Week 8 Tetraplegia SCI Flashcards
How you as a therapist should approach a case is the HOAC model.
Has sensation but no motor below T8
Preserved upper body strength (should be 5/5), should have decent trunk strength up to t8 (abs start at T_), no motor below level of t8. sensation wise – light touch and pin prick should be preserved from at least T8 and above. Below T8 – could have sensation below the neurological level. Sensory still exists but there is no motor.
No voluntary anal contraction – that is a motor function. If you have voluntary anal contraction you are automatically asia (B/C). if you don’t have that you cant be an asia (B/C).
T7; C; C
Limitations – walking, going up the stairs, general mobility,
Positive – lives with parents, has decent trunk control so she can sit,
Negative – two story home, one step to get into the house, home set up, person is a pharmacist (cant go to work right now)
Examination: pin prick and soft touch, DCML, Anterolateral, T8-T11 motor function (trunk testing), motor testing, UE function, spasticity,
Examination: Skin integrity (particularly the sacrum, isch tubes, pressure sensitive areas, sensation testing (sensory tests in particular – light touch and pin prick), VITALS, strength of the UE (mmt – know your myotomes), sitting balance, spasticity (this is an UMN pathology so this could be a part of it), ROM of UE and LE (can test LE because tightness can occur even if they aren’t moving them. Tasks are more difficult with tighter muscles. People can develop contractures even if they aren’t moving their limbs actively),
EOM – edge of mat ?
Reassess hypotheses – if exam starts to show other things compared to the original asia score maybe the pt is getting better or I missed something. Maybe they’re getting a lot of function back. Make sure things fit the mold.
DVT, skin breakdown, pulmonary compromise, atrophy, falls risk,
Bowel and bladder function – could be at risk for the spastic bowel and bladder function above L1, DVTs – person is moving their legs so blood is now pooling in their legs, shoulder function/pain/weakness/fxs – using arms in a WB position and the shoulder is not designed for that, Fx risk – person isn’t wb through their legs like they used to – if they start to transfer – could fx, mental health – traumatic experience,
Wheelchair skills test, NPRS, Assistance level (going from mod to min assist is an objective measure you can take), hand held dynamometry to look at grip strength, modified functional reach test,
Pt diagnosis: T8 Asia B. We can expect to see sensation preserved but muscular deficits below T8. These deficits exist due to damage to the corticospinal tracts. Damage to T8 can result in balance deficits and ambulatory problems.
Prognosis – this person is going to get better because expectations with a paraplegic are independent. They are likely going to get better .environmentally speaking- only one step to get in, not too many impairments, works as a pharmacist, good home set up. This is an incomplete injury – still have pathways that function. ASIA B – Likelihood of walking is very high if they have pin prick below their level of injury.
1 short term goal – Pt will be able to weight shift independently every 30 min to minimize pressure injury risk.
Pt will perform a lateral transfer with min assist to _____
1 long term goal – pt will be independent with lateral transfers from _ to _ surface to promote __
Pts that need physical assistance – bump down one assistance level
Pt education – skin integrity, how to instruct other people to help them with their mobility, work on bed mobility, work on transfers, standing frame – stimulating cortex to start to work when you WB which leads to descending pathways from an efferent motor output have to work. If this person is going to walk you have to stimulate that sensory system to force the brain to find a pathway from the head to the muscles. WB is key to stimulate the sensory afferent pathways.
E stim – releases acetylcholine to tell the motor cortex to start to work. Stim both legs at once if possible. Go quads if have to choose just one. Can still do stim if it is complete sci but expectations change.
Lowest motor and sensory level – C_ . If it is complete (will/won’t) have anorectal sensation or motor function.
Superman – guy in the picture – Christopher reed – C1 Asia A.
C8; won’t;
C1-C4 Complete Tetraplegia
What muscles are functioning? SCM (CN11) Facial muscles (CN7) Trapezius Diaphragm? (C3-5) Cervical muscles
Functional Expectations?
(Independent/Dependent) for most mobility and ADLs
SHOULD be able to verbalize care (independent with instructions)
Power Wheelchair mobility - Mod independent!
Importance on direction of care, medical management, adaptive equipment
Requires full-time attendant care
They are going to be dependent for all mobility and all ADLs – they need physical assist with everything.
They can still turn their head and use their cervical muscles, but unfortunately has a negligible impact on their mobility.
These individuals can be mod independent on a power wheelchair level.
For this population – heavy importance on care giver instruction
Medical management – respiratory function can be compromised depending on the level of the injury
They require around the clock care
Dependent;
https://www.youtube.com/watch?v=RR8mdrh3bRE
Biceps – biggest supporters of this population in regard to their mobility.
How would you utilize these muscles within function? When you only have biceps and periscapular muscles, you lose some of that shoulder integrity – GH joint so dependent on the group of muscles to provide the dynamic stability.
Direction of care is also a high priority.
Someone who is an ex athlete and got into an accident will present differently compared to grandma pearl.
Ambulation – complete tetra – no.
C6/C7 Complete Tetraplegia
Think….what muscle(s) are functioning? Wrist extensors (C6) Supinators
Triceps (C7) - *will need ( 3/5 / 4/5) to assist with transfer, ( 1/5 / 3/5) to lock out
Latissimus Doris (C6-8)
Pectoralis (C5-T1)
Triceps strength is important – in order to utilize the triceps in a functional way have to at least be a 3/5. 4/5 – can utilize the triceps to get a boost in things like the lateral transfers.
Muscle substitution – if we don’t have triceps, have to use (IROTs/EROTs) to substitute. If you ER you get passive (flexion/extension) of your elbows – can makeup the difference if you don’t have extension of the triceps.
4/5; 3/5; EROTs; extension;
C6 is the hardest level of injury to get people to be independent.
If you lack triceps strength and you hold your arm higher than 90 degrees gravity will push it down. People with this level of injury keep their arms (above/below) 90 deg of shoulder flexion to prevent getting hit in the head by their own arm – cant control it eccentrically. Can use (IROT/EROT) at the shoulder and keeping palms (up/down) – locking out at the elbow.
below; EROT; up;
Bed Mobility
Think back – what were some of the considerations to successful bed mobility within the paraplegic lecture?
What’s different now with a C6/7 injury?
Use of momentum to swing arms (above/below) shoulder flexion of 90 degrees (C6)
Use of head movement (away form/toward) side of rotation
(Protraction/Retraction) of the scapula - Serratus anterior, pectoralis major/minor
below; toward; protraction
Rolling: https://www.youtube.com/watch?v=qGA53hWgYgc&list=PLX4uJa5YLZHBbk_gmsx3fnyKMolZ2ePjK&index=4
Supine to long sit: https://www.youtube.com/watch?v=EJjVtXMBr44&list=PLX4uJa5YLZHBbk_gmsx3fnyKMolZ2ePjK&index=1
Long sit to short: https://www.youtube.com/watch?v=xGyJUzXWgtM&list=PLX4uJa5YLZHBbk_gmsx3fnyKMolZ2ePjK&index=6
Hooking arms- compensating for instability of the trunk.
https: //www.youtube.com/watch?v=tDETBkJIUJ8
https: //www.youtube.com/watch?v=kKp8foXoxN4
Lateral Transfer
Technique:
Performed using bilateral UEs to lift pelvis.
Can be performed with a transfer board or without
**(Anterior/Posterior) trunk lean
**Head-Hips Relationship
** Scapular (elevation/depression) and (abduction/adduction) of proximal humerus
**Elbow lock through muscle substitution - shoulder (ER/IR), wrists (flexed/extended), forearms (supinated/pronated)
Potential Barriers: Uneven surfaces Compliant surfaces Fear of Falling Body Type
Anterior; depression; adduction; ER; extended; supinated
Expected Outcomes for Lateral Transfers
C5 Neurological Level
Typical Outcome: (Independent/Dependent) for all Transfers
**Have the potential to be independent with use of transfer boards for even surface transfers.
C6 Neurological Level
Typical Outcome: Requires some assist perform even and uneven surface transfers.
** Have the potential to be independent for even surface transfers and uneven surface transfers with a board.
C7- C8 Neurological Level
Typical Outcome: (Dependent/Independent) with even surface transfers. May require some assistance for uneven transfers.
** Have the potential to be independent with all transfers including advanced transfers: floor, car transfers.
T1 and below
Typical Outcome: (Dependent/Independent) with even surface transfers and most uneven surface transfers.
** The more trunk musculature available improves the ability to maintain unsupported sitting balance with less effort.
Take home – C5 – need physical assist – have potential to be independent with transfer board
C6 – can start doing things on their on.
T1 – life is sweet, all good to go.
Dependent; Independent; Independent;
Rachel - Pt might not need a backboard
ROM Considerations
Hypermobility:
Shoulder (flexors/extensors)
(Quads/Hamstrings)
Hypomobility:
Lumbar
Finger (flexors/extensors) (tenodesis) C6/7
Selective tightening of the finger flexors to assist with compensatory, functional grip
Don’t want to over stretch the back.
Tenodesis - can use to compensate to grip . You extend the wrist to flex the fingers to grip. It is a functional grip, cant use it to open up soda cans.
Bad thing to do with this person – don’t stretch the finger flexors – want those finger flexors to get tight and stiff for tenodesis.
extensors; Hamstrings; flexors;
Pre-Transfer Training Interventions
Seated pelvic lifts Anterior <> Posterior Prop Transitions (Anterior/Posterior) Trunk leans – hands to floor Seated Trunk (Flexions/Extensions) Sit-ups away from backboard support Functional sitting balance training
Anterior; Extensions
** Must use compensatory strategies to get in and out of position if functional strength in triceps not present
Prop sitting – creation of triangle for stability.
If someone’s arms are anterior to the trunk – anterior propped sitting. Same thing for arms posterior and lateral.
Where are you positioning your hands to help facilitate? Put your hands on muscles that should be working.
How would you set up the environment? Make sure there is support for the patient – extra helper, pillows, swiss balls, backboard, etc.
What body structure ideally should be addressed for sitting balance? The pelvis. Can facilitate this by .. Have them in an anterior pelvic tilt – use your hands and put them in an anterior pelvic tilt – put hand on lumbar extensors and press to facilitate an anterior pelvic tilt. Can use a bed sheet by placing it around their back and pull forward. Make sure they have abdominal control so they don’t slide forward. As you pull, use your knees to block their knees so their femur cant move past yours.
Posterior prop > lateral prop > anterior prop
They should be able to hold themselves at the edge of the matt even if they have C6.
Incomplete – can someone do a stand pivot or do they need to do a lateral or squat pivot? Something to think about.
Number 2 – feet got crossed, right arm – picked it up, starting falling toward the matt,
Learning different techniques (squat/stand?) to practice different surface levels. He is Independent with squat pivot. Stand pivot is a progression. If the person is going to get better, don’t celebrate squat pivot independent because they have more in the tank.
How can I promote independence?
I can change the surface height of the mat
Can they do it in fewer steps?
Afo – type of orthotic
Part of therapy intervention will be stretching . Might teach the pt to teach the caregivers. Need to prevent secondary issues.
If someone is going to get better you don’t want to be battling these issues.
Adaptive equipment – huge in this population
Psychological well being – due to traumatic injury to the spinal cord
LE spasticity – stretch, Weight bearing, modalities to help with spasticity
UE muscle weakness – strengthen the muscles
Bone density – Wbing, tilt table, standing frame, e stim
Cardiovascular concerns – RPE scale will be used, arm bike,
AD – signs of dysreflexia – high BP, low HR, sweating, pounding headache, bowel obstruction, sitting on something noxious,
Pain – hot pack, cold pack, massage, active motion, tens, anything to make them feel better
More traditional ther ex is still necessary and can be part of your session.
Working on strength in the context of bed mobility. ER and throwing back your arm to catch yourself.
Good option for those who cant cough on their own.
Positioning in the chair, wearing binder, FES assistance
C2 AIS-B Wheelchair mobility – Pt will be independent with caregiver instruction on dependent wheelchair to and from bed with overhead lift to _____
Can be independent with power wheelchair mobility.
B) Externally rotated shoulders – substitute for extension, supinate elbows through the use of ER, wrist extension, and digits flexed. This creates passive stability.
