Exact cause is unknown
When there is an intital injury to the spinal cord there is a period of days where there is an absence of tone where they are just flaccid due to the shock. As the body reheals you’ll get more UMN presentations. Spasticity will slowly become present and there will be a period of transition as the body starts to figure it out.
If this individual has this presentation have to be careful of PROM because you could stretch the joint to ranges they can’t support and could cause orthopedic injury. Can take the joint to extreme ranges where you can compromise the tissue, the labrum, things like that, etc.
LMNs; days to weeks; PROM;
Pressure Injury (“Pressure wounds/Bed sores”)
Diminished or absent sensation in pressure-sensitive areas can lead to prolonged immobility in areas
Major Complication:
Leads to risk of infection, reduction of sitting time, impacts functional gains, increased LOS, need for surgery
How to we address this?
Need to weight shift Q (every) _ min
20 second lift 2-3x (push up)
3-5 min tilt or lateral lean
Turning in bed: Q _ hours at night; Q _ min in therapy
Education to patient and family
How would you write a goal for this ?
Pet peeve of his is pressure injury
These individuals won’t feel what we feel. If sitting for a long time, butt gets sore and you do micro shifts. Those with sci injuries might not feel this and will be on the bony prominences for a long time and don’t do those micro shifts which will result in a pressure injury.
Someone who has impaired sensation – have to be mindful of skin and tell them how to relieve pressure in whatever position they are in.
Weight shifts every 30 min the individual has to do a weight shift is how we address this.
If someone is sitting, they can do a push up while you are in your chair – that is a form of a weight shift.
If in a tilt chair – need tilt back for 3-5 min
Goal of weight shift – take pressure off whatever area has the highest pressure and allow the blood flow to keep the tissue healthy.
Pressure injuries are the biggest thing a therapist can address.
30; 2; 30;
Death: septicemia
Pneumonia, PE
They stop breathing in pulmonary compromise
Primary – diaphragm – phrenic – C3-C5
Abdominals and intercostals are the big ticket items
If I have a spinal cord injury that affects the cervical C3-C5 they might have a lot of problems breathing.
Part of the therapy is to address how the person is going to manage the secretions and that this is the highest risk for this person to pass away.
Higher levels – c2-3 – need ventilation for life. C1 – vent for life (superman guy)
Lower cervical injuries – limited ability to cough. Coughs that don’t come up – similar sensation – very frustrating
Interventions: Strengthen/stretch (lumbar/thoracic) muscles Medications Assisted cough Abdominal binder Maximize sitting alignment
Lots of stretching
Medications – medications to help produce a cough – expectorants
Lack muscle tone in the abdominal binder and its more flaccid, can use abdominal binder – common in this population
Maximize sitting alignment – challenging to take a breath in the (lordotic/kyphotic) position.
thoracic; kyphotic
Bane of dr. b’s existence
Pain can be mechanical – you can change their pain response with movement – ex – neck retractions and pain goes away
Neuropathic – issues to the spinal cord – specifically spinothalamic tracts – deep ache that doesn’t go away .
No one preferred – if someone is having neuropathic, can start with mechanical tx, but sometimes it isn’t helpful because the pain behaves differently than normal orthopedic mechanical pain.
Mechanical – stretching and strengthening
Autonomic Dysreflexia (AD)
Physiologic response that can occur with SCI (above/below) T_
Classic for the upper level paraplegic or tetraplegic.
AD – a response to a noxious stimuli below the level of T6. Noxious – can be anything – sitting on a pin, anything that the body perceives as irritating. Noxious stimulus is below the level but get symptoms above t6.
Bottom left up to the right - you get a sympathetic response below the level of injury – the response .. The baroreceptors near the c spine sense this and start to make changes in the CV system to keep you alive.
Afferent signal to the brain say something is happening down there and the body tries to respond. In a sympathetic response you get increased BP and it will do things to lower it such as bradycardia. Individuals may experience flushing or sweating, low HR due to the autonomic response.
above; T6
Autonomic Dysreflexia (AD) Treatment
~41% of SCI injuries above T6 have never heard of AD
Keep people upright, remove the stimulus – most likely a bowel bladder issue.
Is body part touching the noxious stimulation?
Keep them upright, monitor their BP, look for the stimuli and you’ll be fine. It takes time to unravel as the ANS starts to resolve itself. That is why taking BP at the tart of the session is key.
Risk factors for fracture include being female, having a lower BMI, complete injury, paraplegia versus tetraplegia, and longer time since injury
Long bones tend to be at greater risk for breaking in those with SCI. wolfs law – if someone isn’t standing or putting weight through its bones you lose all of that in the first 4-6 weeks and you’ll be dealing with osteopenia with basic mobility tasks that shouldn’t’ cause fxs like bed mobility, even putting on a sock.
Have to get weight through their body even if they cant stand on their own – tilt table (benefit of assessing their CV response as well), standing frames (even if they cant stand can sit in a machine to get weight through their body), e stim – when you stimulate a muscle tension is created and bone recycling occurs, and not only do you make the muscle stronger, you make the bone stronger as well
Spinal cord injuries above L1 – B/B – Bowel/bladder – cant empty bladder on command - sphincters are tight
Sci injuries below L1 – flaccid or areflexic
Individuals who cant actively defacate on their own have to train the b/b to empty when they want it to.
Theme of the (UMN/LMN) – preplanned schedule to minimize UTI, bowel obstruction because they don’t know when they have to go.
(UMN/LMN) – Lack control of the sphincter – know you have to go but cant control the stop. The bladder is flaccid and when the fluid is in there itll just go.
Timed void – fluid is in at 10 o clock, gotta make sure to go by noon.
Pelvic pt – help recruit those muscles for the loss of control.
This slide is important because individuals with paraplegia want to change their bowel and bladder routine. If you don’t manage this – lots of accidents, skin issues, etc. they’d rather prioritize this than their mobility. Think of what this does to their QOL.
UMN; LMN
If you have a bony fx, herniated disc, if you let it ride and don’t stabilize it to protect the spinal cord – can cause long term complications
These you will absolutely see.
People with cervical infusions – Miami j or aspen – meant to stabilize the neck and prevent rotation – does it do that? He is not convinced. Want the neck relatively still not to compromise the surgery.
We cant discontinue a collar as a PT.
West coast people don’t use collars – very stable surgeries
Brace at the bottom – clamshell TLSO – same concept – worn around the trunk – limits flexion and extension in the sagittal plane to not compromise whatever surgery was performed
Most individuals will have precautions from the surgeon – BLT (Bending, lifting, twisting). Cant twist in the transverse plane, cant lift more than a 1lb or 2. cant bend – flexion/extension in the sagittal plane.
Tenodesis – c6 complete injury lack digit control. What this population does to compensate for the hand gripping which is tenodesis of the wrist – just extend at the wrist – flexion of the fingers. If you lack gripping, can use tenodesis. Can use it to grab a remote, bedsheets.
Stretching fingers – you lose tenodesis capability, don’t want that in tenodesis. You want the tendons to be relatively shortened.
TLSO – log rolling to get out of bed
If you are unsure – check with physician and hospitals to know what you can or cant do with these pts.
Negative prognosis – cord contusion, edema, hemorrhage – causing tissue death.
Incomplete – the spinal tracts – still passages that can come from the brain to the muscles. A complete injury loses that passage.
Complete – taking a knife and severing the spinal cord. Bad prognosis.
Not all complete injuries are completely severed so potentially still some sparing.
Traumatic – gets better (slower/faster)
Non traumatic – gets better a little (slower/faster)
Both end up at the same spot further down the line in terms of recovery
faster; slower
One of his fav articles – looks at recovery
ASIA exams – what we in therapy can do to classify individuals
A – worst
D- the best
Level of injury can dictate how much better they can get.
If ASIA exam starts bad they’ll end bad.
If it starts off well – Chances of maintaining it are really good.
What the person looks like in the first three days gives a lot of info in what they will look like in a year. If they look good in those three days push them hard to maximize benefits in that year .
If they start off slow – maybe approach with a compensatory mindset since you know the chances of a miracle recovery are slim.
People that start with ASIA A – likelihood of walking is next to nothing. Maybe don’t prioritize walking since it is honestly not realistic. Maybe prioritize other things they will need early on as opposed to walking.
AIS B – no motor function below their injury but can still feel something.
If you have these individuals in front of you and they can walk – push push push
Complete – no motor or sensory function below the injury
C1-C4 – will be dependent – bed mobility and walking. Can be modified independent with power wheel chair
C6 – go from max assist to min independent
Difference between c5 and c6 is this huge jump to be able to be functionally more independent
T12 – may gain the ability to walk with knee ankle foot orthoses
L2 – may be able to walk
T12/L2 – therapeutic walking in nature – not going to just be walking down the street all willy nilly.
Does everyone always follow this projection – absolutely not
The more strength they have straight out the gate, the better they get.
In SCI, they classify the deficit based on the ASIA exam > next slide
Governing body of the spinal cord in America.
When people have a SCI, depending on how severe the deficits are dictates the overall level of their injury and what is expected of them functionally.
This is the crux of anything spinal cord that we will talk about in the next 4 weeks.
Pts, doctors, spinal cord research will refer to their ASIA level
ASIA Guidelines
American Spinal Injury Association (ASIA)
International Standards for Neurological Classification of SCI (ISNCSI)
Standardized assessment used to define level and completeness of injury
ASIA Impairment Scale (AIS)
Neurological Level:
the most (rostral/caudal) level of the spinal cord with normal motor and sensory function on both the left and right sides of the body.
Sensory and motor levels
Motor level: lowest myotome with at least _ on MMT provided that key muscles above are (4/5/ (5/5) MMT
Sensory scoring is used for those levels that don’t have a key muscle to test (i.e. C1-4)
Sensory level: most (rostral/caudal) level with normal light touch and pinprick sensation
Developed in the 1980’s Consistent standardized exam Consistent identification of neurological level and severity Standardized classification system Reliability data to NSCISC
You get a neurological level – the level that works (C1, L2, C5, etc
caudal; 3; 5/5; caudal;
Middle two columns look at (motor function/light touch through the DCML and pin prick through the spinothalamic pathway).
Each little black dot is where you would test for sensation
light touch through the DCML and pin prick through the spinothalamic pathway
0 – absent
1 - Impaired – something Is there but it feels different compared to the reference point (cheek in the face in the ASIA world)
Normal – 2
Light touch – cotton swab
Anal sensation – absent or present
Do it with eyes closed to minimize guessing.
The cheek is the sensation they compare whether their sensation is normal or not
Incorrect component – if they give you inconsistent responses – if they get less than 8/10 it is impaired – can feel something but it isn’t’ accurate.
Go through all 28 bullet points
Common pitfalls:
Pin/prick contact time – touch the dull side , don’t press into the skin to give them more sensation. Touch and release.
Did you feel that – they’ll lie and say yeah because they want to do well
Inaccurate use – have to follow the dermatomal pattern from the ASIA score study
5 upper and 5 lower muscles
No pluses or minuses because they haven’t been validated across consistency of graders
Done in supine position which is different from MMT positions
Can the muscle produce force, is it working?
If pain or amputation and cant test muscle – say not tested. As of 2019 the ASIA group added asterisks to give people credit for their strength that don’t involve sci conditions.
Specific myotomes they chose to test.
These myotomes get majority of their input from one specific nerve root. Read the muscle group next to the C5, C6, ETC
Key Muscles
C5 - Elbow (flexors (biceps)/extensors (triceps))
C6 - Wrist (flexors/extensors) (flexor/extensor) carpi radialis
C7 - Elbow (flexors (biceps)/extensors (triceps))
C8 - Finger (flexors/extensors) (flexor/extensor) digitorum profundus of the middle digit
T1 - Small finger (adductors/abductors) (adductor/abductor) digiti minimi
flexors (biceps); extensors; extensor; extensors (triceps); flexors; flexor; abductors
Key Muscles
L2 - (Hip flexors (iliopsoas)/Hip extensors (glute max))
L3 - (Knee flexors (hamstrings)/Knee extensors (quadriceps))
L4 - (Ankle dorsiflexors (tibialis anterior)/Ankle plantar flexors (gastroc-soleus complex))
L5 - (Great toe flexor/Great toe extensor (extensor hallucis longus))
S1 - (Ankle dorsiflexors (tibialis anterior)/Ankle plantar flexors (gastroc-soleus complex))
****Trunk: no formal way to test myotome
SENSORY LEVEL = MOTOR LEVEL T_-L_
Both sides tested—sparing/loss is usually assymetrical
No way to measure the trunk.
If the sensation is 2 (normal) in the thoracic region, can make the assumption the muscle is innervated and would be a full 5/5 for muscles
Hip flexors (iliopsoas); Knee extensors (quadriceps); Ankle dorsiflexors (tibialis anterior); Great toe extensor (extensor hallucis longus); Ankle plantar flexors (gastroc-soleus complex); T2-L1
Measured through the S4/S5 dermatome
Light touch and pin prick 1 cm lateral to the anus
Voluntary anal contraction – can they contract anus as if they were holding a bowel.
Huge component of the exam and if they perform “well” that is huge
If they cant feel pressure when they insert – that is a no “N”
0 in the S4/S5 – creates the term noon
If someone has a complete injury you (will/won’t) see a noon at the bottom of the score sheet.
will
AIS A – NOON description he was referring to.
Everything apart from AIS _ is incomplete.
AIS (C/B) – can still feel sensory components. Sensory is there, motor is not.
AIS (C/B) – motor incomplete. Below the level of injury they still have muscles that work
AIS (A/D) – more strength and more sensation
Each letter gets a little bit better in terms of strength and sensation as you go down
Read the back of the scoresheet, explains all of this
AIS (D/E) – normal function – doesn’t present with a SCI. if they have injury to their neck and they have all strength and sensation, would be AIS E
If someone starts of AIS A, likelihood of moving to AIS b is like 3-5%.
If someone is AIS b and has pin prick sensation, likelihood of walking and converting to AIS c is pretty good.
Individuals cant skip a level ex – AIS B – AIS D. individuals also don’t go backwards .
Incomplete – force recovery. Complete injury – doesn’t mean cant try recovery, but maybe emphasize compensatory while recovering what can still be recovered.
A; B; C; D; E
Complete injury population – zone of partial preservation – attempt to give these people credit for the strength they do have. You can grade those muscles and still give them credit, doesn’t change their ASIA score really.
Copied and pasted from the worksheet.
Make sure you understand the details.
Bold is more important points in each category.
Substitution of muscles – if the person doesn’t have isolated bicep strength – could use shoulder flexion to make the difference. Be mindful of this substitution.
Can test non key muscles to be thorough even if the test doesn’t call for it especially if you know its an incomplete injury.
AIS – B – Can you abduct the hip? Can you evert an ankle? Asking them to move any muscles that aren’t specifically stated on the ASIa exam to give credit where credit is due.
Spinal shock – be mindful of how you move their limbs
Non tested if cant test in normal position.
ROM NEEDS – tenodesis – someone with a c6 injury might not want full finger flexion ROM because it isn’t functional for them.
Someone that cant use their legs – what do you think of shoulder ROM?
When people don’t have tension in the abdominal cavity when you push up the shoulders go one way. If you let the lumbar extensors get tighter you get that passive tension when everything moves at once. Want adaptive shortening at the trunk in a paralyzed population.
Hamstrings have to be flexible for this population especially for those that are sitting majority of the day. When sitting hamstrings are shortened, want them to be flexible instead.
Beneficial tightening/limitation in SCI
Goal:
Allowing some muscle and soft tissue to tighten to compensate for lost motor control
to promote function and skin integrity
Low back-promote neutral to slight PPT posture if injury above L_ - Allow mild tightening of lumbar muscles/structures
Hands:
Stretch with tenodesis if hand function affected (C_-C_) - Improves finger flexion with compensatory movements
Remember Spinal Shock initially present so do not overstretch!!
There are benefits to allow body parts to keep tight to compensate for the loss of motor control.
PPT – Posterior pelvic tilt
L2; C4-C8
