Chapter 16 (Spinal cord injuries)
Symptoms of HO
Swelling Warmth Decreased joint ROM
S1 - S2 expected functional outcomes
- A person with an S2-spared injury has the potential to ambulate without devices or orthoses - A wheelchair is generally not required - Hip extensors/abductors, knee flexors, and ankle plantar flexors are weak at the S1 level of injury - As with all other preceding levels, bowel and bladder function is impaired, but managed independently at this level through adapted devices/techniques
Reflex arc definition
- A reflex, which is built in and does not need conscious thought to take effect, is the total of any particular automatic response mediated by the nervous system - A reflex arc is usually a simple reflex, such as a knee jerk, which involves only 2 nerves and 1 synapse - When the sensory nerve injury is stimulated, a nerve impulse travels along a sensory (afferent) neuron to the spinal cord - An association neuron, or interneuron, then transfers the impulse to a motor (efferent) neuron, which carries the impulse to a muscle, which then contracts and moves the body part
Flaccid bowel
- Also referred to as a LMN bowel - Usually ____ during the phase of spinal shock and may remain in that state if the injury involves the cauda equina or sacral areas (same as the bladder) - As with the bladder issue with the same name, the ____ bowel cannot be stimulated to empty reflexively - Stool often remains in the rectum after attempts at evacuation, and it may be necessary to remove it manually to prevent impaction
C6 expected functional outcomes
- Amount of assistance needed from another person varies from moderate to minimal with just a few specific activities - Some decreases in respiratory capacity and productive cough - Has potential for independence in pressure relief - Independently uses a manual wheelchair on level surfaces and gradual inclines; rim adaptations provide propulsion abilities - Generally requires a power wheelchair for long distances or rough terrain - Ability to transfer varies --> some strong people are able to transfer independently with the use of a sliding board to a car, chair, bed, commode, or tube seat - Has the potential for independent bed mobility and positioning with rails, power controls, and trapeze - With some adapted devices, usually independent with hygiene, shaving, and grooming - Potential for independence in bathing and bowel/bladder care with equipment - Generally independent with UE dressing, and potential for independence in LE dressing with adapted devices (although LE dressing is quite time consuming) - Independent with feeding (although a wrist-hand orthosis and setup may be required) - Generally able to drive independently using hand controls and adapted devices (if transfers are challenging/inconsistent, driving directly from the wheelchair is indicated)
Decubitis ulcers
- An ulcer caused by local interference with circulation - Usually occurs over a bony prominence at the sacrum, hip (trochanter), heel, shoulder, or elbow - It begins as a reddened area and can quickly involve deeper structures and become an ulcer - Also called a bedsore or a pressure sore
Flaccid bladder
- Bladder complication - Also referred to as a LMN bladder - This type of bladder functions is usually seen during the spinal shock phase and may remain if the injury affected the cauda equina area - With this type of injury, a reflexive emptying of the bladder cannot occur, as the reflex is destroyed - Because the bladder is ____ and does not spontaneously empty, urine will accumulate continuously - Persons with this must catheterize according to a schedule or must apply external pressure to force urine from the bladder --> Crede's maneuver or Valsalva maneuver
Reflex/spastic bladder
- Bladder complication - Also referred to as an UMN bladder - The bladder can contract and void reflexively --> although this action is involuntary, some persons with SCI can trigger the reflex through various stimuli (much like the knee-jerk reflex being triggered by tapping with a reflexed hammer) --> this is because impulses can enter the cord below the level of injury, synapse, and exit - People with this may use various types of catheters and additional techniques to ensure that the bladder does not become distended or retain urine - They generally cannot rely on sensation to alert them that the bladder has exceeded its normal capacity; rather, they must rely on an established voiding schedule
Reflex/spastic bowel
- Bowel complication - Also referred to as an UMN bowel - Stool can be eliminated reflexively if nerves located in the rectum are stimulated - This stimulation may be done manually through digital stimulation or in conjunction with the use of suppositories - Establishing and following a regular schedule for bowel management can reduce occurrence of incontinence
CNS
- Brain - Spinal cord
Below C4 respiratory complications
- Breathing may be shallow - The ability to cough productively may be compromised - Various deep-breathing and assistive-coughing techniques may be taught, along with other procuedures to keep the lungs clear - Prevention and early management of these complications is crucial
Lumbar cistern
- CSF-filled meningeal space between L2 and L4 - The site where diagnostic or therapeutic lumbar punctures, spinal taps, are performed, because the spinal cord is not present, yet CSF is accessible
Cauda Equina - prognosis of recovery
Due to peripheral nerves having a regenerating capacity that the cord does not, there may be a better prognosis for recovery.
T1 - T3 expected functional outcomes
- Can live independently, although assistance required for high/low/heavy tasks - Respiratory capacity and coughing abilities significantly improved compared to previous levels - All transfers generally independent unless other complicating factors (e.g., excessive tone challenges, contractures, shoulder dysfunction) - Independent with all self-care - Finger dexterity, strength, and coordination are functional - Drives independently with hand controls - Typically able to stow certain types of manual wheelchairs in a car, but may be excessively time consuming, energy depleting, and adversely impacting shoulders, and as such a van may be indicated - Able to stand with minimal assistance, KAFO, and use of walker or parallel bars - Ambulation is generally not practical because of reduced trunk control/balance and high energy expenditure
T4 - T8 expected functional outcomes
- Can live independently, although assistance required for high/low/heavy tasks - Respiratory status stronger than T1 - T3 level - Only slightly decreased pressure relief - Independent in wheelchair use, bed positioning, and all self-cares - Driving independently with hand controls - May have potential to ambulate short distances with the use of a walker or Lofstrand crutches and KAFO on level surfaces only --> however, even if able, high energy output is required and wheelchair use remains the predominant form of mobility
Cervical spinal nerves
- Carry afferent (sensory) and efferent (motor) impulses for the head, neck, diaphragm, arms, and hands
Sacral spinal nerves
- Carry impulses for the remaining foot musculature, bowel, bladder, and the muscles involved in sexual functioning
Lumbar spinal nerves
- Carry information to and from the legs and a portion of the foot
Lower motor neuron injuries
- Complete injuries below the level of the conus medullaris (near the level of L2) - The injury has affected the spinal nerves after they exit from the spinal cord (in fact, injuries involving spinal nerves after they exit the cord at any level are referred to as these) - In these injuries, the reflex arc cannot occur, because impulses cannot enter the cord to synapse - Characterized by 1. A loss of voluntary function below the level of the injury 2. Flaccid paralysis 3. Muscle atrophy 4. Absence of reflexes
Upper motor neuron injuries
- Complete injuries where the reflex arcs are intact below the level of the injury but are no longer mediated by the brain - Characterized by: 1. A loss of voluntary function below the level of injury 2. Spastic paralysis 3. No muscle atrophy 4. Hyperactive reflexes
ASIA A
- Complete injury - No motor or sensory function is preserved in the sacral segments S4 through S5 - No motor or sensory function preserved below the level of the injury
C8 movements allowed
- Complete wrist extension, adduction, and abduction (ulnar and radial deviation) - Stronger finger flexion (as compared to previous level) - Thumb flexion, abduction, adduction, and opposition - Weak flexion at MCP with IP extension
Meningeal covering of the spinal cord
- Contains the CSF that bathes the structures of the CNS - Extends past the end of the spinal cord to the L4 vertebral level
C1 - C3 movements allowed
- Depression of hyoid - Neck extension, flexion, rotation, and lateral flexion
C7 movements allowed
- Elbow extension - Forearm pronation - Wrist flexion - Trace finger flexion - Weak finger extension - Weak thumb extension
Spinal nerves C1 through C7
- Exit ABOVE the corresponding vertebrae
Spinal nerves C8 through S5
- Exit BELOW the corresponding vertebrae
Treating autonomic dysreflexia
- Finding the cause and alleviating it - May require emptying the bladder, checking for obstructions in external urinary drainage tubing, assessing for bowel impaction, or evaluating for other factors - Helps to decrease BP if the person assumes an upright position
T1 movements allowed
- Finger abduction and adduction - Strong thumb abduction - Strong MCP flexion with IP extension - Thoracic spine extension - Increased respiratory function with presence of intercostals
C6 movements allowed
- Full shoulder rotation, adduction, flexion, and extension - Scapular abduction - Horizontal shoulder adduction - Strong elbow flexion - Strong forearm supination - Weak wrist extension - Tenodesis action of hand - Very weak wrist flexion
S2 - S5 movements allowed
- Genitourinary function (bladder) - Bowel functions
S1 - S2 movements allowed
- Hip extension, abduction, and stability - Knee flexion - Ankle plantar flexion - Ankle inversion and stability - Ankle eversion and stability - Hip extensors/abductors, knee flexors, and ankle plantar flexors are weak at the S1 level of injury
ASIA D
- Incomplete injury - Motor function is preserved below the neurologic (injury) level - The majority of key muscles below the neurologic (injury) level have a muscle grade > or = 3
ASIA C
- Incomplete injury - Motor function is preserved below the neurologic (injury) level - The majority of key muscles below the neurologic (injury) level have a muscle grade < 3
ASIA B
- Incomplete injury - Sensory, but not motor, function is preserved below the neurologic (injury) level and extends through the sacral segments S4 through S5
Brown-Sequard syndrome clinical signs
- Ipsilateral (same side) loss of motor function below the level of injury - Ipsilateral (same side) reduction of deep touch and proprioceptive awareness (there is a reduction rather than loss as many of these nerve fibers cross) - Contralateral (opposite side) loss of pain, temperature, and touch
Cauda equina injury clinical signs
- Loss of motor function and sensation below the level of injury - Absense of a reflex arc (as the transmission of impulses through the spinal nerves to their synapse point is interrupted) - Motor paralysis is of the LMN type, with flaccidity and muscle atrophy seen below the level of injury - Bowel and bladder functions are also areflexic
Anterior cord syndrome clinical signs
- Loss of motor function below the level of injury - Loss of thermal, pain, and tactile sensation below the level of injury - Light touch and proprioceptive awareness are generally unaffected
L4 - L5 movements allowed
- Lumbar extension and stability - Hip adduction and rotation - Knee extension - Weak knee flexion - Weak ankle dorsiflexion
C7 - C8 expected functional outcomes
- May be able to live independently without much attendant care, although assistance required for high/how/heavy tasks - Some decreased respiratory endurance - Independent in pressure relief - Independently uses a manual wheelchair - Generally able to transfer without a sliding board, depending on the surface characteristics - Generally independent with positioning, bed mobility, hygiene, feeding, shaving, hair care, dressing, bathing, cooking, and light housekeeping - Generally independent with bowel/bladder care with adapted equipment/techniques - Drives independently with hand controls/steering adaptations - Generally able to stand in parallel bars once assisted to upright position, with the use of a knee-ankle-foot orthosis (KAFO)
C5 expected functional outcomes
- May require 24-hr availability of a caregiver - Decreased respiratory endurance, but not using a ventilator - A strong person at this level may be independent in pressure relief by leaning side to side; a weaker person may require maximal assistance - Independent on level surfaces with a power chair and occasionally wrist/forearm supports - A manual wheelchair with rim adaptations may be used by a strong person for short distances, but is typically not a reasonable mobility strategy - Moderate to maximal assistance is required for all transfers, and generally a sliding board or mechanical lift is used - Moderate assistance required for bed mobility - A strong person at this level may assist with some dressing, hygiene, and grooming activities with the aid of adapted equipment - Feeding is generally possible with the use of adapted utensils and setup - Driving is feasible at this level (in the absence of additional complications such as extensive UE tone/contractures) --> a person may be able to drive with specially adapted steering, braking, and acceleration hand controls, and due to transfer limitations would drive directly from the wheelchair
Reflex arc
- Most nerve impulses move up the spinal cord to the brain and back through the cord to the peripheral nerves - However, some impulses directly enter the cord through the dorsal nerve root, synapse, and exit by the ventral nerve root --> this causes certain muscle functions or responses to occur without direction from the brain --> this activity is referred to as ____ ___ - In persons with an intact spinal cord, afferent nerve impulses also travel to the brain almost instantaneously --> this allows an awareness, or "feeling", of the initial stimulation (knee tap) and subsequent response (knee jerk) - This explains why some individuals with a SCI continue to have reflexes, but do not have voluntary control of their muscles - It also explains why others have no reflexes at all below the level of their injury
Central cervical cord syndrome clinical signs
- Motor and sensory functions in the LEs are less involved/affected than those in the UEs - Improvements in intrinsic hand function are generally evidenced last, if at all - A potential for flaccid paralysis of the UEs (as the anterior horn cells in the cervical spinal cord may be damaged) - Because these are synapse sites for the motor pathways, an LMN injury may result
Peristalsis
- Nerves in the rectal musculature are stimulated, triggering a reflexive ____ and a relaxation of the rectal sphincters --> a bowel movement may be prevented at this step of the process if the brain overrides the reflex, sending down an impulse to tighten the sphincter muscle until an appropriate time - The worm-like movement by which the alimentary canal or other tubular organs with both longitudinal and circular muscle fibers propel their contents, consisting of a wave of contraction following along the tube
Incomplete injuries
- Occur if damage to the spinal cord does not cause a total transection - There will be some degree of voluntary movement or sensation below the level of injury - There may be a mixture of UMN and LMN signs after this type of injury in the lower thoracic/upper lumbar region - May be further categorized according to the area of the spinal cord that was damaged and the clinical signs that are present
Complete injury
- Occurs with a complete transection of the spinal cord - All ascending and descending pathways are interrupted - There is a total loss of motor and sensory function below the level of injury
After spinal shock
- Once it subsides, the area of the spinal cord above the level of the lesion operate as they did prior to the injury. Below the level of the lesion, reflexes will resume if the reflex arc is intact - After it subsides, there is often an increase in spasticity, especially in the flexor muscle groups --> the reflex arc "fires" and the brain is unable to interfere - After the flexion spasticity phase, there may be a period of 6 to 12 months after injury when an increase in the spasticity of the extensor groups is common - Usually, after 1 year post-injury, the wide fluctuations in tone will cease
Common sources of irritation causing autonomic dysreflexia
- Overfull bowel or bladder - Urinary tract infections (UTIs) - Decubitis ulcers - Even something such as an ingrown toenail can cause it - These irritations would be bothersome to people with an intact spinal cord, he/she would feel uncomfortable and act to remediate the situation --> but a person with a SCI lacks this feeling, and AD is the body's way of warning that something is wrong below the level of the injury
L1 - L3 movements allowed
- Pelvic elevation - Hip flexion - Lumbar extension
Above C4 respiratory complications
- Persons with complete injuries here generally require a respirator - Some may be candidates for a phrenic nerve stimulator if the nerve shows the ability to conduct an impulse
Cauda equina injuries
- Type of incomplete injury - Do not involve damage to the spinal cord itself, but rather to the spinal nerves that extend below the end of the spinal cord - Injuries to the nerve roots and spinal nerves that compromise the cauda equina are generally incomplete - Because this type of injury actually involves structures of the peripheral nervous system (exiting spinal nerves), there is some chance for nerve regeneration and recovery of function if the roots are not too severely damaged or divided - These injuries are usually the result of direct trauma from fracture dislocations of the lower thoracic or upper lumber vertebrae
Autonomic dysreflexia
- Post-injury complication - Also called hyperreflexia - An unihibited and exaggerated reflex of the autonomic nervous system to stimulation - The response occurs in about 85% of all patients who have a spinal cord injury above the level of T6 - It is potentially dangerous because of attendant vasoconstriction and immediate elevation of blood pressure, which in turn can bring about hemorrhagic retinal damage or CVA - Less serious effects include severe headache, changes in heart rate, sweating and flushing above the level of the spinal cord injury, and pallor and goose bumps below the level of injury - Most important aspect of managing this is finding the source of the problem and alleviating it - Most people with tetraplegia will experience an episode at least once, but if it is a constant problem medication may be required
Respiratory complications
- Post-injury complication - Persons with spinal cord injuries at or below the level of T12 generally have a normal respiratory status - Injuries above T12 compromise the respiratory system to some degree - Generally, injuries at levels C4 and below do not require ventilators, but complications may still persist - Currently, these complications are the most common cause of death after a SCI
Deep vein thrombosis
- Post-injury complication - Problem in SCIs for 3 main reasons (edema is also seen for the same reasons): 1. Reduced circulation caused by decreased tone 2. Frequency of direct trauma to legs, causing vascular damage (e.g., repeated trauma during transfer or bed mobility activities) 3. Prolonged bed rest - Undetected or untreated may result in an embolism or death - In persons with SCI, it appears that the greatest risk of this is seen within the initial 2 weeks post-injury
Spinal shock
- Post-injury complication - The period of altered reflex activity immediately after a traumatic SCI - Result of an acute transverse lesion of the spinal cord that causes immediate flaccid paralysis and loss of all sensation and reflex activity (including automatic functions) below the level of injury. On return of reflex activity, there is an increased spasticity in all muscles and exaggerated tendon reflexes. - As a result of the injury, spinal cord segments below the level of the lesion/injury are deprived of excitatory input from higher CNS centers - Generally lasts from 1 week to 3 months after the injury
Vertebral column
- Protects the spinal cord - Composed of 33 vertebrae
Spinal cord
- Receives sensory (afferent) information from PNS and sends to higher structures (i.e., thalamus, cerebellum, cerebral cortex) in the CNS - Descending motor (efferent) information, originating from the cortex, is also transmitted from this back to the peripheral nervous system
Tetraplegia
- Refers to impairment or loss of motor or sensory function in the cervical segments of the spinal cord that is the result of damage of neural elements within the spinal cord - Causes an impairment of function in the arms as well as in the trunk, legs, and pelvic organs - It does not include brachial plexus injuries or injury to peripheral nerves outside the neural canal
L1 - L3 expected functional outcomes
- Respiration is functional - Independent in pressure relief, wheelchair use, transfers, positioning, bed mobility, self-care, and homemaking (except heavy tasks) - Able to drive with hand controls - Generally able to ambulate with KAFO and Lofstrand crutches on level surfaces, with improved ambulation distances - Wheelchair is often required for long distances
T9 - T12 expected functional outcomes
- Respiration is functional - Independent in pressure relief, wheelchair use, transfers, positioning, bed mobility, self-care, and homemaking (except heavy tasks) - Able to drive with hand controls - Generally able to ambulate with KAFO and Lofstrand crutches on level surfaces, with somewhat less energy demands - Wheelchair use remains predominant form of mobility
L4 - L5 expected functional outcomes
- Respiration is functional - Independent in pressure relief, wheelchair use, transfers, positioning, bed mobility, self-care, and homemaking (except heavy tasks) - Driving may be independent without adaptive devices - Ankle dorsiflexion and tone must be assessed - Generally able to ambulate with AFO and canes - Wheelchair generally not needed for household ambulation, but may be indicated for long distances
C5 movements allowed
- Scapular downward rotation - Weak shoulder external rotation, flexion, and extension - Shoulder abduction and rotation - Weak approximation of humeral head to the glenoid fossa - Elbow flexion
Thoracic spinal nerves
- Serve the chest and upper abdominal musculature
C4 movements allowed
- Shoulder elevation, - Scapular adduction and depression - Independent breathing
ASIA Impairment Scale
- Spinal cord injuries are classified further based on this - Classified as A, B, C, or D
T9 - T12 movements allowed
- Strong thoracic spine extension - Trunk flexion, extension, rotation, and stability - Pelvic control and stability
T4 - T8 movements allowed
- Stronger thoracic spine extension (as compared to previous level) - Stronger respiratory function (as compared to previous level) - Thoracic flexion - Weak trunk flexion
Autonomic dysreflexia signs
- Sudden, pounding headache - Diaphoresis (sweating) - Flushing - Goosebumps - Tachycardia followed by bradycardia - These are caused by an irritation of nerves below the level of the injury
DVT signs
- Swelling in the LEs - Localized redness - Low-grade fever - However, it may be asymptomatic
Cauda equina
- The actual spinal cord ends just below the L1 vertebra, but some of these continue and exit beyond the point where the spinal cord ends - Because of their visual resemblance, this bundle of nerves is often referred to as this - The collection of dorsal and ventral nerve roots descending from the lower spinal cord and occupying the vertebral canal below the cord at the L1 region
Reflex arc example
- This "looping" can be seen in the knee-jerk reflex - If the knee is tapped with a reflex hammer, the knee will extend without any influence from the brain - The stimulation by the hammer causes afferent impulses to enter the cord, synapse, and exit, causing a contraction of the muscle fibers
Osteoporosis
-May develop pathological fractures a year after injury -Daily standing may slow osteoporosis
Central cervical cord syndrome
- Type of incomplete injury - In this injury, the neural fibers serving the UEs are more impaired than those of the LEs --> this occurs because the fibers that innervate the UEs travel more centrally in the cord, and the central structures are the ones that are damaged - Injury to the central portion of the spinal cord is often seen, along with structural changes in the vertebrae - Most commonly, hyperextension of the neck, combined with a narrowing of the spinal canal, results in this type of injury - Because arthritic changes can lead to spinal canal narrowing, this syndrome is more prevalent in aging populations
Brown-Sequard syndrome
- Type of incomplete injury - This syndrome occurs when only one side of the spinal cord is damaged - A hemisection of this nature frequently is the result of a penetrating (e.g., stab, gunshot) wound - Clinically, a major challenge presented by this syndrome is that the extremities with greatest motor function have the poorest sensation
Anterior cord syndrome
- Type of incomplete injury - This syndrome results from damage to the anterior spinal artery or indirect damage to the anterior spinal cord tissue
Spinal cord after injury
- Unlike a plant, which may die entirely if its stem is cut in half, the spinal cord is still alive and functional above and below the level of injury - The problem is one of communication: the brain cannot receive sensory information beyond the lesion site and cannot voluntarily control motor function below that point
Valsalva maneuver
- Use of manual external pressure on the bladder to empty urine, particularly in bladder training for individuals with paralysis - Involves closing the glottis and contracting the abdominal muscles, as if resisting a forceful exhilation
Crede's maneuver
- Use of manual external pressure on the bladder to empty urine, particularly in bladder training for individuals with paralysis - The hands are held flat against the abdomen, just below the umbilicus (belly button). A firm downward stroke toward the bladder is repeated 6 or 7 times, followed by pressure from both hands placed directly over the bladder to remove all urine - Chronic use of this may lead to multiple complications, including inguinal hernias, hemorrhoids, and vesicouretral reflex
Spinal shock clinical signs
- What is observed clinically during this phase is a flaccid paralysis of muscles below the level or injury and an absence of reflexes - The bladder is also flaccid, requiring catheterization, and there is no voluntary control of the bowel - Depending on the level of the injury, the person with a SCI may require a ventilator because of lost or temporary interrupted innervation to the diaphragm, intercostals, and abdominal musculature
Occupational and Psychological Status of SCI
-Assessing baseline neurological, clinical and functional status helps to make an early intervention plan -Always observe the patient's psychosocial adjustment to the disability and life -client's motivation, determination and contexts are invaluable assets
ASIA E
-Incomplete -Normal sensation and movement
Physical Status
-Observe medical precautions -accurate manual muscle testing determines neurological levels -Sensory testing including light touch, superficial pain (pin prick) and kinesthesia help establish the level of injury and determine functional limitations
Why is therapy done for SCI?
-To prevent further medical complications through education, to maintain and improve strength and skills that are present, to maximize function in self-care activities, to facilitate mobility, to optimize lifestyle options for the patient and their family.
Stage 1 Pressure sore
-characterized by a surface reddening of the skin; skin is unbroken and the wound is superficial
Causes of SCI
1. MVA 2. Falls 3. Acts of violence 4. Sports-related injuries (2/3 from diving accidents) 5. Other (such as disease)
C4 expected functional outcomes
24-hr caregiver; can be weaned off ventilator, difficulty coughing/deep breathing Max assist- pressure relief, propels wheelchair independently with adapted switches, req max set up; Max assist transfers, positioning, bed mobility, dressing, and bowel/bladder care; AE for feeding/grooming
C1 - C3 expected functional outcomes
24hr caregiver; ventilator dependent Max assist pressure relief, transfers, positioning, bed mobility, dressing, feeding, hygiene, grooming, bowel/bladder care Adapted Switches to independently propel wheelchair (pneumatic, chin, head, mouthstick); requires max set up
Intervention Methods
Acute phase Active phase After discharge from acute rehabilitation
Establishing Intervention Objectives: psychosocial adjustment
Allow the patient to talk about the disability as they need to without pushing them
Heterotopic Ossification
Also called "ectopic bone" Develops in abnormal anatomical locations May occur 1-4 months after initial injury
Establishing Intervention Objectives: communication and health
Assist the client in developing communication skills needed for training caregivers in safe assistance
Sensation and Perception in Brown-Sequard Syndrome
Below the level of the injury, there is motor paralysis and loss of proprioception on the same side and loss of pain, temperature, and touch sensation on the opposite side.
Clinical Syndromes
Central Cord Syndrome Brown-Sequard Syndrome (Lateral Damage) Anterior Spinal Cord Syndrome Cauda Equina (Peripheral) Conus Medullaris Syndrome
Spaticity key notes
Changes over the first year Spasticity may help maintain muscle mass Assists in the prevention of pressure sores Can be used to assist with ROM and bed mobility May be managed with medications
Decreased Vital Capacity
Decreased chest expansion Decreased endurance level for activity Decreased ability to cough due to weakness or paralysis of the diaphragm and intercostal and latissimus dorsi muscles
Orthostatic Hypotension
Decreased muscle tone in the abdomen and LE's leads to pooling of blood resulting in hypotension. Moving from supine to upright causes BP to drop
Intervention Methods - Active Phase
Developing upright tolerance, relieving sitting pressure (leaning forward can help with weight shifting every 30-60 minutes). Cont A/AROM to prevent contractures, use PRE & mimimize AE. Use tenodesis to increase hand function through flexing and extending the wrist.
Symptoms of Orthostatic Hypotension
Dizziness Nausea Loss of consciousness
Establishing Intervention Objectives: health
Educate the client and caregivers about the benefit of being healthy Maintaining healthy and responsible lifestyle habits are helpful with long-term function and the aging process (be proactive, not reactive)
If the level of injury is a C7; what muscles are being tested?
Elbow Extensors (triceps)
If the level of injury is a C5; what muscles are being tested?
Elbow Flexors (biceps, brachialis)
Establishing Intervention Objectives: safety
Ensure safe and independent home and environmental accessibility; Using consultation, safety and accessibility recommendations
Physical status continued
Evaluate wrist and hand function for manipulation Also check cognitive and perceptual function
Establishing Intervention Objectives: DM
Evaluate, recommend, and educate the client in the use and care of DME and adaptive equipment
If the level of injury is a C8; what muscles are being tested?
Finger flexors (flexor digitorum profundus)
OT Evaluation: Function and Early Intervention
Function may require changes in intervention and equipment Early intervention is helpful for high priority areas like splinting, positioning, and family training
If the level of injury is a L2; what muscles are being tested?
Hip Flexors (iliopsoas)
Symptoms of Autonomic Dysreflexia
Immediate pounding headache Anxiety Perspiration Flushing Chills Nasal congestion Paroxysmal hypertension Bradycardia
Anterior Spinal Cord Syndrome includes what regarding sensation and perception
Includes paralysis and loss of pain, temperature, and touch sensation. Proprioception is preserved.
Establishing Intervention Objectives: physical endurance and occupations
Increase physical endurance, performance skills/patterns through purposeful activities Maximize independence in all occupations; Including ADL's, IADL's, education, work, play, leisure, and social participation.
Conus Medularis
Injury of the sacral cord and lumbar roots within the neural canal; Typically results in an areflexic bladder, bowel and LE's
Spasticity
Involuntary muscle contraction below the level of the injury that results from lack of inhibition from the brain
Cauda Equina
Involve peripheral nerves typically with fractures below the L2 level and results in a flaccid-type paralysis
Managing Autonomic Dysreflexia
Is life threatening and emergent. Place client in upright position and remove all restrictive clothing to reduce BP. Bladder should be drained or leg bag tubing checked for kinks. Monitor BP until it has returned to normal
If the level of injury is a L3; what muscles are being tested?
Knee extensors (quadriceps)
What kind of injections can help decrease Spacticity?
Local injections of nerve blocks or Botox
Traumatic Causes of SCI
MVA, GSW/Stab wound, Falls, Sports Injuries/Diving accidents
Establishing Intervention Objectives: Body Functions
Maintain or increase joint ROM Increase strength, address body function issues Skin problems (breakdown), splinting, positioning and client education Address problems associated with body functions (sensation, cognitive functions, emotional functions)
Diseases that cause SCI
Myelomeningocele Multiple Sclerosis Cancer Amyotrophic Lateral Sclerosis
SCI Prognosis for Recovery continued
No amount of hard work will cause nerve function to return. Rehabilitation will not affect the degree of recovery.
Functional Status
Observe for present and potential levels of functional ability Begin with light activities (feeding, hygiene and object manipulation) Direct interaction with the family helps determine patient's support system
Brown-Sequard Syndrome
Occurs when only one side of the spinal cord is damaged, as in a stabbing or gunshot wound.
Central Cord Syndrome
Occurs when there is more cellular destruction in the center of the cord than in the periphery resulting in greater loss of sensory and motor function in the UE's
Central Cord Syndrome typically seen in what population
Often seen in elderly with arthritic changes that may cause narrowing of the spinal canal. Also, cervical hyperextension without vertebral fracture may cause central cord damage
Occupational Therapy Evaluation of SCI
Ongoing from day one and beyond discharge on outpatient follow-up basis Client's functional progress is continually monitored Assessing the client's past and future living situations help with planning an intervention Early intervention
Intervention Methods - Active Phase - DME
Order DME (wheelchairs, seating/positioning equipment, mechanical lifts, beds and bathing equipment) after detailed evaluation and order only when definite goals and expectations are known
Aging with SCI continued
Problems begin to occur about 20 years after the injury (typically prematurely) May begin to require assistance with transfers (in and out of the w/c, bed, car, etc.) May need assistance with self-care May need to transition to a power chair (will decrease cardiopulmonary conditioning that manual chair provided)
Results of Spinal Cord Injury
Quadriplegia and Paraplegia
Signs of Skin Breakdown
Redness and then blanching with pressure Later the area will not blanch with pressure (necrosis) Finally, a blister or ulceration appears in the area.
Anterior Spinal Cord Syndrome
Results from injury that damages the anterior spinal artery or the anterior aspect of the cord
Autonomic Dysreflexia
Seen in patients with injuries above T4-T6 level Caused by a reflex action of the ANS in response to a stimulus
Skin Breakdown
Sensory loss increases the risk of skin breakdown. Pressure causes the loss of blood supply to the area. Decreased sensation impairs the patient's ability to feel pressure and know when to change position
Complications of SCI
Skin breakdown, pressure sores or decubitus ulcers Decreased vital capacity Osteoporosis Orthostatic Hypotension Autonomic Dysreflexia Spasticity Heterotopic Ossification
If the level of injury is a T1; what muscles are being tested?
Small Finger abductors (abductor digiti minimi)
Medical and Surgical Management of SCI
Transfer patient with cervical collar and on spine board at initial injury Administer anti-inflammatory or steroidal drugs to minimize swelling Careful neurological exam to determine the site and type of injury Surgery is primarily for decompressing the spinal cord and achieving spinal stability and normal bony alignment.
Causes of Spinal Cord Injury
Trauma or Disease
Treatment of HO
Treatment includes medication and maintenance of joint ROM
Aging with SCI
Urinary and respiratory infections Osteoporosis Arthritis Joint Degeneration Constipation Weakening of skin Substance abuse
Stage 2 pressure sore
a blister either broken or unbroken, a partial layer of the skin is injured, no longer superficial
If the level of injury is a L4; what muscles are being tested?
ankle dorsiflexors (tibialis anterior)
If the level of injury is a S1; what muscles are being tested?
ankle plantar flexors (gastrocnemious, soleus)
Quadriplegia
any degree of paralysis of the four limbs and trunk musculature.
How to increase vital capacity
assisted breathing, vigorous respiratory and physical therapy. Strengthening of the sternocleidomastoids and the diaphragm, manually assisted cough, and deep breathing exercises are essential to maintain optimal vital capacity
Stimulus of Autonomic Dysreflexia
distended bladder, fecal mass, bladder irritation, rectal manipulation, thermal or pain stimuli, or visceral distention. Paroxysmal hypertension - triggered by anxiety or emotions
Intervention Methods - after discharge
exploration of vocational potential - assess motivation, functional aptitudes, attitudes, interests and personal vocational aspirations
Stage 4 pressure sore
extends through skin & involves muscle, tendons, and bone; depth of wound is more important that size and shape; very serious, possible life threatening infection
Intervention Methods - Acute Phase
follow all medical precautions, splint & proper positioning, perform A/AROM within strength, ability and tolerance levels. Encourage self-care activities using adaptive equipment (universal cuff). Discuss possible equipment needs for discharge.
If the level of injury is a L5; what muscles are being tested?
long toe extensors (extensor hallucis longus)
Paraplegia
paralysis of the lower extremities with some involvement of the trunk, depending on the level of the lesion
Medical and Surgical Management after initial trauma
patient moved carefully to avoid further injury (cervical collars, spine board, etc) Drugs to minimize swelling and neurological damage at site of lesion Exam includes placing a catheter to empty the bladder, x-rays taken
Surgery may include placement of a halo (cervical injuries) or a thoracic brace or body jacket for thoracic injuries.
placement of a halo (cervical injuries) or a thoracic brace or body jacket for thoracic injuries
Intervention Methods - Active Phase continued- psychological
psychological support as needed (support groups, training in stress management, coping-skills training, and education for social connectedness, sexuality, and relationship-building strategies).
Ways to reduce Orthostatic Hypotension
quickly recline patient with feet elevated, tip the wheelchair backwards use of Abdominal binders, leg wraps, TED hose, and medications help pt. build sitting tolerance
Skin Breakdown can be prevented by
relieving & eliminating pressure points, protecting vulnerable areas from shearing, moisture & heat, protect bony prominences & weight shift Teach patient & family to inspect skin & know signs and symptoms of skin breakdown.
SCI Prognosis for Recovery
severity of injury determines if recovery will occur Incomplete injuries are associated with a better chance of further recovery than complete injuries. Most of the recovery that will occur starts within the first few weeks
Incomplete
some degree of preservation of the sensory or motor nerve pathways below the level of the injury or lesion
90% of getting better is
the patients attitude
Pathological fractures occur in
the supracondylar area of the femur, proximal tibia, distal tibia, intertrochanteric area of the femur and the neck of the femur. Daily standing helps keep bone density. (standing program must fit into patient's ADL routine after discharge)
Early SCI Treatment goals
to restore normal alignment of the spine, maintain stabilization of the injured area, and decompress neurological structures that are under pressure
Complete Injury
total paralysis and loss of sensation below the level of the injury or lesion.
HO may lead to
trunk deformities including scoliosis and kyphosis and skin breakdown at the ischial tuberosities, trochanters and sacrum
Studies have shown that patients
who have earlier transport to an SCI unit had shorter acute-care lengths of stay and a lower incidence of skin problems and spinal instability. (SCI hospitals are better educated in SCI care)
Stage 3 pressure sore
wound extends through all layers of the skin; primary site for a serious infection to occur
If the level of injury is a C6; what muscles are being tested?
wrist extensors (extensor carpi radialis longus and brevis)