Spinal Cord Injury

SCI: Home Programming

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SCI: Active Rehabilitation Stage

*Maximize functional independence* Continuing activities Skin inspection Mat programs Prescriptive w/c Ambulation/ gait trng Functional E-Stim Prevention, health promotion, fitness, and wellness

SCI: Acute Rehabilitation Phase

*Prevent indirect impairments/complications and facilitate active movement in available musculature.* -Respiratory management -ROM and Positioning -Selective strengthening -Orientation to vertical position

Postural Hypotension (orthostatic hypotension)

-*Occurs* when assuming an erect or vertical position. -*caused by* loss of sympathetic vasoconstriction control. -*symptoms:* lightheaded, dizzy, fainting -*Intervention* adapt gradually to vertical, raise head of bed, use tilt table, compressive stockings and abdominal binders help minimize effects. -*meds* ephedrine↑BP & diuretics relieve edema

SCI: Ambulation/ gait trng

-A swing-through type of gait pattern should be the ultimate goal for functional ambulators w/ KAFO's. -Teach to don and doff orthoses -Sit-to-stand -Trunk balancing - Push-ups -Turning around -Jack-knifing -Ambulation activities in the // bars -Assistive device -Standing from w/c w crutches -Crutch balancing -Ambulation activities -Travel activities -Elevation activities -Falling

SCI: Selective Strengthening

-B UE activities for asymmetry -B manually resisted motions in straight planes -B UE PNF -Progressive resistive exercises using cuff weights/dumbbells -biofeedback -Tetraplegia: Emphasis should be on strengthening anterior delt, shoulder extensors, biceps, lower trap, radial wrist extensors, triceps, and pectorals -Paraplegia: All UE w emphasis on shoulder depressors, triceps, and lats for transfers and ambulation.

SCI: Respiratory management

-Deep-Breathing Exercises, glossopharyngeal breathing, Airshift maneuver, strengthening exercises, assisted coughing, abdominal support, chest mobility/stretching.

Flexion injury

-Head on collision in which head strikes steering wheel -Blow to back of head or trunk -Most common mechanism of SCI

Respiratory Impairments

-High SCI C1-C3, phrenic nerve, phrenic nerve stimulator required to sustain life. -All tetraplegia and high level SCI have a compromise of respiratory function. -Involvement can be life threatening, bronchopneumonia, or pulmonary embolism -MM. of inspiration: diaphragm, exter intercostal -mm. of expiration: abdominals, inter intercostals these mm help maintain intrathoracic pressure -SCI susceptible to secretions, atelectasis, and pulmonary infections.

Symptoms of Autonomic Dysreflexia

-Hypertension -Bradycardia -headache (severe pounding) -profuse sweating -↑ spasticity -restlessness - vasoconstriction ↓ level of lesion -Vasodilation ↑ level of lesion (flushing) -constricted pupils -nasal constriction

Impaired Temperature control

-Hypothalamus can no longer control cutaneous blood flow, pt, can not shiver or sweat from heat to keep cool, and there is a loss of internal themoregulatory responses. -There is diphoresis (excessive sweating) above the level of lesion: -Teach pt. to rely on head and neck to determine appropriate environmental temperature.

autonomic dysreflexia

-Onset occurs from noxious stimuli below level of lesion. Elevation of BP and can not be lowered. It is a critical emergency situation ( could result in death.)

SCI: ROM and Positioning

-Paraplegia: No SLR's more than 60 deg, no hip flexion past 90 deg (during combined hip and knee flex) -Tetraplegia: Motion of head and neck is contraindicated until cleared by orthopedist , avoid stretching shoulders in acute phase -Selective stretching: Understretch and overstretch certain muscles to improve function -Positioning splints for wrists, hands, fingers -Ankle boots or splints -Sandbags or towel rolls to maintain neutral hip rotation

SCI: Prevention, health promotion, fitness, and wellness

-Prevention of shoulder pain is vital: Postural alignment, strengthening/stretching shoulder muscles -Exercise to increase endurance: UBE, w/c propulsion, swimming, circuit resistance trng -Strength trng exercises: 8-12 reps, free weights, elastic tubing, weight machines. -Education: lifelong management of disability

SCI: Prescriptive w/c

-Primary means of locomotion because it provides lower energy expenditure and greater speed and safety

SCI: Orientation to vertical position

-Pt must be cleared for upright activities -Gradual acclimation -The use of abdominal binder and elastic stockings will prevent venous pooling -Slowly elevate HOB and progress to a reclining w/c -Tilt-table -Carefully monitor vital signs

Indirect impairment and complications

-Respiratory complications -Pressure sores -DVT -Contractures -Heterotopic Ossification -Pain (traumatic, nerve root, dyesthesias, musculoskeletal, osteoporosis)

Sexual Dysfunction

-Sexual information is a vital part of the rehabilitation process and is a complex issue. -Characterized by a physiological dysfunction, and sensory and motor impairment and accompanied by social and psychological distress. -A sexual counselor may be a team member -Sexual capabilities are divided between UMN and LMN lesions.

SCI: Skin inspection

-Skin inspection and care must become a regular and lifelong component of the pt's daily routine. -Wall mirrors adjacent to bed may assist w independence w/ this activity. -If incapable of self-inspection it is important that these pt's direct others to examine skin

Clinical manifestations of SCI are:

-Spinal Shock -motor and sensory impairments -autonomic dysreflexia -Postural Hypotension -Impaired Temperature control -Respiratory Impairments -Spasticity -Bladder and Bowel Dysfunction -Sexual Dysfunction -Indirect impairment and complications

Hyperextension injury

-Strong posterior force such as rear-end collision. -Falls with chin hitting a stationary object (elderly population)

Intervention for Autonomic Dysreflexia

-Tx. as medical emergency -Sitting position (to lower BP) -check catheter for clamp (release) -loosen tight clothing -notify physician and nursing staff

Bladder and Bowel Dysfunction

-UTI's are common -A flaccid or nonreflex (autonomous) (LMN) bladder develops (SCI at S2-S4) -A spastic or reflex (UMN) bladder contracts and reflexively empties when full. (SCI's above S2-4) -Bowel and bladder training programs

Compression injury

-Vertical or axial bow to head (diving, surfing, or falling objects)

Spasticity

-results from intact reflex arcs -characterized by hypertonicity -increases for 1st 6 mos. -plateaus at about 1 yr. -vary in degree of severity -management w/ drugs(valum, baclofen) nerve blocks, and in severe cases severance of nerve (tenotomy, or nerve roots rhizotomy, or nerve fibers mylotomy)

There are two etiological categories

1. Traumatic Injury 2. Nontraumatic Injury

Complete Injuries

A complete transection of the spinal cord is rare, but an incomplete can still present as complete. Having no sensory or motor function in the lowest sacral segments (S4-S5) *Sensory and motor function @ S4 and S5 are determined by anal sensation and voluntary external anal sphincter contraction.*

Sacral Sparing

An incomplete lesion in which the most centrally located sacral innervation remains intact.

Paraplegia

Complete paralysis of all or part of the trunk and both LE's resulting lesions of the thoracic or lumbar spinal cord or cauda equina.

Objective # 4

Describe the clinical manifestations of SCI.

Objective #1

Discuss the etiology of spinal cord injuries

Nontraumatic Injury

Disease or pathological: *Vascular malfunctions* -Arteriovenous Malformation, thromus, embolus, or hemmorhage; *Verterbral subluxation* secondary to arthritis or DJD; *Infections* such as syphilis or transverse myelitis; *spinal neoplasms*, *syringomyelia*, *abscesses of spinal cord*, and *neurological diseases* such as MS or ALS. Nontraumatic account for 30 % of (SCI)

Mechanisms of SCI

Indirect force and direct force Indirect force is the most common These forces move the spine into flexion, compression, hyperextension, and flexion-rotation and result in fracture or dislocation. The highest frequency of injury are between (C5-7) and (T12-L2) See table 23.2 pg. 942

Ojective #2

Explain the classification of spinal cord injuries.

Posterior Cord Syndrome

Extremely rare. Deficits of posterior column functions

Cauda Equina Injuries

Frequently incomplete. LMN injuries. They have some potential to regenerate nerves elsewhere in the body. Full return of innervation is not common.

Anterior Cord Syndrome

Frequently related to flexion injuries of the cervical region. There is typically compression of the anterior cord from fracture, dislocation, or cervical disk protrusion.

Objective #3

Identify the mechanisms of spinal cord injuries.

Spinal Shock

Immediately following SCI there is a period of complete absence of reflex activity called spinal shock. Flaccidity and loss of sensation below the level of lesion.

SCI: Functional E-Stim

Low-level electrical current to improve function in paralyzed and/or weak muscles

SCI: Continuing activities

Many of the activities initiated during the acute phase will be continued; ROM, respiratory care, positioning

Zones of partial preservation

May have motor and/or sensory below the neurological level but does not have function.

Central Cord Syndrome

Most commonly occurs from hyperextension injuries to the cervical region. Also associated w/ congenital or degenerative narrowing of the spinal cord. The compressive forces cause hemmorrhage and edema, producing damage to the central cord.

Traumatic Injury

Most frequent cause, 45% auto, 19% falls, 17% violence, 10% sports

Flexion-rotation injury

Posterior to anterior force directed at rotated vertebral column. Example: Rear-end collision w passenger rotated toward driver.

SCI: Mat programs

Rolling Prone-on-Elbows Prone-on-Hands Supine-on-Elbows Pull-Ups (w/ tetraplegia) Sitting Quadruped Kneeling Transfers

(SCI) 2 functional categories

Tetraplegia and Paraplegia

Sensory Level

The most caudal segment of the spinal cord with normal sensory function bilaterally. But is determined by tests. Light touch and pinprick on R and L side of body at key dermatomes. 0=absent, 1=impaired and 2=normal

Cause of autonomic dysreflexia

The most common cause is urinary retention ( bladder distention). Other Stimuli include: rectal distention, pressure sores, urinary stones, bladder and kidney infections.

motor and sensory impairments

complete or partial loss of motor and/or sensory below the level of the lesion.

Tetraplegia

complete paralysis of all four extremities and trunk including mm. of respiration and results from lesions of the spinal cord.

Incomplete Injuries

having motor and/or sensory below the neurological level including S4 and S5.

Neurological level

is the most caudal level of the spinal cord with normal motor and sensory function of both the left and right sides of the body.

Brown-Sequard Syndrome

occurs from hemisection of the spinal cord (damage to one side) and is typically caused by penetration wounds (gunshot, stab)

Right and left sides

should be tested and documented separately due to differences in terms of level of sensory and motor function. Example: A pt's sensory level may be at C5 on the left and C8 on the right

Motor Level

the most caudal segment of the spinal cord with normal motor functions bilaterally. Motor level is determined by testing the strength of a key muscle on the right and left side of body at myotomes.