Rehab, Mod 7 Spinal Cord Injury

Correlating Diagnostic Information w/ spinal Level: C7

Primary Motor Test: Triceps Primary Sensory Derma Area: Middle Finger Reflex: Triceps

Determining Level of lesion

*Complete lesion*- no sensory or motor function below the level of the lesion. Caused by a complete transection, severe compression, or extensive vascular impairment to the cord. *Incomplete lesion*- preservation of some sensory or motor function below the level of injury, caused by partial transection, contusion or swelling.

SCI injury classification: Complete vs. Incomplete

*Complete lesion*- no sensory or motor function below the level of the lesion. Caused by a complete transection, severe compression, or extensive vascular impairment to the cord. *Incomplete lesion*- preservation of some sensory or motor function below the level of injury, caused by partial transection, contusion or swelling.

Key Muscles and Functional Levels: C4 Lesion, Diaphgram

*Functional muscles:* C1-C3 mm's, partial diaphgram & Levator Scap *Available movements:* Respiration, Scap Elevation and previous levels of movement *Functional capabilities:* Respirator dependent Use of electric wheelchair with sip/puff attachment Total dependency on others for self care

Key Muscles and Functional Levels: C5 Lesion, Deltoid, Biceps

*Functional muscles:* C1-C4 muscles, biceps, brachialis, brachioradialis, deltoids, infraspinatus, rhomboids, and the supinator *Available movements:* Elbow flexion, supination, Shoulder ER, abduction to 100 degrees, and limited shoulder flexion *Reflexes:* Biceps *Functional capabilities:* self feeding with adaptive utensils

Key Muscles and Functional Levels: C6 Lesion, Wrist Extensors

*Functional muscles:* C1-C5 muscles, extensor carpi radilais, latissimus dorsi, clavicular portion of pectoralis major, prontaor teres, serratus anterior, and teres minor *Reflexes:* Biceps, Brachioradialis *Available movements:* Shoulder flexion, extension, IR, adduction, scapular abduction and upward rotation, pronation, and wrist extension using tenodesis grasp *Functional capabilities:* Self feeding Dressing and care with adaptive equipment independent coughing by pressure to abdomen manual w/c with handrim projections or friction surfaces

Key Muscles and Functional Levels: C7 lesion, Triceps

*Functional muscles:* C1-C6 muscles, extensor pollicis longus and brevis, extrinsic finger extensors, flexor carpi radialis, and triceps *Reflexes:*Biceps, Brachioradilis, Triceps *Available movements:* Elbow extension, wrist flexion and finger extension *Functional capabilities:* Independent with self feeding, self dressing, and care with some adaptive devices Independent transfers with sliding board Independent bowel and bladder care with equipment Independent cough

Key Muscles and Functional Levels: C8 Lesion, (Flexor Digitorum Profundus)

*Functional muscles:* C1-C7 muscles, extrinsic finger flexors, flexor capri ulnaris, flexor pollicis longus and brevis *Available movements:* Perform independent skin checks *Functional capabilities:* Manual wheelchair with standard rims Independent housekeeping in wheelchair accessible environment Able to work in buildings free of barriers

Key Muscles and Functional Levels:L3 Lesion, quadriceps

*Functional muscles:* C1-L2 muscles, quadriceps, quadratus lumborum, and sartorius *Reflexes:* Patellar *Available movements:* Knee extension *Functional capabilities:* Ambulation with HKAFO, KAFO, AFO (depending on which muscles are innervated) with forearm crutches

Key Muscles and Functional Levels:L4-L5 Lesion (Tibialis Anterior & Extensor Hallucis Longus)

*Functional muscles:* C1-L3 muscles, tibialis anterior, extensor hallucis longus, extensor digitorum, low back muscles, weak medial hamstrings, tibialis posterior *Reflexes:* Hamstrings (L5) *Available movements:* stronger hip flexion, stronger knee extension, weak knee flexion *Functional capabilities:* Greater strength and balance Ambulation with AFO

Key Muscles and Functional Levels: L2 Lesion, Iliopsoas

*Functional muscles:* C1-T12 muscles, gracilis, iliopsoas *Available movements:* Hip flexion, adduction *Functional capabilities:* ambulation with HKAFO with aid of crutches or walker and wheelchair for energy conservation and convenience.

Key Muscles and Functional Levels: T1 Lesion, Hand Intrinsics

*Functional muscles:* Full innervation of all upper extremity musculature

Key Muscles and Functional Levels: T9-T12 Lesion (Check sensory level, refer to dermatome chart)

*Functional muscles:* Intercostals and lower abdominals *Functional capabilities:* Increased endurance Household ambulation with use of HKAFO and the aid of crutches or a walker as well as a wheelchair for energy conservation

Key Muscles and Functional Levels: S1 Lesion, Peroneals

*Functional muscles:* Medial hamstrings, gastrocnemius, soleus *Reflexes:* Achilles

Key Muscles and Functional Levels: T4-T6 (check sensory level, refer to dermatome chart)

*Functional muscles:* Top half of the intercostals, muscles of the back *Available movements:* Improved trunk control and increased respiratory reserve *Functional capabilities:* T6 and above lesions require increased attention to autonomic dysreflexia. Standing table for pressure relief and circulation Non-functional ambulation for short distances with hip-knee-ankle-foot orthoses (HKAO) with spinal attachment Can perform independent wheelies for curb climbing Full participation in wheelchair sports

Key Muscles and Functional Levels: C1, C2, C3 Lesion

*Functional muscles:* face and neck musculature *Available movements:* talking, chewing, sipping, and blowing *Functional capabilities:* Respirator dependent Total dependency on others for care Use of electric wheelchair with sip/puff attachment

SCI injury classification: Tetraplegia vs. Paraplegia

*Quadriplegia/Tetraplegia* - is partial or complete paralysis of all four extremities and trunk, including the respiratory muscles, and results from a lesion of the cervical cord through T1. *Paraplegia* - partial or complete paralysis of all or part of the trunk and both lower extremities, resulting from lesions of the thoracic or lumbar spinal cord or sacral roots (T2 and lower).

Bladder and Bowel Dysfunction

*Reflex neurogenic bladders* occur with SCI lesions above the conus medullaris. They contract and reflexively empty the bladder as a response to a certain level of filling pressure. The bladder training program most frequently used is intermittent catheterization. *Nonreflex bladders* occur with a lesion at the conus medullaris. They are essentially flaccid due to the interruption of S2, S3, and S4 reflex arcs. Emptying the bladder can be achieved via use of the Valsalva maneuver or by manually compressing the lower abdomen using the Crede Maneuver. Reflex bowel management requires use of suppositories and digital stimulation techniques to initiate defecation. The prime goal is establishment of a regular pattern of evacuation. Treatment sessions should be coordinated around the bowel and bladder program.

Decubiti Ulcers: Stages

*Stage I*- red spot that blanches (indicating presence of capillary supply). Skin is unbroken. Mark fades within 30-60 minutes after pressure is removed. This is reversible. *Stage II*- skin loss involving the epidermis/dermis. Ulcer is superficial and presents as a blister, abrasion or shallow crater. Pain is present. *Stage III*- full thickness skin loss with damage or necrosis of subcutaneous tissue that extends down but not through the underlying fascia. Usually presents as a deep crater that is not painful due to nerve damage. *Stage IV*- full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. There is no pain *Stages III and IV can typically require surgery*

Autonomic hyperreflexia/Dysreflexia: Treatment

*This is a MEDICAL EMERGENCY.* Check for a kink in the catheter, sit the patient up to decrease the blood pressure. Check for tight or irritating clothing. Monitor blood pressure closely, notify medical/nursing staff immediately if symptoms do not subside. Medication (Amyl Nitrate) is used to treat autonomic dysreflexia as it causes the vessels of the heart to dilate and decrease blood pressure. Nitroglycerin can also be used.

Incidences and Mechanisms of SCI

-It is estimated that approximately 11,000 new cases of spinal cord impairment occur in the United States annually. -A Spinal Cord Injury (SCI) is a relatively low-incidence disability affecting a predominately young population and is associated with lengthy and costly care. -Spinal cord injury costs, in the United States are now estimated at three billion dollars annually. *Spinal cord injuries are divided into traumatic and non-traumatic classifications.*

Pain

Acute injuries will experience some sort of nerve root pain, spinal cord dysesthesias, musculoskeletal pain, etc. Chronic conditions may persist in 5-30% of cases. Chronic musculoskeletal stresses on extremities can produce bursitis, tendinitis, capsulitis, DJD, etc. Pain can be treated with TENS with caution, careful attention to posture and control, anti depressants, nerve blocks, and activity.

Respiratory Management: Abdominal Support

An abdominal corset or binder is indicated for patients, whose abdomens protrude, allowing the diaphragm to "sag" into poor position for function.

Motor Tracts (Descending)

Anterior (15%) and Lateral ( 85%) Corticospinal tracts are responsible for coordination and voluntary motor. Lateral Rubrospinal tracts are responsible for tone, posture, and coordination. Anterior and Lateral Reticulospinal tracts are responsible for tone and sweat.

Sensory Tracts (Ascending)

Anterior and Lateral Spinothalamic tracts are responsible for crude touch and pressure (anterior) and pain and temperature (Lateral). Anterior, Posterior and lateral Spinocerebellar tracts responsible for subconscious proprioception. Posterior Fasciculus Gracilis and Fasciculus Cuneatous tracts are responsible for two-point discrimination, conscious proprioception and vibration.

Progression of Treatment for SCI's: Progression Exercises BED MOBILITY

Assisted rolling, bilaterally, with arm swing Weighted arm rolling Crossed leg rolling Combination of arm/leg weights Curl and roll (flex C-spine and trunk)

Progression Exercises: SIDELYING

Assisted sidelying to prone with legs crossed. Exaggerated UE movement is used to accomplish all sidelying/rolling activities. Sidelying/supine to prone with legs crossed and cuff weight at wrist. Rolling with legs crossed and no cuff weight, pillow behind back. Rolling with legs crossed and no cuff weight or pillow. Supine to prone with legs uncrossed. Prone-on-Elbows Position The functional implications of this activity are improved bed mobility and preparation for assuming the quadruped and sitting position. This component of the mat progression facilitates head and neck control as well as proximal stability of the glenohumeral and scapular muscular via contraction. Scapular strengthening exercises also can be accomplished in this position.

Rehabilitation of the SCI Patient: Precautions, Paraplegia

Avoid straight leg raises over 100-110 degrees of hip flexion in acute phase (this will cause strain to the lower thoracic and lumbar spine.) In acute stages (first few weeks) avoid resistance to hip and trunk.

Progression Exercises: SITTING, Short Sitting

Balance with 2 arm support. Rhythmic stabilization provided initially, progressing to balance disturbances. Activity in this position starts when there is stability in long sitting; difficulty is greater due to absence of hamstring tension. Balance with 1 arm support. Balance without arm support. Push-ups. Lateral scooting

Meninges

Dura Mater - extends from the foramen magnum where it is fused with the filum terminale. Arachnoid - Also continuous with that of the brain. Pia Mater - The subarachnoid space where CSF circulates from the fourth ventricle and is the innermost meninges that adheres to the surface of the spinal cord and brain and contains numerous blood vessels.

Progression Exercises: SUPINE

Bilateral and symmetrical shoulder/trunk extension-elbows close to trunk, lift neck and upper shoulder through extension into mat Stabilizing on elbows- assist to this position; apply gradual rhythmic stabilization. Push-up- patient lifts upper trunk on fixed elbows. Scapular adductors provide lift. Lateral weight shift. Supine-on-elbow to prone. Supine to supine on elbows-patient contracts elbow flexors and walks elbows backward until under shoulders. Rolling Rolling is a frequent starting point of mat programs. It requires the patient to learn to use the head, neck, and upper extremities. It is usually easiest to begin rolling activities from the supine position. Rolling should be initiated with movement toward the weaker side. The activity is initially taught on a mat. However, rolling must be mastered also on the surface of a bed.

Blood Supply

Blood supply to the spinal cord is supplied by the anterior and posterior arteries and the vascularized radicular arterioles of the Pia Mater.

Respiratory Impairments

Bronchopneumonia and pulmonary embolism are responsible for a high incidence of mortality during the early stages of quadriplegia. With high spinal cord lesions C1- C3, phrenic nerve innervation is lost and a ventilator or phrenic nerve stimulator is used to sustain life. In contrast to this, those patients with lumbar lesions have full innervations of primary and secondary respiratory muscles and have far fewer associated problems. With paralysis of the abdominals this support is lost, causing the diaphragm to assume an unusually low position. This lowered position in conjunction with decreased abdominal pressure that moves the diaphragm upward during forced expiration lead to a decrease in the expiratory reserve volume. This is what inhibits the coughing ability of the SCI patient. Paralysis also results in the development of an altered breathing pattern. This pattern is characterized by some flattening of the chest wall and decreased chest wall expansion. Conversely the abdomen will show greater vertical displacement. Over time this altered breathing pattern will lead to permanent postural changes.

Levels of Function: The presence of these key muscles classifies the intact functional level

C3, 4, 5- Diaphragm C 5- Deltoid and/or Biceps C 6-Wrist extensors C 7-Triceps C 8-Flexor Profundus T 1- Hand intrinsic T 2, L 1- Use sensory level to determine L 2-Iliopsoas L 3- Quadriceps L 4- Tibialis Anterior L 5-Extensor hallucis longus S 1- Gastrocnemius

Exercise Program: Strengthening

Concentrate on anterior deltoids, shoulder extensors, biceps, and lower traps for your quad patient. Wrist extensors, triceps, pectorals if functioning. All upper muscles for your patients with paraplegia, especially scapular depressors, triceps, and latissimus dorsi. Monitor muscle function return, especially with incomplete injuries. Endurance training low weight, high repetition upper extremity exercise, progressive distance w/c propulsion, UBE are possibilities.

Exercise Program: ROM, Stretching

Continue program as initiated in acute phase. *100-110 degrees of hamstring flexibility is desirable.* Selectively stretch the hamstrings while maintaining the pelvis in a neutral position this will prevent stretching of the low back area and thus improve sitting posture. Initiate self ROM program as soon as feasible and/or teach patient how to instruct caregiver in ROM program

Respiratory Management:

Continue to monitor and improve breathing strengthening exercises Depending on the individual patient, the following treatment activity may be appropriate:

Contractures

Contractures develop with prolonged shortening of structures across and around a joint resulting in limitation of movement. Contractures initially produce alterations in muscle tissue but rapidly progress towards involvement of capsular tissue. Once the tissue changes have occurred, the ability to reverse the changes is poor. *The most important management consideration related to the potential development of contractures is prevention.* Maintenance of joint motion is effectively achieved by a consistent and concurrent program of ROM and positioning.

Deep Vein Thrombosis (DVT)

DVT's can occur due to the loss of the normal "pumping" mechanism provided by active contraction of the lower extremity muscles. *Most frequently, DVT's occur within the first two months of injury. Look for swelling, erythema, and heat.* Complicating conditions can include diabetes, stroke and heart failure. The most common types of occlusive disorder are from arterial thrombosis, embolism and vasospastic disease. Vasospastic disease is more frequently referred to as Raynaud 's phenomenon. Raynaud's can be precipitated by exposure to cold or by emotional stress with symptoms of skin pallor to cyanosis and rubor with pain and numbness. Intermittent claudication is the earliest symptom of this process and presents with pain, diminished/absent pedal pulse and positive signs of rubor (redness). As this process continues, there are increased trophic changes and the foot becomes cooler to touch. In the later stages, there is presence of ischemia and resulting ulceration's.

Levels of Function: C5

Deltoid and/or Biceps

Respiratory Management: Deep Breathing

Diaphragmatic breathing should be encouraged. To facilitate diaphragmatic movement and to increase vital capacity, the therapist can apply light pressure during both inspiration and expiration. This creates a compressive force on the thorax, resulting in a more forceful expiration followed by a more efficient inspiration.

Levels of Function: C3, 4, 5

Diaphram

Levels of Function: L5

Extensor Hallucis Longus

Levels of Function: C8

Flexor Profundus

Fracture Stabilization, post surgery

Following thoracic or lumbar surgery the patient is placed in a spinal orthoses, such as a Jewett hyperextension orthoses or a custom made, plastic, bivalved body jacket (TLSO-Thoracolumbarsacral orthosis) for a minimum of three months.

Correlating Diagnostic Information w/ spinal Level: C6

Primary Motor Test: Wrist Extensors Primary Sensory Derma Area: Lat Forearm, Thumb, Index Finger Reflex: Brachioradialis

Incomplete SCI's: Anterior Cord Syndrome

Frequently related to flexion injuries of the cervical spine with damage occurring to the anterior portion of the cord or its vascular supply from the anterior spinal artery. There is typically compression of the cord from a fracture dislocation. This syndrome is characterized by motor loss due to damage to the corticospinal tract and loss of touch/pressure and pain/ temperature due to damage to anterior and lateral spinothalamic tracts, respectively. Below the level of the lesion, proprioception, kinesthesia, and vibration are generally preserved. There can also be some sacral sparing.

Levels of Function: S1

Gastrocnemius

Heterotropic Ossification

Growth of new bone (more than calcification of muscle) with major traumas. *Occurs below the level of the lesion with SCI*. This can affect tendons, joint capsules, and connective tissue by forming in these structures. It does not usually form within the muscle tissue as in myositis ossificans. Myositis ossificans usually occurs with an injury to the muscle itself and forms bony deposits within that muscle tissue. Myositis ossificans will resolve with rest. *Typically occurs adjacent to large joints, with hips the most commonly involved, then knees, shoulders, and elbows.*

Levels of Function: T1

Hand intrinsic

Progression Exercises: SITTING, Long Sitting

Hands behind hips. Rhythmic stabilization applied through head/shoulders (using triceps) Hands hooked forward under knees. Rhythmic stabilization applied (using biceps) Hands at Greater trochanter (Trochanter propping) Rhythmic stabilization applied. Slight flexion of patient's head and trunk will aid stability. Slow disturbance to offset balance. Slow disturbance with one arm support. Slow disturbance without are support. Catching/throwing a ball. A pillow should be placed on the patient's legs for protection if the ball is weighted. Push-ups. Lifts are slow and sustained. Bending trunk forward will help maintain balance. Scooting sideways. First seat, then legs. Supine to long sit.

Rehabilitation of the SCI Patient: Precautions

If the patient is in a halo device, avoid bumping halo apparatus, rings or uprights. Do not use uprights to assist moving the patient. Patient is to use any spinal orthotics prescribed whenever upright or performing mobility skills until the physician authorizes otherwise. Watch for orthostatic hypotension, recline patient and/ or elevate legs if present. Exercises should be completed daily except those areas that are contraindicated or require selective stretching

Levels of Function: L2

Iliopsoas

Fracture Stabilization

Immobilization of unstable cervical fractures is achieved via skeletal traction. Traction can be applied by the use of tongs or Halo device attached to the skull. With the halo device, tongs/calipers are inserted laterally on the outer skull. Traction is attached to a traction rope and then to the skull fixation. With the patient in supine position the weights hang freely The patient is generally immobilized for about 12 weeks until healing occurs. Several types of frames and beds are used during this period (12 weeks) of immobilization

Rehabilitation of the SCI Patient: Precautions, Quadraplegia

In acute stages (first few weeks), avoid resistance to shoulders and scapula. Avoid head and neck motion pending orthopedic clearance. (SCI patients do not require full ROM in all areas. In some cases in is beneficial for the patient to have tightness in order to enhance function) Tenodesis Grasp- tightness in the long finger flexors allow for improved grasp with use of wrist extension Anti-tip bars should be on all w/c used until the patient demonstrates ability to control weight shift in the w/c

Exercise Program: Wheelchair Mobility

Instruct in weight relief techniques, i.e. wheelchair pushups, hooking an elbow or wrist around push handle and lean toward the opposite wheel or forward. (Patient can lean without hooking wrist if triceps are available). Weight shifting should occur every 15 minutes for at least 30 seconds to prevent decubiti. Instruct in use of head/shoulder positioning and momentum to increase propulsion force and maintain balance. Mobility skills to be addressed: propulsion on smooth, level surface, light terrain propulsion, performing wheelies, ramp ascent/decent, management of stairs and curbs, opening and closing doors.

Mechanism of Spinal Injury: Distraction

Involves a pulling apart agent; least common. Whiplash is a milder example and hanging is a severe form.

Incomplete SCI's: Cauda Equina

Lesions are frequently incomplete due to the mobility of the nerves as well as the greater number of roots themselves. This is a peripheral nerve injury and, therefore has the same potential for recovery as any other PNS lesion.

Non-traumatic Injuries

Non-traumatic injuries generally result from a disease or pathologic influence. Examples are thrombosis, embolus, vertebral subluxation secondary to rheumatoid arthritis, infection such as syphilis and spinal neoplasm. It is estimated that non-traumatic etiologies account for 30% of all spinal cord injuries.

Exercise Program: Mat Progressions

Mat activities constitute a major component of treatment during the rehabilitation phase. The sequence of activities typically progresses from achievement of stability within a posture and advanced through controlled mobility to skill in functional use. Rolling Prone on elbows and prone on hands (in paraplegia) Supine on elbows Long sitting Short sitting Quadruped position (in paraplegia) Early activities are bilateral and symmetrical. A progression is then made to weight shifting and movement within the posture. A gradual emphasis is placed on improved timing and speed. Mat activities should be initiated as soon as the patient is cleared for activity. Progression through the sequence of mat activities develops improved strength and functional ROM, improves awareness of the new center of gravity, promotes postural stability, facilitates dynamic balance and assists with determining the most efficient and functional methods for accomplishing specific tasks.Several components can be worked on concurrently to build strength, functional ROM, postural stability, dynamic balance, and functional patterns of movement.

Exercise Program: Gait Training

May use electrical modalities and/or progressive resistive exercise for strengthening of lower extremities and trunk musculature. Train patient in orthotic donning/doffing, ambulate with appropriate assistive device including obstacle negotiation, curbs, ramps, and protective falling techniques.

Treatment for Heterotropic Ossification

Medication (Didronel prophylactically) will decrease incidence and severity by half. Requires 6 to 12 months to become mature, inactive bone. Surgery is a possibility to remove heterotopic ossification if it is affecting hip ROM and posing functional limitations. Can result in joint ankylosing if it is allowed to progress. Can mimic thrombophlebitis. *Early onset is characterized by elevated serum alkaline phosphate levels but negative findings on film.* During later stages soft tissue edema subsides and the films are positive. Management of this includes medication (didronel), ROM, and surgery.

Incomplete SCI's: Brown Sequard Syndrome

Occurs from damage to one side of the cord and is typically caused by stab wounds. Partial lesions will be seen more often than a true complete hemi-section of the cord. The clinical features of this syndrome are asymmetrical. Due to the decussation of afferent/efferent impulses in the CNS, a lesion on the left side will affect the motor on that same side (ipsilateral) whereas the spinothalamic tracts will be affected on the opposite side (contralateral) beginning approx. 2 levels below the injury.

Autonomic Function

Parasympathetic system slows the body down, exits at the brain stem and sacral levels. Sympathetic system produces the fight or flight response and exits at the thoracic level.

Exercise Program: Transfers

Preparation/completion of transfers to include management of w/c parts, self positioning, and placement/ removal of sliding board if used. Use of head/shoulder to control momentum should be taught to achieve a high lift with push up while balancing through transfer. Teach patient how to instruct caregiver in assisting. Transfers to be addressed: bed, couch/chair, bath/tub/bench, toilet, car, and floor

Correlating Diagnostic Information w/ spinal Level: L4

Primary Motor Test: Anterior Tibialis Primary Sensory Derma Area: Medial Lower Leg Reflex: Patellar

Correlating Diagnostic Information w/ spinal Level: C5

Primary Motor Test: Biceps Primary Sensory Derma Area: Lat Upper Arm Reflex: Biceps

Correlating Diagnostic Information w/ spinal Level: L5

Primary Motor Test: Extensor Hallucis Longus Primary Sensory Derma Area: Lateral Lower Leg, Dorsum of Foot Reflex: Hamstrings

Correlating Diagnostic Information w/ spinal Level: C8

Primary Motor Test: Finger Flexors Primary Sensory Derma Area: Ring Finger, Pinkie & Medial Forearm Reflex: None

Correlating Diagnostic Information w/ spinal Level: S1

Primary Motor Test: Gastrocnemius/Soleus Primary Sensory Derma Area:Lateral Border of Foot, Center of Post, Lower Leg Reflex: Achillies

Correlating Diagnostic Information w/ spinal Level: T1

Primary Motor Test: Hand Intrinsics Primary Sensory Derma Area: Medial Elbow Reflex: None

Correlating Diagnostic Information w/ spinal Level: L1, L2

Primary Motor Test: Iliopsoas Primary Sensory Derma Area: Anterior Upper Thigh Reflex: None

Correlating Diagnostic Information w/ spinal Level: L3

Primary Motor Test: Quadriceps Primary Sensory Derma Area: Anterior Knee Reflex: Patellar

Ligaments

Primary ligaments that give support to the column include: Anterior and Posterior Longitudinal Ligaments Ligamentum Flavum Interspinal and Supraspinal Ligaments Coccygeal Ligament (the threadlike termination of the spinal dura mater, surrounding and fused to the filum terminale of the cord, and attached to the deep dorsal sacrococcygeal ligament; extends from S2-3 to Co2 vertebral levels.)

Respiratory Management: Strengthening Exercises

Progressive resistive exercises can be used to strengthen the diaphragm. This can be accomplished by manual contacts over the epigastric area below the xiphoid. Strengthening exercises for enervated abdominal and accessory musculature are also indicated. Assisted coughing - Manual contacts are placed over the epigastric area. Therapist pushes quickly in an upward direction as the patient attempts to cough. Review this with the patient/family caregivers.

Levels of Function: L3

Quadriceps

Mechanism of Spinal Injury: Hyperextension

Rear end collisions, or falls with the chin hitting a stationary object. Fractures of the spinous processes, lamina, and facets

Incomplete SCI's: Sacral Sparing

Refers to an incomplete lesion that has degrees of intact sacral fragments, usually with sparing of the long ascending and descending tracts. Sacral sparing is often the only early evidence of incomplete quadriplegia because the long tracts that serve the sacral function are more protected from injury. The primary criterion for sacral sparing is proprioception in the rectum and, depending upon the involvement, active sphincter contraction as well as toe flexion.

Incomplete SCI's: Sacral Sparing

Refers to an incomplete lesion that has degrees of intact sacral fragments, usually with sparing of the long ascending and descending tracts. Sacral sparing is often the only early evidence of incomplete quadriplegia because the long tracts that serve the sacral function are more protected from injury. The primary criterion for sacral sparing is proprioception in the rectum and, depending upon the involvement, active sphincter contraction as well as toe flexion.

Spasticity

Results from the release of intact reflex arcs from CNS control and is characterized by hypertonicity, hyperactive stretch reflexes, and clonus. Typically occurs below the level of the lesion after spinal shock subsides. This will plateau and stabilize within the first year. Mild to moderate spasticity can assist ADL's, maintain muscle bulk, aid in appearance, maintain padding over bony prominences, and improve respiratory function. Severe spasticity interferes with rehab and can impair independent function.

Decubiti Ulcers: Risk Factors

Risk factors would include atrophy over bony prominences, lack of sensation, emotional stress (make patient aware of risk), spasticity, nicotine, nutrition. Protein, vitamin A and C are keys to collagen health. Patients need to build a tolerance to sitting. Relief measures should be every 10-15 minutes for 10-15 seconds initially, especially if not pushing W/C independently. Monitor as needed thereafter. Turning in bed should be done every 2 hours by nursing staff. Always think prevention. Common areas for pressure sores include the occiput, scapula, vertebrae, elbows, knees, sacrum, coccyx, and heels.

Correlating Diagnostic Information w/ spinal Level

See chart:

Levels of Function: C6

Wrist Extensors

Autonomic hyperreflexia/Dysreflexia

Spinal cord injuries cause the reflex arc to lose inhibitory control *above the spinal injury level*. The sympathetic response is no longer in control. This syndrome is unique to SCI and occurs primarily in high-level spinal cord injuries. *T6 is an important level as injuries below this level do better due to intactness of the systems to visceral organs.* AUTONOMIC DYSREFLEXIA occurs when *there is an irritating stimulus introduced below the level of the lesion.* The afferent input from the stimulus reach the spinal cord and can only travel as far as the injury site. A mass reflex response is activated that *increases the activity of the sympathetic portion of the autonomic nervous system by constricting the blood vessels which elevates the blood pressure.* The nerve receptors in the heart and blood vessels detect this rise in the blood pressure and a message is sent to the brain. The brain then sends a message to the heart *causing the heart beat to slow down and the blood vessels above the level of the injury site to dilate.* The brain is not able to send messages to the body below the site of the injury so the blood pressure cannot be regulated and the body becomes confused.

Spinal Shock

Spinal shock is a period of time that follows spinal injury that involves transient reflex depression. It is characterized by absence of all reflex activity, flaccidity, and loss of sensation *below the level of the lesion.* It may last for several hours to several weeks but usually subsides after 48-72 hours. This reflex may be present several weeks before DTR's are seen in the extremities. Impaired temperature control occurs because the damage to the spinal cord no longer allows the hypothalamus to control cutaneous blood flow or perspiration. The lack of sweating is often associated with excessive compensatory diaphoresis above the level of the lesion. This dysfunction of the sympathetic nervous system results in the loss of internal thermoregulatory reactions. The ability to shiver has been lost and vasodilation does not occur in response to heat nor does vasoconstriction with the application of cold. Patients must rely heavily on sensory input from the head and neck region to assist in determining appropriate environmental temperatures.

Exercise Program: Functional Timelines

Stabilization Mobilization in bed Mobilization on a mat Increased sitting tolerance with weight shifting Increase balance and endurance Increasing independent mobility in bed, for transfers, transportation Gait training

Progression Exercises: PRONE

Stabilizing on elbows-assist patient to elbows; apply very gradual rhythmic stabilization. Push-ups- pectorals stabilize elbow, scapular depressors provide the lift. Therapist may need to assist. Prone on elbows- elbows push into mat to elevate trunk up. Lateral shifts. Lateral shift and lift of arm- shift to the point of sidelying, over to supine and back. Moving sideways on elbows, forward on elbows.

Fracture Stabilization, surgical interventions

Surgical intervention for cervical fractures may include decompression and fusion. Fusion is achieved by bone grafting and may be combined with posterior wiring of the spinous processes. Frequently, surgery requires use of an internal fixation device, which may be used in combination with bone grafts (internal fixation rods)

Functional Classifications & Capabilities: The International Standard Neurological Classification of Spinal Cord Injury (ISNCSCI)

The American Spinal Injury Association (ASIA) created the International Standards of Neurological Classification of Spinal Cord Injury (ISNCSCI) to provide common standards to determine the extent of motor and sensory function following a spinal cord injury. An example of the sensory assessment in the patient with a spinal cord injury is available in O'Sullivan on page 892.

Decubiti Ulcers

Ulceration's of soft tissue caused by unrelieved pressure and shearing forces. *Use Caution:* Pulling on clothes when transferring can cause tremendous shearing forces on skin. Pressure relief efforts can cause shearing. Educate your patient accordingly. Sores start deep and work outward through four stages

Internal Structures

The integral structures of the spinal cord are composed of two principle parts: GRAY MATTER is located in the middle of the cord and grossly forms an "H". It is composed of nerve cell bodies and *unmyelinated* axons of motor nerves. WHITE MATTER surrounds the gray and is composed of *myelinated* axons of motor and sensory neurons.

Mechanism of Spinal Injury: Flexion

The most common mechanism of SCI. Head on collision with the head striking the steering wheel or the windshield, or a blow to the back of the head and wedge fractures of the anterior vertebral body.

Primary Function of the Spinal Cord

The primary function of the spinal cord is to transmit motor/sensory impulses and integrate reflexes. The transmission of impulses are carried via tracts: MOTOR and SENSORY

Spinal Cord

The spinal cord begins as a continuation of the Medulla Oblongata and extends to L 2. It tapers at the Conus Medullaris and is segmented into the Cauda Equina and extends to the Coccyx. It attaches as the Filum Terminale which is composed of the Pia Mater and fibrous connective tissue. The spinal cord has enlargements at the cervical(C3-T2) and lumbar (T10-L1) areas which are due to the concentration of spinal nerves in this area. The spinal cord is located in the vertebral canal of the vertebral column, with the canal being formed by the vertebral foramen. The spinal cord is enclosed with a ring of bones and is well protected. Some protection comes from the meninges, Cerebrospinal fluid (CSF), and vertebral ligaments

Mechanism of Spinal Injury: Shearing

The spine experiences a horizontal force. Disrupts ligaments and causes fractures.

Respiratory Management: Glossalpharyngeal Breathing

This activity is often appropriate for patients with high-level cervical lesions. The technique utilizes accessory muscles of respiration to improve vital capacity. The patient is instructed to inspire small amounts of air repeatedly, thus utilizing available facial and neck muscles.

Postural/Orthostatic Hypotension

This is a decrease in blood pressure which occurs when a patient is moved from a horizontal to a vertical position. It is caused by the lack of sympathetic vasoconstriction. The problem is also associated with the lack of muscle tone causing peripheral venous pooling. Reduced cerebral flow and decreased venous return to the heart may also be present. To minimize these effects gradual elevation prior to assuming a vertical position must be performed. Initially at the acute stage of rehab, a tilt table will be required to slowly adapt these patients to the upright position. Although the exact mechanism is not understood, the cardiovascular system adjusts over time gradually reestablishing sufficient vasomotor tone.

Levels of Function: L4

Tibialis Anterior

Progression Exercises: TRANSFERS

Transfer training is generally initiated once the patient has achieved adequate sitting balance. The technique most frequently used by patients with spinal cord injury is some variation of a sliding transfer (with or without the use of a sliding board). Some experimentation and problem solving between the patient and therapist is generally required to determine the most efficient and safest method for an individual patient.

Traumatic Injuries

Traumatic influences are by far the most frequent cause of injury and result from damage caused by a traumatic event such as a motor vehicle accident, falls, or gunshot wounds. Auto accidents are the leading cause of SCI in the United States for people age 65 and younger, while falls are the leading cause of SCI for people 65 and older. Motor vehicle related accidents are the most frequent cause of traumatic SCI with 45.6% being automotive. Falls ranked second at 19.6%, acts of violence at 17.8 %, recreational sports injuries at 10.7 %, and injuries resulting from other etiologies at 6.3%. 82% are males and 18% female with ½ of the population in the 16-30 year-old age group. A proportionately higher incidence of injuries (31.6%) occurred during the three summer months with 38.6% of the injuries occurring on weekends. Sports and recreation-related SCI injuries primarily affect people under age 29.

Levels of Function: C7

Triceps

Levels of Function: T2. L1

Use Sensory level to determine

Incomplete SCI's: Central Cord Syndrome

Usually is the result of a hyperextension injury to the cervical spine. The resultant compressive forces lead to hemorrhage and edema that result in damage to the most central portion of the cord. There is typically more involvement of the upper extremities than that of the lower extremities. This is due to the more central positioning of the UE tracts. Sensory function tends to be less affected than are the motor. Patients typically recover with the ability to ambulate but have difficulty with UE function. Surgical decompression is of great benefit to these patients.

Incomplete SCI's: Posterior Cord Syndrome

Very rare syndrome which results in greater effects to the tracts in the posterior cord. It results in loss of proprioception and vibration due to hyperextension and compression injuries.

Autonomic hyperreflexia/Dysreflexia: Symptoms

hypertension bradycardia headache blotching profuse sweating above the lesion nasal congestion goose bumps blurred vision

Mechanism of Spinal Injury: Flexion Rotation

posterior to anterior force directed at rotated vertebral column. (i.e. rear end collision with the passenger rotated toward the driver) Fracture of the posterior pedicles, facets, and laminae.

Autonomic hyperreflexia/Dysreflexia: Triggers

primarily by bladder distension rectal distension pressure sores urinary stones bladder infections environmental temperature changes fractures childbirth ingrown toe nails

Mechanism of Spinal Injury: Compression

vertical or axial blow to the head (diving, surfing, or falling). Burst fractures can also compress the spinal cord.