Week 7 Paraplegia SCI Flashcards
CASE A:
Intact – meaning 2
Impaired – 1
Go across the board and see which is the lowest line with 2s across the board. T3. total sensory level right and left is T3.
Step 2: motor level on the right. T3 – looking for the muscle that has a 3 or greater. On the right, all the UE myotomes are fine. If they have intact sensation in the thoracic region can presume motor function is also normal. T3 would be the motor level because it has 2s in that level.
Motor on the left – T6.
3- T3 on the right, T6 on the left. Neurological level would be T3. caudal segment of the cord with intact sensation is this level.
Step 4 - Look for NOON. Bottom row – N O O O O N
This is T3 ASIA A
CASE B:
Sensory level on the right side: T9 – lowest level that has 2s across the board. Left side: C8. c8 is the last level that has 2s for light touch and pin and prick
Step 2 – Right side: C8 – muscle that has 3/5 as long as all other muscles above are 5s. Left side : C7 – C7 has 3, everything else is 5 and above.
Step 3 – most cranial level – highest level - C7.
Step 4 - Complete or incomplete? Incomplete – no noon sign so it is incomplete
Step 5 – motor complete injury? Is there voluntary anal contraction ? Yes. Sensation at S4 and S5? Yes . Deep anal pressure? Yes. So we have motor function. This is at least ASIA C or D. there is motor function below the level of injury.
Are half of the muscles below the neurological level 3 or greater? There are 14 key muscles in total to determine if level C or D injury. Are 7 muscles or more graded at least 3/5? Answer is no.
C7 ASIA C is the final answer.
Hallmark of this exam is S4-S5.
A lot of this population wont feel everything in their body and the risk of pressure injuries is a lot higher.
Q – every
Q1 – first level that takes out the arms ? T_ and below start to be classified as a paraplegic. If you have a cervical level energy – tetraplegia.
Anything below T_ is dealing with an individual with paraplegia.
Incomplete injury – voluntary anal contraction or sensory sparing in (S4/S5/ T11/T12)
Hallmark of spinal cord injury is the anatomy of knowing what muscles are working and what muscles aren’t working.
Back of the asia score sheet – memorize it. Know the key myotomes in the UE/LE. Have to know the myotomes.
Lecture – dealing with complete paraplegic is the assumption for this lecture.
A complete injury – compensatory plan of care.
Stroke – recover recover recover
This is the pure opposite- compensatory based to make them as independent as possible
T1; T1; S4/S5
LTG expectation (complete paraplegia)
T1-T12/L1
Bed Mobility: (dependent/independent)
Transfers: (dependent/independent)
W/c mobility: MOD I within community; independent with pressure relief
Ambulation?:
Abdominals? (T7 below)
Independent with physiological standing and ambulation for exercise over short distances in the home (with crutches and (H)KAFOS)
*Dependent on motor level innervated
Contextual factors and personal factors of ICF
This population should be independent.
At the level of thoracic and L1 – likelihood to be able to walk is minimal. This population has a wheelchair based style of living. In a wheelchair should be independent – setting up brakes, transferring in and out, etc.
Ambulation – likely not going to happen
Depending on the motor level innervated you would expect different muscles to be innervated or not. If they are innervated – use them to the best of your ability.
independent; independent;
Pressure injury can develop within minutes or hours. If riding in a car and butt is sore – developing pressure injury. Only difference is we have sensation to sense it and then move, get up, and prevent that pressure injury.
People who are underweight who are just hanging out on their bones can have pressure injuries.
Each gets more severe as you go down the stage
Blanching – if you were to take your skin and put pressure on it – hold it there for minutes – when you release it there will be a discoloration and return back to your normal skin colour pigmentation in seconds. Non blanching – it will stay the same colour when you release.
Stage 2 – skin is disrupted. Infection risk goes through the roof. Bacteria and fungus can get in there due to the open ulcer. Sepsis can occur.
Deeper in the skin in stage 3.
Stage 4 – muscle and or bone is reached.
All stages are bad and avoidable.
Flap surgery – take a piece of tissue from different part of the body and stuff it and stitch it up like a patch essentially. It works!
Bed rest – not moving – locked in bed for a full month – time tissue needs to recollaganize – cant disturb this process.
BID – 2 x a day
Lost 3 months of mobility due to a skin issue which is a massive setback.
First and foremost hallmark thing we cand do is teach people weight shifts – shift weight from a pressure sensitive area. What areas of your body are taking the most weight?
Reducing sheering – within your session make sure they aren’t sliding or grinding skin into the wheelchair. If someone slides skin across the matt it is hard on the skin. Can add insult to injury if they already had a pressure injury.
High risk activities – riding a recumbent bike is an ex
Pressure maps – flat piece of fabric that lies across the surface you put it on and it takes a thermal mapping of where someone is putting pressure. Will sit on pressure map to see modifications that need to be made in weight shifts.
Have to educate these pts on the importance of weight shifts –
Dosage?
Every _ minutes for ALL types!
Tilt back:
ALL the way back for 3-5mins
Push Up: 30 seconds (2 x 15seconds
Lateral or Anterior:
2-3 minute holds
Supine/Bed:
Quarter turns q 2 hours
5 different ways to approach a weight shift
Weight shift be done every 30 minutes!!!! No excuses, has to be done!!
Push up – 2x15 if not that strong.
30;
Need back extensors and abdominal control to make this happen.
Lateral – bringing weight off of one ischial tube for a 2 minute hold.
Push up – pushing up
Tilt back – not strong enough in upper body and tilt back for 3-5 min. can be independent with tilt back weight shift by teaching the pt to teach someone to help them weight shift.
Experiment with different weight shifts to see the one the pt can be independent with.
Need these three components to have successful mobility. These are all compensatory.
Muscle substitution – learn to use muscles differently
Review of what we did in lab in writing form
Rolling
If t10 ASIA A – have to know what muscles are working and what muscles aren’t’ working
In rolling, people have to generate force and momentum.
The use of arm momentum – check video. Turn head and at the very end can protract scapula. Generate momentum, turn head, protract scapula are the three big ticket items.
Modification & Progression
Modification
Wedge assisted rolling – lifts trunk away from mat surface decreasing the force needed to achieve side lying.
Crossing of legs in the direction of roll
Adding a weight to the patient’s wrist
Manual assistance
Use of air splints to maintain UE extension
Progression:
Leaving Legs (crossed/uncrossed)
Performing skill on more compliant surface
(Increasing/Decreasing) the number of “rocks” used
Going to provide physical assist or challenge them? If someone needs physical assist, give it to them.
If pt can do it individually, maybe make it harder. If takes them three arm swings to do it, maybe try less swings.
uncrossed; decreasing
T12 injury
Using equipment can help to achieve a modified independent rolling technique.
Leg loops
Bed rails
Leg lifters
If someone needs physical help, they can learn how to physically assist themselves without assistance from another person to make them as independent as possible – video
Downside of this, to put that loop on and off is very challenging. There is a lot of dependence of this. Could be point of no return when someone builds habits with these skills. If leg gets caught they are fucked and are going down. Leg loops are an option for a pt who just needs that little push.
Clamshell brace from surgery to stabilize the spine.
Log roll technique wont be an individual technique because of the BLT precautions.
Chris in the video bent the pts right knee when they were turning to the left to prevent the trunk from twisting. When you bend the leg, they wont have the rotation at the hip which leads to rotation at the spine. When you bend their knee you create a mechanical advantage and the turn is very simple. Chris had his hands on the thigh and shoulder to create the roll. Further hands are closer together – lose stability of the roll. Have hands more spread apart for more stability on the roll.
Goal for this pt in the short term since they probably wont be independent – instruct the caregiver. Pt will be independent with caregiver instruction with dependent log roll technique.
If wearing a C collar patient cannot be in prone position
C curve – flexibility is huge. Hip mobility is huge. If you have tight hips it is more challenging. Wasn’t easy to do this technique. Maybe 1 or 2 shots at it during the session.
Can potentially stretch the hips to improve ability to do the c curve if initial attempt was wack due to noticed flexibility deficits.
This pt doesn’t have triceps. Chris has been behind the pt the whole time – will be behind the pt 9 times out of 10 so if they lose their balance you are right there.
Think if someone were to lose their balance where would they go? Most likely getting pushed down with gravity so have hands in gravity dependent positions to make sure that they are safe. Hands are on the pts trunk, not on their arms. Chris transitions to the front of the pt at the very end. This pt took 4-5 min to do this. Pts might be wiped out doing this and still have 55 min left in the session – just something to think about.
Can challenge her by having her do this on a sofa by changing the surface compliance, have her get out of a deeper surface (either king or twin size bed depending on what she is used to), have her do it in the dark, time them (can she go faster? – “house is on fire, can you get up and move quickly?”),
If wearing a C collar patient cannot be in prone position
If someone is struggling on a specific part, work on task part practice. Struggling with getting legs off of the matt, work on just doing that part.
Shadowing – doing the technique with the pt – kind of like the second brain in the operation – close supervision is also another name for it.
Sitting to supine – first part – need a lot of hip flexibility .
Chris is shadowing – letting the pt do his own thing
Can teach someone this transition if they are T1-T12.
Reasons to get someone in a long sit – to increase the surface area of the skin (skin integrity concerns), starting position for those who work on sitting balance (gives them a safety net if they fall forward)
Prop sitting – holding balance with arms – pic in the thumbnail
Squat pivot – someone has muscle activation of their legs
Lateral pivot – someone who does not have muscle activation of their legs
Whatever direction your head moves your hips go in the other direction – head-hips relationship.
Head hips relationship is important because you can compensate to be as independent as they can. If you use the head the hips will go no matter the strength. Individuals who lack strength need to rely on the head hip relationship to makeup for the muscles that are now lost.
Most important muscle for lateral pivot (assuming at least T4) – triceps.
Transfer boards – ben doesn’t try to use the transfer board unless absolutely necessarily. Will use the board if the surfaces have too much of a gap to transfer safely – ex – car transfer.
Majority of these individuals wont be walking with complete paraplegia. Have to be able to manage their wheelchair – adds value.
Chair most appropriate – lighter wheelchair – wont be tested on this so fuck it.
Super high risk for developing orthopedic shoulder pain in these individuals.
Overstretching – cant transfer because over stretched – lose head-hips relationship.
Arcing – not efficient
Double loop and semi circular are the most efficient
Can someone take on and off their leg rests, lock their brakes, set up their chair on their own?
Can they negotiate obstacles? Person going down sidewalk has to negotiate obstacles.
People have to learn how to do wheelies to independently get over elevated surfaces.
Anterior view and posterior view
WB is important in this population.
Tilt tables are great WB options for the neurological population. Probably going to start with this in this population. Orthostasis – high in this population. Need to get someone up and standing – tilt table is a good place to start. Can progress to standing frames.
A standing frame – can do movements with the UE to challenge their balance, can work on breathing exercises to promote the compensatory use of other muscles to promote breathing, strengthening of the upper body (can do simple therx)
When you go to breathe out or cough you use your abs - create pressure to pump air out of the lungs
When you put e stim on people in wb who have complete paraplegia it creates a bone mineral adaptation that helps maintain the integrity of the bone. When wb a pt can put e stim on a pt that will be helpful.
It works because message is being sent from the brain to the spinal cord.
Usually never too low on the parameters.
In neuro population – can typically tolerate more e stim due to their condition. If you can tolerate more stimulus, that can have a lot of value.
Muscles that are working – UE muscles are working
T5 roughly lands below nipple level. Everything below T5 is not working.
Pt will complete bed mobility independently in all aspects of bed mobility to be independent at home or to reduce caregiver burden
Pt will be able to independently perform lateral transfers to go from “blah” to “blah”
Will I be able to walk again? T5 ASIA A – Most likely not.
Push up q 30mins q 30seconds
Every 30 min is the most ideal.
