Week 7 - SCI and FES Flashcards
What are the tracts located in the white matter in the spinal cord?
Exterior white matter - conduction tracts (bundles of axons)
Ascending tracts - fibres that run to the higher cord of brain centres
Descending tracts - fibres that run to lower levels for motor output
what happens with a Lower Motor Neuron lesion?
Affects nerve fibres travelling from the anterior horn of the spinal cord or the motor nuclei of the cranial nerves to the relevant muscle
what happens with a Upper Motor Neuron lesion?
Occurs in the neural pathway above the anterior horn cell of the spinal cord or the motor nuclei of the cranial nerves (in the brain or the spinal cord)
what neurons are affected in most SCIs and why?
UMN lesions because the spinal cord is a part of the CNS
Where are LMN lesions seen?
when the damage is to the peripheral nerves (the cauda equina) or following an infarct to the cord.
is it possible to have both LMN and UMN spinal cord damage?
yes if there is spinal cord damage and the adjacent spinal root is involved
what is the difference between Quadriplegia/Tetraplegia and Triplegia (Important)
Quadriplegia/Tetraplegia:
- Partial or total loss of use of all 4 limbs and torso.
- Usually sensory and motor.
- Levels C1-C7.
Triplegia:
- Partial or total loss of use of 3 limbs (usually both legs and one arm; but can also involve both arms and one leg)
what is Paraplegia?
- Partial or total loss of use of lower extremities.
- Torso may be involved.
what is Monoplegia?
Partial or total loss of use of one limb (usually the arm).
what is Diplegia?
Stiffness, weakness, or lack of mobility in muscle groups on both sides of the body (eg diplegic cerebral palsy)
Where are lesions found in UMN and LMN disorders?
UMN Lesion:
- Cerebral hemispheres
- cerebellum
- brainstem
- spinal cord.
LMN Lesion:
- Anterior horn cell
- nerve roots
- peripheral nerves
- neuromuscular junction
- muscles.
How does muscle weakness present in UMN vs LMN lesions?
UMN Lesion:
- Quadriplegia
- hemiplegia
- diplegia
- paraplegia
LMN Lesion:
- Proximal weakness (myopathy)
- distal weakness (neuropathy).
How does muscle tone differ in UMN and LMN lesions?
UMN Lesion:
- Spasticity
- rigidity
LMN Lesion:
- Hypotonia (reduced muscle tone)
Are fasciculations present in UMN and LMN lesions?
UMN Lesion:
- Absent
LMN Lesion:
- Present, especially in the tongue
How are deep tendon reflexes affected in UMN vs LMN lesions?
UMN Lesion:
- Hyperreflexia (exaggerated reflexes)
LMN Lesion:
- Hyporeflexia or areflexia (reduced or absent reflexes)
Are abdominal reflexes present in UMN and LMN lesions?
UMN Lesion:
- Absent (depending on the spinal level involved)
LMN Lesion:
- Present
What type of sensory loss occurs in UMN and LMN lesions?
UMN Lesion:
- Cortical sensory loss.
LMN Lesion:
- Peripheral sensory loss
How does Electromyography (EMG) differ in UMN and LMN lesions?
UMN Lesion:
- Normal nerve conduction with decreased interference pattern and firing rate.
LMN Lesion:
- Abnormal nerve conduction
- large motor units
- fasciculations
- fibrillations.
How does muscle wasting differ in UMN and LMN lesions?
UMN Lesion: Appears later, mainly due to disuse.
LMN Lesion: Usually present with lower motor neuron damage.
what are the levels of the American Spinal Cord Association Impairment Scale (ASIA)?
ASIA A: Complete
- No motor or sensory function
ASIA B: Incomplete
- Sensory but NOT motor function is preserved below the neurological level
ASIA C: Incomplete
- Motor function is preserved below the neurological level, half of muscles grade of less than 3
ASIA D: Incomplete
- Motor function, more than half of muscles greater than or equal to 3
ASIA E: Normal
- Normal motor and sensory function
What does ASIA A L7 mean?
complete break of the spinal cord at lumbar 7 with the loss of motor and sensory below that region
what are 6 Spinal Cord Injury Syndromes?
1.Central Cord Syndrome
2.Brown-Sequard Syndrome
3.Anterior Cord Syndrome
4.Posterior Cord Syndrome
5.Conus Medullaris Syndrome
6.Cauda Equina Syndrome (Note: not considered a true SCI)
what is Central cord syndrome?
- Usually occurs in the cervical spine
- injury from a fall or an MVA
- tumours and cervical disc bulges are common
- Is the most common of the SCI syndromes
- Often exhibits bladder dysfunction and can present with varying degrees of sensory loss below the neurological level
what is Brown-Sequard Syndrome?
- Results from a hemisection of the spinal cord
Causes:
- Spinal tumor
- Spinal cord infection (e.g., tuberculosis)
- Inflammation of the spinal cord (e.g., multiple sclerosis)
- Penetrating wounds (e.g., knife stabbing, gunshot wound)
Ipsilateral (same side) losses below injury level:
- Proprioception
- Vibration
- Two-point discrimination
- Fine touch
- Possible motor function loss
Contralateral (opposite side) losses:
- Pain sensation
- Temperature
- Crude touch
what is Anterior Cord Syndrome ?
Primarily affects:
- Anterior two-thirds of the spinal cord
- Spares the posterior third (posterior columns)
Common causes:
- Flexion injuries
- Direct bone fragments
- Vascular insufficiency
- Herniated discs
Affected tracts:
Corticospinal tract (motor) → Variable motor paralysis below the lesion
Spinothalamic tract (sensory) → Variable loss of pain, temperature, and indiscriminate touch sensation
Spared functions (posterior column remains intact):
- Proprioception
- Kinesthesia
- Touch
- Two-point discrimination
- Vibration sense
Prognosis:
- Typically poorer functional recovery compared to other syndromes
what is Posterior Cord Syndrome?
Caused by:
- Infarct in the posterior spinal artery
- Lesions on the posterior portion of the spinal cord
Examples:
- Penetrating injury/trauma
- Multiple Sclerosis
Effects:
- Loss of proprioception and vibration
Additional Notes:
- Rare type of incomplete spinal cord injury
- Least common of the six spinal cord injury syndromes (incidence <1%)
What is Conus Medullaris Syndrome?
Location:
- Terminal end of the spinal cord (T12-L2 in adults)
Causes:
- Trauma
- Tumors at the base of the spinal cord
Clinical Signs:
- UMN and Lower LMN signs
- Saddle anesthesia (loss of sensation in the groin area)
- Areflexic bladder and bowel (loss of reflex control)
- Variable lower extremity (LE) weakness
What is Cauda Equina Syndrome?
Location:
- Lesion below the conus medullaris, at L2-S5 (cauda equina)
Classification:
- Not a true spinal cord injury (SCI) → affects nerve roots, not the spinal cord itself
- Considered a pure Lower Motor Neuron (LMN) lesion (no UMN signs)
Causes:
- Trauma
- Tumors
- Spinal stenosis
- Disk compression
- Infection
- Post-surgical epidural hematoma
- Can be acute or slow-progressing
Clinical Considerations:
- Can occur alone or with conus medullaris syndrome
- Early surgical decompression is key for better recovery
- Nerve roots can regenerate, making recovery possible
what is the clinical picture of an SCI?
Spinal Shock:
- Period of areflexia (no reflexes) lasting days to months
Motor & Sensory Deficits ->
Clinical Presentation Depends On:
- Level of injury
- Completeness of injury (complete vs. incomplete)
- Symmetry of lesion
- Sacral sparing (preservation of function in the sacral region)
Impaired temperature control: Difficulty sensing hot/cold
- Respiratory impairment: May require deep breathing exercises
- Spasticity: Increased muscle: tone and reflexes
- Bowel & bladder dysfunction Possible incontinence or retention
what are some SCI Secondary Complications?
- Pressure sores
- Autonomic dysreflexia (AD)
- Postural hypotension – edema
- Heterotopic bone formation (extra bone in area)
- Contractures
- Pain
- Deep Vein Thrombosis (DVT)/reduce risk with ROM exercises
- Osteoporosis - Reduce risk by being able to walk and get up (weight bearing resistance exercises)
- Muscle spasms - mostly when the brake is incomplete
What is a Muscle Spasms, it’s cause and how to reduce the risk of getting one?
- Involuntary muscle movements.
- Time length of spasm can vary greatly (from short such as twitching to a long painful sustained contraction).
Often caused by:
-Interrupted signals between reflexes and the brain
-Spasticity
-Irritation such as pressure sore or a full bowel/bladder
Reduce risk by stretching their legs and ROM
what is Autonomic Dysreflexia (AD), it’s cause and symptoms?
- Overactivity of autonomic nervous system
- Causes sudden onset of excessively high blood pressure
- Lesions at or above T6 level
Symptoms include:
- Throbbing headache
- flushing
- sweating
- bradycardia
- blurred vision
- nausea
- nasal congestion
Below injury level:
- pallor
- chills
- goosebumps
what are some Precipitating factors and intervention to help with autonomic Dysreflexia?
Precipitating factors :
- bladder distension
- open pressure sores
- kinked Foley catheter
Intervention:
- place patient is upright position
- check lines for kinks
- loosen tight clothing
What are some PT intervention for acute SCI?
Emphasis on:
- respiratory management - deep and expanding
- prevention of complications
- ROM maintenance,
- strengthening/facilitation of active movement as permitted medically
- Orientation (horozontal) to vertical
*full ROM not required for all muscle groups—may enhance function: “selective stretching”
what are some PT interventions for rehab SCI?
- Functional expectations
- Education including skin inspection
- ROM, strength, function – mat activities
- Wheelchair prescription and management
- Ambulation (as appropriate)
what is Tenodesis Grasp and Release in SCI?
Common in individuals with C6-level SCI, where wrist control is present, but finger control is limited.
what is the mechanism for Tendosis Grasp and Release?
A biomechanical occurrence where wrist movement passively controls finger flexion and extension due to tendon mechanics
what is the function of Tendosis Grasp and Release?
Wrist extension causes finger flexion (grasp), while wrist flexion leads to finger extension (release).
what is the Clinical importance of Tendosis Grasp and Release?
Used to enhance independence in daily activities like eating and brushing teeth by utilizing passive grip control.
Why does tenodesis require brain retraining?
The brain is not naturally wired to use the wrist for finger movement, so repetition and practice are needed to develop this skill
Why is strengthening wrist extensors important for tenodesis function?
Strong wrist extensors enhance finger flexion during wrist extension, improving grip strength and endurance.
How can a patient improve their tenodesis grasp?
Through education, repetition, and strengthening wrist extensors with resistance exercises
Why is it important to prevent overstretching of finger flexors in tenodesis?
Overstretching can reduce the effectiveness of tenodesis grasp, so care must be taken during passive movements and activities like transfers.
Why is edema prevention important for tenodesis function?
Swelling in the hand can limit movement and affect tenodesis grasp, making functional activities more difficult.
What is the best splinting or taping strategy for tenodesis?
- No single strategy has been proven superior
- various approaches are used to support function.
what is functional mobility and what does it require?
- The ability to move from one place to another to complete an activity or task
- Requires integration of cognitive and affective resources with motor skills
what is the purpose of functional assessments?
- Measures functional abilities; helps identify functional limitations
- Information base for goal setting
- Assists with determination of progress
- Assists with decisions regarding ongoing care needs
- Guide to determine safety/risk of injury
- Assists with determination of effectiveness of rx
what are some components of functional mobility?
- Moving in bed
- Transitional movements
- Lying ↔ sitting, sit ↔ stand - Transfers
- Ambulation
- Walking, wheelchair skills
- Stairs
what are some ways to progress functional mobility?
Progressive increase in patient participation:
- Decrease “hands-on” by PT/PTA
- Decrease need for cueing/prompting
Progressive increase in patient independence:
- Dependent → 2PA → 1PA, etc.
Progressive decrease in need for aids:
- e.g. 2 wheeled walker → 4 wheeled walker → cane → no aid
what is the purpose of Functional Electrical Stimulation (FES)?
FES is a neurological treatment that uses electrical stimulation to activate weak or flaccid muscles for functional task training
How is FES used during therapy?
Electrodes are placed on specific weak muscles while the patient performs a functional task to retrain movement
How does FES promote muscle recovery?
Repetitive electrical stimulation helps the brain relearn how to send impulses to weak muscles, improving muscle activation and movement
How does repetitive practice with FES improve function?
Repetition helps muscles relearn correct sequencing and coordination for functional movement
How does Functional Electrical Stimulation (FES) activate muscles?
Electrode pads are placed on specific muscles and connected to an EMS device, which sends electrical currents to stimulate muscle contractions. Intensity and timing are controlled through the EMS unit
What sensations might a person feel when FES is turned on?
- pins and needles to tingling
- buzzing
- thumping
- twitching, depending on the settings used by the physiotherapist.
When is Functional Electrical Stimulation (FES) used?
FES is used to improve impairments, promote motor return, and decrease pain
When should FES not be used?
FES should be avoided on:
- pregnant belly
- open wounds
- areas with decreased sensation
- bony prominences
- metal implants
- piercings
- individuals with pacemakers, heart conditions, or cognitive impairments
What are the benefits of Functional Electrical Stimulation (FES)?
- FES can restore muscle tone
- reduce joint pain and swelling
- relieve muscle discomfort
- prevent or reverse muscle atrophy
- increase range of motion
- improve blood circulation.
What is a potential risk of using FES?
- It might feel uncomfortable when turned on
- sensations ranging from tingling to twitching.
What should you remember when applying electrode pads for FES?
- Use enough gel to prevent shocking the patient
- ensure pads are at least ~2” apart
- do not add gel if the pads already have adhesive
What safety precautions should you follow when using FES?
- Increase intensity slowly while checking in with the patient
- avoid adjusting intensity during “OFF” time
- do not fight the contraction to prevent muscle fatigue
What abilities and functions are affected in C1-C3?
- Limited movement of head
and neck - Breathing: Depends on a ventilator for breathing.
-Communication: Talking is sometimes difficult, very limited or impossible.
What abilities and functions are affected in C3-C4?
- neck and down but usually has head and neck
control. Individuals at C4
level may shrug their
shoulders - Breathing: May initially require a ventilator for breathing, usually
adjust to breathing full-time without ventilator assistance
What abilities and functions are affected in C5?
- Typically has head and
neck control, can shrug
shoulder and has shoulder
control. Can bend his/her
elbows and turn palms face
up. - Mobility: May have strength to push a manual wheelchair for short
distances over smooth surfaces
What function might someone have with a SCI in C6?
- Has movement in head
- neck
- shoulders
- arms and wrists
- Can shrug shoulders
- bend elbows,
- turn palms up and
down - extend wrists
What function might someone have with a SCI in C7?
Has similar movement as
an individual with C6, with added ability to straighten
his/her elbows
What function might someone have with a SCI in C8-T1?
Has added strength and
precision of fingers that
result in limited or natural
hand function
What function might someone have with a SCI in T2-T6?
Has normal motor function in:
- head
- neck
- shoulders
- arms
- hands and fingers.
- Has increased use of rib
and chest muscles,
or trunk control.
What function might someone have with a SCI in T7-T12?
- Has added motor function
from increased abdominal
control - Able to perform unsupported seated activities
What function might someone have with a SCI in L1-L5?
- Has additional return of
motor movement in the
hips and knees - Walking can be a viable function, with the help of specialized
leg and ankle braces
What abilities and functions are affected in S1-S5?
- Depending on level of
injury, there are various
degrees of return of: - voluntary bladder
- bowel
- sexual functions
- Increased ability to walk with fewer or no supportive
devices
What is the recommended amount of aerobic activity per week for adults with a spinal cord injury (SCI)?
At least 20 minutes of moderate-to-vigorous intensity aerobic activity two times per week.
Name some examples of aerobic activities suitable for individuals with a spinal cord injury (SCI)?
- Wheeling
- arm cycling
- body weight-supported treadmill walking
- recumbent steppers
- water exercise.
What is the recommended structure for strength training exercises for adults with SCI?
Strength training should consist of 3 sets of 8-10 repetitions of each exercise for each major muscle group
What are some examples of strength training activities that can help prevent muscle and bone atrophy in adults with SCI?
- Free weights
- elastic resistance bands
- weight machines
Why is it important for inactive individuals with SCI to start slowly with physical activity?
To allow the body to adjust and gradually increase the length and intensity of physical activity over time.
