3.1 ACUTE CLINICAL MANAGEMENT OF SCI

Acute-Care PT Examination Priorities: respiratory

1. Function of respiratory muscles 2. Chest Expansion 3. Breathing Pattern 4. Cough 5. Vital Capacity

SCI Incidence

It is estimated that the annual incidence of spinal cord injury (SCI), not including those who die at the scene of the accident, is approximately 54 cases per one million population in the U. S. or approximately 17,810 new cases each year.

ASIA E

Normal. If sensation and motor function as tested with the ISNCSCI are graded as normal in all segments, and the patient had prior deficits, then the AIS grade is E. Someone without an initial SCI does not receive an AIS grade.

Acute Care Priorities for individuals with Chronic SCI

Often admitted for medical issues due to infection: UTI, URI, pneumonia or wounds. Or after elective procedure such as tendon transfer, diaphragm pacing, baclofen pump/spasticity management Priorities will shift based on reason for admit Often if hospitalized for medical issues, patients not getting OOB as much and may have difficulty with orthostasis

SCI Prevalence:

The number of people in the United States who are alive in 2018 who have SCI has been estimated to be approximately 294,000 persons, with a range of 250,000 to 368,000 persons.

Tetraplegia

means the level of injury is somewhere in the Cervical Spine

"Typical" Functional Outcomes for People with Motor COMPLETE SCI: C4

(biceps, brachialis, brachioradialis, deltoid, infraspintus, rhomboid, supinator) Breathing: independent; may require assist for secretion clearance Mobility: Independent driving power chair and performing pressure relief (tilt/recline) with hand control; able to propel a manual wheelchair on uncarpeted indoor surfaces independently or with assistance; benefits from plastic coated hand rims or power assist Transfer: assisted with transfer board uBed skills: Assistance required; able to participate in positioning Driving: independent with adaptive controls

"Typical" Functional Outcomes for People with Motor COMPLETE SCI: T1-T12

(intercostals, long muscles of back (sacrospinalis and semispinalis) abdominal musculature (T7 and below) Breathing: independent in breathing and secretion clearance Mobility: Independent in pressure relief and manual w/c propulsion Transfer: independent level and non level transfers; independent floor to chair Bed skills: independent Ambulation: physiological standing and ambulation for exercise in home with lofstrand crutches and KAFO Driving: Independent with hand controls

Other Factors that Influence Functional Outcomes

- Muscle tone - Comorbidities - Body weight and proportions - Arm length to trunk length for example - Age - Premorbid activity level - Access to and quality of medical and rehab services

ASIA-AIS Exam: Neurological Assessment: Motor Exam:10 key muscle groups

1. C5=elbow flexors 2. C6=wrist extensors 3. C7=elbow extensors 4. C8=finger flexors 5. T1= 5th finger abductor 6. L2=hip flexors 7. L3=knee extensors 8. L4=ankle dorsiflexors 9. L5=long toe extensors 10. S1=ankle plantarflexors

Acute-Care PT Intervention Priorities: Respiratory Management

1. Deep Breathing exercises 2. Glosso-pharyngeal Breathing 3. Forced Expiratory Strengthening Exercises 4. Assisted Coughing 5. Abdominal Support: abdominal binder 6. Stretching

Acute-Care PT Intervention Priorities ROM and Positioning :

1. Done daily 2. Ideally in supine and prone unless unstable fx. And/or respiratory compromise in these positions. 3.Contraindications for tetraplegia and paraplegia 4. Use of UE and LE splints/braces

SCI Level of Lesion

1. Incomplete tetraplegia (47.2%) 2. Incomplete paraplegia (19.6%) 3. Complete paraplegia (20.2%) 4. Complete tetraplegia (12.3%) uLess than 1% of persons experienced complete neurologic recovery by hospital discharge. u Over the last 20 years, the percentage of persons with incomplete tetraplegia has increased while complete paraplegia and complete tetraplegia have decreased.

Causes of SCI in the U.S as of 2/2018 (highest to lowest)

1. MVA 2. Falls 3. Violence 4. Sports 5. Other

Secondary Complications of SCI

1. Muscle atrophy 2. Osteoporosis-loss of bone mineral content 3. Decubitus 4. Ulcers 5. Urinary tract infections 6. Septicemia 7. Pneumonia 8. Spasticity 9. Impaired circulation 10. Impaired capacity of the cardiovascular system

Acute-Care PT Examination Priorities

1. Respiratory 2. Integument 3. Sensation 4. Muscle Performance and ROM 5. Muscle Tone and DTR

Acute-Care PT Intervention Priorities (5)

1. Respiratory management 2. ROM and positioning 3. Functional status 4. Selective strengthening 5. Orientation to the Vertical Position

ASIA: Sensory exam

28 key dermatomes from C2-S4/5 bilaterally Examines: Pin prick (sharp vs. dull) Light touch Graded: 0=absent; 1=impaired; 2= intact

Acute-Care PT Intervention Priorities Functional Status :

A detailed exam is usually deferred until the acute rehab phase when the patient is medically stable and cleared for activity. (Depending on medical status) Getting the patient to tolerate upright and start to get OOB is very important and should be done in acute-care BUT you must be aware of any contraindications or precautions to movement. Assessment of tolerance to upright is important (Head of bed Chair position of bed OOB with lift to loaner chair with cushion)

Acute-Care PT Examination Priorities: Sensation

A detailed examination of both superficial and deep sensations (LT, Pin Prick, Proprioception) Light Touch and Pin Prick used especially to classify sensory level of lesion Note - Sensory level of injury may not match the motor level of injury.

Respiratory Infections and Failure

A variety of sequelae of SCI contribute to the high risk of retained secretions, atelectasis, pulmonary infections, and respiratory failure, including: Expiratory muscle weakness, which results in an ineffective cough Altered levels of consciousness from concomitant head trauma or sedating medications Ileus, with increased diaphragmatic excursion and an increased risk of aspiration of gastric contents Failure to spontaneously sigh Bronchial mucus hypersecretion, which occurs in approximately 20 percent of acute cervical level SCI patients, possibly from impairment of the peripheral sympathetic nervous system Associated rib fractures or thoracoabdominal surgery Dysphagia and aspiration associated with tracheostomy and/or cervical spine surgery using an anterior approach

ASIA: Motor exam

AIS muscle grading (Different from MMT!!!!) 0=absent 1=any visible or palpable contraction 2=muscle can move thru full ROM in gravity minimized position at least once 3=muscle can move through full ROM against gravity at least once 4= able to perform through full ROM against gravity and some resistance 5=able to perform through full ROM against gravity and "normal" resistance Test position: Supine

SCI Complete injuries

Absence of sensory & motor function in the lowest sacral segment (S4/5)

SCI Potential for Recovery

Although research for a cure to SCI is encouraging, there is currently no proven way to fully restore function following SCI, but this fact does not necessarily mean there is no chance for recovery of function. There is almost always hope for at least some improvement after SCI, but there are no guarantees. You have to wait to see what happens in the months after injury.

Acute-Care PT Intervention Priorities Selective Strengthening :

Application of resistance may be contraindicated to avoid stress to the fracture sites. Emphasize B UE activities (within precaution guidelines) to avoid asymmetric, rotational stresses on the spine. Early involvement in functional activity re-training.

Spinal Cord Injury Facts and Figures: occupational status

At 1 year post injury 13% of persons with SCI are employed About 1/3 of persons with SCI are employed by 20 years post injury

Deep Vein Thrombosis

Blood Clot that forms in the deep veins; often in the legs or arms. Usually is the result of either decreased flow rate of the blood, damage to the blood vessel wall or an increased tendency of the blood to clot. This population is at risk secondary to having been immobilized or unable to move either the upper extremities or lower extremities due to absent strength, impaired blood vessel tone, fractures, etc.

"Typical" Functional Outcomes for People with Motor COMPLETE SCI: C4

Breathing: independent without ventilator; total assist secretion clearance Mobility: Independent driving power chair and performing pressure relief (tilt/recline) with head, chin, mouth or breath control Transfer: total assist Bed skills: total assist

"Typical" Functional Outcomes for People with Motor COMPLETE SCI: C1-C3

Breathing: ventilator Mobility: Independent driving power chair and performing pressure relief (tilt/recline) with head, chin, mouth or breath control Transfer: total assist uBed skills: total assist

"Typical" Functional Outcomes for People with Motor COMPLETE SCI: C6

C6 (extensor carpi radialis, infraspinatus, lat dorsi, pec major (clavicular portion), pronator teres, serratus anterior, teres minor Breathing: Breathing: independent; may require assist for secretion clearance Mobility: Independent driving power chair using hand control, may requires tilt/recline for pressure relief; independent indoor manual wheelchair propulsion, partial or total assist outdoors with manual chair, requires plastic coated rims/extension; benefit from power assist Transfer: independent to some assist with slide board Bed skills: independent to some assist with adaptive equipment Driving: independent car/van with adaptive controls

"Typical" Functional Outcomes for People with Motor COMPLETE SCI: C7/C8

C7 (extensor pollicus longus and brevis, extrinsic finger extensors, flexor carpi radialis, triceps) C8 (extrinsic finger flexors, flexor carpi ulnaris, flexor pollicus longus and brevis, intrinsic finger flexor) Breathing: independent; may require assist for secretion clearance Mobility: Independent in pressure relief and manual w/c propulsion indoors and level outdoors, partial assist uneven terrain; benefits from plastic coated hand rims and/or power assist Transfer: independent; may require assist between uneven surfaces uBed skills: independent; may require adaptive equipment (bed rail, leg loops) Driving: Independent with adaptive controls

ASIA-AIS Exam: Scoring/Classification: neurological level

Can have a R sensory level, L sensory level, R motor level and L motor level uOverall neurological level: Most cephalad of the sensory and motor levels determined in step one Most caudal segment of cord with intact sensation and antigravity (3 or more) muscle function as long as there is normal (intact) sensory and motor function rostrally respectively

Pulmonary Emboli - (PE)

Caused by part of a DVT travelling from the leg to the lungs. Can lead to a partial or complete lung obstruction. Onset of a PE can be sudden, with symptoms of SOB, tachycardia, chest pain, or a blue tinge to the fingers, toes or lips. Immediate medical assistance is necessary!

Thoracic Lumbar Sacral Orthosis (TLSO): spinal precautions

Check in the acute discharge notes for what the neuro/ortho surgeon ordered Does the patient need the TLSO on when the head of bed is greater than 30 degrees? If the patient also has swallowing issues and needs to take medication, does he/she need the TLSO on to come to full 90 degrees for this short duration? Does the patient need to don the TLSO in supine? uIf the orders have cleared the patient to donn in sitting, if so, communicate with team.

ASIA A

Complete. No sensory or motor function is preserved in the sacral segments S4-5.

Zone of Partial Preservation

Determine the zone of partial preservation (ZPP). The ZPP is used only in injuries with absent motor (no VAC) OR sensory function (no DAP, no LT and no PP sensation) in the lowest sacral segments S4-5, and refers to those dermatomes and myotomes caudal to the sensory and motor levels that remain partially innervated. With sacral sparing of sensory function, the sensory ZPP is not applicable and therefore "NA" is recorded in the block of the worksheet. Accordingly, if VAC is present, the motor ZPP is not applicable and is noted as

Acute-Care PT Examination Priorities: Muscle Tone and DTR's

Document quality, muscle groups involved, and factors that seem to increase or decrease tone. DTR's most commonly examined: Biceps (C5), Extensor Carpi Radialis Longus (C6), Triceps (C7), Quadriceps (L3), and Gastrocnemius (S1).

Orthostatic Hypotension

Due to an interruption of the cardiovascular sensory input to the brainstem and the sympathetics in the spinal cord. Blood vessels are not able to vasoconstrict effectively to counteract the change in pressure- which often results in venous pooling. The increase in heart rate with this change isn't enough to counterbalance the drop in BP Check to see if they need to have on TEDS, ace wraps and a binder for out of bed. Check to see if there is an order for Midodrine to be administered prior to therapy.

SCI Functional Potential

Due to variability in voluntary motor function in SCI injuries, it is difficult to predict functional potential A greater chance of return of some or all of a person's motor and sensory function with an Incomplete injury. Functional potential in AIS C and D is influenced by level and completeness of damage to spinal cord

Acute Care Priorities for individuals with Chronic SCI: URI/PNA: bronchopulmonary hygiene

Exam and treat acutely Review home program (consider needs in conjunction with team is changes)

Acute-Care PT Examination Priorities: integument

Examine areas most prone to pressure in supine, prone, and side-lying positions

T or F The longer you go without seeing improvement, your chances for improvement are higher

F he longer you go without seeing improvement, your chances for improvement are lower

Recovery of Walking

Grossly ½ of AIS B recover ambulatory function, but may be with devices and limited distances uPreserved pin pick sensation is positive prognostic indicator for this group. Better for AIS C than AIS B (sensory incomplete)-grossly 75% Age is strong prognostic indicator: those older than 50 have 30-40% chance vs 80-90% in those younger than 50 AIS D have excellent potential for walking with almost all patients younger than 50 ambulating at a year Lower extremity motor score, presence of pinprick sensation and younger age have been correlated with better outcomes in several studies Van Middendorp et al developed clinical prediction rule for ambulation outcomes at 1 year. Identified age (<=65), Motor score of L3 and S1, light touch score of L3 and S1 as prognostics indicators for walking independently at one year. (Article uploaded to D2L)

ASIA E = NORMAL

If Sensation and motor function as tested with the ISNCSCI are graded as normal in all segments, and the patient had prior deficits, then the AIS grade is E. Someone without an initial SCI does not receive an AIS grade.

SCI Mortality

Life expectancy for persons with SCI remains significantly below life expectancy of persons without SCI Mortality rates are significantly higher during the first year after injury. uMortality rates have declined for cancer, heart disease, stroke, PE, urinary diseases, digestive diseases and suicide Mortality rates have increased for endocrine, metabolic, nutritional diseases, accidents, nervous system disease, mental disorders and musculoskeletal disorders There has been no change in mortality rates for septicemia in the past 40 years and only a slight decrease in mortality from respiratory diseases

Spinal Cord Injury Facts and Figures: marital status

More than half of persons with SCI are single/never married at the time of injury % of persons who are married increases over time, as does divorce

ASIA D

Motor Incomplete. Motor function is preserved below the neurological level**, and at least half (half or more) of key muscle functions below the NLI have a muscle grade > 3.

ASIA C

Motor Incomplete. Motor function is preserved below the neurological level**, and more than half of key muscle functions below the neurological level of injury (NLI) have a muscle grade less than 3 (Grades 0-2).

ASIA D = MOTOR INCOMPLETE

Motor function is preserved below the neurological level**, and at least half (half or more) of key muscle functions below the neurological level of injury (NLI) have a muscle grade > 3.

ASIA C = MOTOR INCOMPLETE

Motor function is preserved below the neurological level**, and more than half of key muscle functions below the neurological level of injury (NLI) have a muscle grade less than 3 (Grades 0-2). > 50% of the muscles below the neurological level are grades < 3 (0, 1,2) on motor grading scale.

ASIA-AIS Exam: Scoring/Classification: Motor Level

Motor level: most caudal "normal" spinal nerve segment. The key muscle with a grade 3 or above with the key muscle group above it being a "5" -ie. C6 = 3 and C5 = 5, it is C6 motor level -Ie. C6 =1 and C5 =5, it is C5 motor level - C1-4, T2-L1, S2-S5 = no key muscle uMotor level is presumed based on sensation. Therefore, if Sensory score is 2 then motor score is a 5.

Spinal Precautions

No excessive bending or twisting Maintain Logroll at all times Spine in neutral alignment for all mobility No lifting > 10 pounds or what is indicated by surgeon Cervical collar braces to be worn at all times Or per MD order Some patients may be able to use a soft collar while in bed Or patients may be allowed to have a cervical collar for supine but must have a Miami JTO/Aspen CTO for all out of bed or sitting up in bed

ASIA A = COMPLETE

No sensory or motor function is preserved in the sacral segments S4-5.

Autonomic Dysreflexia

Often occurs in patients who have sustained a T6 or higher complete spinal cord injury. uDue to loss of supraspinal control of blood pressure Balance of excitation and inhibition between sympathetic and parasympathetic system is disrupted Higher incidence in individuals with motor complete injuries A result from a noxious stimuli below the level of injury that the patient is unaware of because of the lack of sensation. The inhibitory tracts of the sympathetic nervous system are unable to be controlled and causes a regional vasoconstriction of the peripheral vascular resistance = High BP and Bradycardia If this does occur, take immediate action: -Sit the patient up (may need a second person to assist) -Remove any compression garments that could be constricting -Check the catheter to make sure it isn't kinked or plugged -If symptoms or signs have not resolved, bring patient back to room and alert nurse. -If in an OPD or Homecare environment - Call 911

Acute-Care PT Intervention Priorities Orientation to the Vertical Position:

Once medically cleared for upright activities Will have orthostatic hypotension so use abdominal binder and elastic stockings to minimize venous pooling. (Abdominal binder with also decrease work of breathing by providing abdominal support) Slowly progress and monitor and document hemodynamic responses closely!

Spinal Cord Injury Facts and Figures: gender

Overall, ~ 78% of spinal cord injuries reported to the national database have occurred among males. Over the history of the database, there has been a slight trend toward a decreasing percentage of males. Prior to 1980, 81.8% of new spinal cord injuries occurred among males.

SCI Incomplete injuries

Partial preservation of sensory &/or motor function in the lowest sacral segment (S4/5) Sensory: LT/PP at anal musculocutaneous junction or deep anal sensation Motor: voluntary anal contraction of external anal sphincter

Potential for Recovery: complete injury

People with a complete injury often regain 1 or 2 levels of injury. This means you often regain control of 1 or 2 levels of muscle movement.

ASIA and the AIS

Physicians use the International Standards of Neurologic Classification of Spinal Cord Injury (ISNCSCI) to measure the extent of neurologic injury following a spinal cord injury. The ASIA Impairment Scale (AIS) is used to categorize the degrees of injury into different groups. American Spinal Injury Association Impairment Scale = AIS

SCI Primary Causes of death in those with SCI

Pneumonia Septicemia

SRH SCI Program Guidelines DVT:

Prior to PT evals check to see if an Ultrasound has been ordered and completed. Results in paper chart. If not check with MD prior to starting eval. Check to see if patients need TEDS, ace wraps or Venodyn boots at night. Check to see if the patient does have an IVC (inferior vena cava) filter placed. Review the type of anti-coagulation therapy the patient is on

"Typical" Functional Outcomes for People with Motor COMPLETE SCI: L4-L5, S1-S5

Quad (L4), Ant tib (L5), Hamstring (L5-S1), gastroc (S1), glut med and max (L5-S1), extensor digitorum, post tib, peroneals, flexor digitorium (L5, S1) Ambulation: independent ambulation home and community with lofstrand crutches, canes and AFO L4 may elect to use wheelchair long distance

ASIA B

Sensory Incomplete. Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-5 (light touch or pin prick at S4-5 or deep anal pressure) AND no motor function is preserved more than three levels below the motor level on either side of the body.

ASIA B = SENSORY INCOMPLETE

Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-5 (light touch or pin prick at S4-5 or deep anal pressure) AND no motor function is preserved more than three levels below the motor level on either side of the body.

Spinal Cord Injury Facts and Figures: etiology

Since 2010, motor vehicle crashes account for 38% of reported SCI cases. The next most common cause of SCI is falls, followed by acts of violence (primarily gunshot wounds) and sports and recreation. The proportion of injuries that are due to sports has decreased over time while the proportion of injuries due to falls has increased. Violence caused 13.3% of spinal cord injuries prior to 1980, and peaked between 1990 and 1999 at 24.8% before declining back to 13.8% since 2010.

ASIA-AIS Exam: Scoring/Classification: Single neurological level

Single NEUROLOGICAL LEVEL Lowest segment where sensory and motor function is normal on both sides. Remember that a muscle grade of 3 with a 5 above is considered "normal" for the AIS uImportant for further classification (ie. ASIA C vs. D) Caution as a neurological level does not always reflect an individual's strength or function well!

T or F As long as you are seeing some improvement, like regaining muscle movement, your chances for improvement are better.

T

Urinary Tract Infections (UTI's)

UTI's are a common complication for individuals with voiding dysfunction. An infection occurs when bacteria grows in the bladder. The most common way for a UTI to occur in individuals with SCI is for bacteria to enter the bladder while catheterizng. Other ways are from delayed use of the toilet or incomplete emptying of urine. The first signs of a Urinary Tract Infection may be fever, chills, pain with urination, or increased spasticity.

Acute-Care PT Examination Priorities use extreme caution when...

Use extreme caution when performing MMT and examining PROM around the neck and shoulders in tetraplegia, and lower trunk and hips in paraplegia Work with OT in facilitating and maintaining a Tenodesis Grasp in people with mid- to high- Cervical injuries (above C6).

Acute-Care PT Examination Priorities: Muscle Performance and ROM :

Using MMT - Palpation is KEY due to common muscle substitutions used! (e.g. can look like the patient is actively flexing their knee with the hamstrings in prone when they are really flexing and externally rotating their hip with the Sartorius, which will bring the knee along with it when in prone). Besides testing the "key muscles" identified in the International Standards for Neurological and Functional Classification of Spinal Cord Injury (ISNCSCI), other muscle groups should be tested throughout the myotomes with intact innervation.

Acute Care Priorities for individuals with Chronic SCI: Spasticity

Work with team on assessment of tone with various medical interventions If change in tone affecting functional exam and suggest modifications to transfers ROM/splinting as needed

Acute Care Priorities for individuals with Chronic SCI: wound

Work with time on positioning, OOB time, assessment of wound Assess cushion and wheelchair (refer for pressure mapping or to wheelchair clinic if modifications needed) Assess transfer to see if shearing and adapt transfer if needed Re education in pressure relief

"Typical" Functional Outcomes for People with Motor COMPLETE SCI: L1-L3

gracilis, iliopsoas, quadratus lumborum, rectus femoris, satorius Breathing: independent in breathing and secretion clearance Mobility: Independent in pressure relief and manual w/c propulsion Transfer: independent level and non level transfers; independent floor to chair Bed skills: independent Ambulation: independent ambulation home short distances with lofstrand crutches and KAFO or AFO depending on innervated muscles Driving: Independent with hand controls

•With an/a ___________ injury, it is impossible to accurately predict the eventual amount of return of an individual's function.

incomplete

Paraplegia

means the level of injury is somewhere below C7 in the Thoracic, Lumbar, Sacral Spine.

Traumatic SCI Age of Injury

primarily affects young adults. Nearly half of all injuries occurred between the ages of 16 and 30. From 1973 to 1979, the average age at injury was 29 years. As the median age of the general population of the United States has increased by approximately 9 years since the mid-1970, the average age at injury has also steadily increased over time. The average age at injury is now 43 years. uOther possible reasons for the observed trend toward older age at injury might include changes in either referral patterns to model systems, the locations of model systems, survival rates of older persons at the scene of the accident, or age-specific incidence rates.

Potential for Recovery: incomplete injury

uPeople with an incomplete injury are more likely than people with a complete injury to regain control of more muscle movement, but there is no way to know how much, if any, will return.