WEEK 3 SCI

Acute-Care PT Examination Priorities: Sensation

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

"Typical" Functional Outcomes for People with Motor COMPLETE SCI --> C4

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

What is a pressure injury? Where are the common areas?

-Localized injury to skin/underlying tissue over bony prominence as a result of ischemia from prolonged pressure -Even a when a full thickness pressure sore is fully healed the new skin is only 60-70% of the tensile strength of original tissue -Everyone's risk of pressure injuries different depending on level of injury, where they have sensation, how well they can move in bed, and what orthotics they are using → when educating patients important for them to understand this! -No matter what pt level of injury is, they must be sure to do skin checks 2x/ day on their ENTIRE body Common areas = any bony area including occiput, ears, nose, scapula, elbows, wrists, sacrum, vertebrae, coccyx, ischial tuberosity, trochanter, knees

FES for Ambulation: Parastep

-Micro-computer controls FES system -Allows for independent un-braced short distance ambulation -Need adequate muscle contraction for standing/stepping -Sensation needs to be impaired enough to allow for tolerance of levels of stimulation needed

Secondary Complications of SCI

-Muscle atrophy -Osteoporosis-loss of bone mineral content -Decubitus ulcers -Urinary tract infections -Septicemia -Pneumonia -Spasticity -Impaired circulation -Impaired capacity of the cardiovascular system

Acute Care Priorities for individuals with Chronic SCI

-Often admitted for medical issues due to infection: UTI, URI, pneumonia or wounds. -Or after elective procedure such as tendon transfer, diaphragm pacing, baclofen pump/spasticity management -Priorities will shift based on reason for admit 1) URI/PNA: bronchopulmonary hygiene -Exam and treat acutely -Review home program (consider needs in conjunction with team is changes) 2) Wound -Work with time on positioning, OOB time, assessment of wound -Assess cushion and wheelchair (refer for pressure mapping or to wheelchair clinic if modifications needed) -Assess transfer to see if shearing and adapt transfer if needed -Re education in pressure relief 3) Spasticity -Work with team on assessment of tone with various medical interventions -If change in tone affecting functional exam and suggest modifications to transfers -ROM/splinting as needed -Often if hospitalized for medical issues, patients not getting OOB as much and may have difficulty with orthostasis ***REFER TO APPROPRIATE NEXT LEVEL OF CARE!

Tetra vs paraplegia

-Tetraplegia means the level of injury is somewhere in the Cervical Spine -Paraplegia means the level of injury is somewhere below C7 in the Thoracic, Lumbar, Sacral Spine

Foam cushions

Ideal for patients who are at low risk for skin breakdown, spend minimal time sitting, and are independent in their pressure reliefs -Low to no maintenance -Stable -Lightweight -Not optimal for pressure relief -Ottobock -Roho Airlite -Matrx PS -Matrx Vi

Gel cushions

Ideal for patients who are at mod-high risk for skin breakdown and need additional stability not provided by air. - Low to no maintenance - Stable - Optimal pressure relief - Advanced positioning -Heavy FOAM/GEL ⇒ -Ottobock Terra -Aquos -Matrx Flovair -Jay Fusion Gel -Jay 3 Gel -Jay 2 -Invacare Stabilite -Jay Easy

Describe the different stages of pressure injuries

STAGE 1 -Non- blanchable (or slow to blanch) redness -Skin is intact -Will resolve quickly (24-72 hours) when pressure is removed STAGE 2 -Partial thickness loss of skin (up to dermis) -May look like a blister or a shallow open area -Red/pink wound bed -No slough/ bruising STAGE 3 -Full thickness loss -Bone/tendon/muscle is not exposed although subcutaneous fat may be -Slough may be present -May have tunneling or undermining STAGE 4 -Full thickness loss with bone/ tendon/ muscle exposed. -May have slough or eschar. -Often will have undermining/ tunneling UNSTAGEABLE -Full thickness loss in which the base cannot be visualized due to slough or eschar -Will always end up as a stage III or IV pressure sore DEEP TISSUE INJURY -Purple/ maroon discoloring of skin or blood blister -May be firm (indurated) painful, boggy, warmer or cooler than surrounding skin MOISTURE ASSOCIATED SKIN DAMAGE -Skin damage from moisture -Generally superficial and red -Generally blanchable with no induration Irregular borders -"Crack in the crack"

Mechanical devices that can help with airway clearance - High frequency chest wall compression

-(HFCC) is a method to deliver high frequency vibration over the chest wall to cause transient increases in airflow and improve mucus movement -In theory, these vibrations to chest wall cause transient increases in air flow in the lungs to improve gas-liquid interactions and the movement of mucus -Low level evidence on effectiveness -Disadvantages: High cost and size -Commonly used HFCWC system: THAIRapy vest -The vest employs an inflatable, non stretchable vest that is worn by the patient -The vest is connected to an air pulse delivery system (via tubing) -The patient then uses a foot pedal to apply pressure pulses and vibration on exhalation -Pulse frequency is adjustable from 5 to 20 Hz -Patient can progress from low to high frequencies, spending 5 to 10 minutes at each frequency -Pressure in the vest varies from 28mm Hg at 5Hz to 39mm Hg at 25 Hz

Tenodesis

--> For C6, C7, or C8 levels of injuries patient will use active wrist extension to achieve passive thumb adduction against the 1st metatarsal and passive finger flexion. OT will prescribe daytime and nighttime hand splints to facilitate this. → Need to allow the long finger flexors to tighten so DO NOT perform PROM into wrist extension with the finger joints in extension, but DO make sure you maintain joint ROM at all finger joints (MCP's, IP's, DIP's → see "Functional Outcomes for C6!

ASIA motor grading scale (different than MMT!)

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

Exoskeletons for Para Gait: Indego and Ekso and ReWalk

-1st Picture is the Vanderbilt Exoskeleton called the Indego and the 2nd Picture is the Ekso Bionics Exoskeleton -ReWalk is the first exoskeleton to receive FDA clearance for personal and rehabilitation use in the United States -This link is to the story of Cory, a NH man who has come into our class before. He was the first recipient of the ReWalk (Personal version vs. Rehab Version): https://www.youtube.com/watch?v=lqcAnBAelWo

Cervical orthoses - halo

-A cervical orthosis that includes a metal ring secured to the skull, 4 vertical posts, and a thoracic vest. -Eliminates 90-95 % of normal motion -Not used as often as it used to be after a SCI due to updated surgical techniques, but it is still often used as the initial treatment for odontoid fractures (located at the second cervical vertebrae of the neck) -A "halo" metal ring is secured to the skull with pins and to two metal rods attached to a well-fitted plastic jacket -With this apparatus, it is possible to obtain complete fixation and to arrest almost all movement of the cervical spine -The outcome of this treatment varies with fractures healing and fusing within 3 months in 15% to 85% of patients -The halo vest remains the orthosis of choice when rigid immobilization is required of an unstable cervical spine injury -A halo vest is the most rigid external immobilizer, especially in the upper cervical spine -It restricts up to 75% of flexion-extension at C1-C2, and offers superior control of lateral bending and rotation when compared with all other cervical braces -Used in pediatric as well!

Acute-Care PT Examination Priorities: Functional status

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

Respiratory Infections and Failure

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

Acute-Care PT Intervention Priorities: Selective Strengthening

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

"Typical" Functional Outcomes for People with Motor COMPLETE SCI --> C5

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

Deep Vein Thrombosis/PE

-Blood Clot that forms in the deep veins; often in the legs or arms -Usually is the result of either decreased flow rate of the blood, damage to the blood vessel wall or an increased tendency of the blood to clot. -This population is at risk secondary to having been immobilized or unable to move either the upper extremities or lower extremities due to absent strength, impaired blood vessel tone, fractures, etc. SRH SCI Program Guidelines: -Prior to PT evals check to see if an Ultrasound has been ordered and completed. Results in paper chart. If not check with MD prior to starting eval. -Check to see if patients need TEDS, ace wraps or Venodyn boots at night. -Check to see if the patient does have an IVC (inferior vena cava) filter placed. -Review the type of anti-coagulation therapy the patient is on Pulmonary Emboli - (PE) -Caused by part of a DVT travelling from the leg to the lungs. -Can lead to a partial or complete lung obstruction. -Onset of a PE can be sudden, with symptoms of SOB, tachycardia, chest pain, or a blue tinge to the fingers, toes or lips. -Immediate medical assistance is necessary!

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

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

Costophrenic assist

-Can be used in any position -Therapist assists in both the buildup of intrathoracic pressure and the force of expiration -Start by providing instructions to maximize all four coughing stages (a. inspiration, b. closure of glottis, c. build up of intrathoracic and intra-abdominal pressure, and d. glottis opening and expulsion) -Used for patients with weak or paralyzed intercostal/abdominal muscles -After giving the patient instructions for maximizing all four coughing stages, the therapist places his or her hands on the costophrenic angles of the rib cage -At the end of the patient's next exhalation, the therapist applies a quick manual stretch down and in toward the patient's navel to facilitate a stronger diaphragmatic and intercostal muscle contraction during the succeeding inhalation -The therapist can also apply a series of repeated contractions based on proprioceptive neuromuscular facilitation throughout inspiration to facilitate maximal inhalation -The patient may assist the maneuver by actively using his or her upper extremities, head and neck, eyes, trunk, or all the above to maximize the inspiratory phase. -The patient is then asked to "hold it." -Just a moment before asking the patient to actively cough, the therapist applies strong pressure with his or her hands, again down and In toward the navel -In this manner the therapist is assisting both the buildup of intrathoracic pressure and the force of expiration

PT interventions for pressure sores

-Caused by lack of blood flow -Still too common -85 % of dependent sitting individuals develop pressure sores -Can be prevented -Costs involved in SCI care Extrinsic factors: friction, shear, moisture, pressure Intrinsic factors: smoking, immobility, lack of sensation, nutrition, age, infection, incontinence Prevention strategies -Maximize pressure distribution -Reduce pressure over bony prominences -Effective method of pressure relief -Establish sitting tolerance Use of pressure mapping systems -Allows you to measure pressure between the wheelchair cushion or mattress and the individual -Electronic sensors feed information to a computer with specialized software. -Forces are displayed on a color coded map, grid or numeric array

Thoracic Lumbar Sacral Orthosis (TLSO)

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

Thoracic Lumbar Sacral Orthosis (TLSO) considerations

-Check in the acute discharge notes for what the neuro/ortho surgeon ordered → Does the patient need the TLSO on when the head of the bed is greater than 30 degrees? → If the patient also has swallowing issues and needs to take medication, does he/she need the TLSO on to come to full 90 degrees for this short duration? → Does the patient need to don the TLSO in supine? sitting? -Many patients with SCI have multi-trauma and will have multiple internal injuries and additional orthopedic injuries that will require specific precautions as well → clarify what those are! -Custom-made "clamshell-type" TLSO pictured was THE gold standard for bracing of the Thoracic-Lumbar-Sacral spinal regions but in the last 2-3 yr either patients are not coming with any spinal orthosis (T-L-S regions only, rigid cervical collars still prevalent) or, a less total contact TLSO is being used -Aspen Vista 464 TLSO is becoming more common vs. a clamshell TLSO

Knee Ankle Foot Orthoses (KAFO's)

-Consists of an AFO with metal uprights, a mechanical knee, and a thigh component. -Controls and aligns the knee and ankle for weight bearing -Can be metal or plastic -KAFO's are more difficult to don/doff than an AFO -KAFO'S are heavier Metal vs. plastic? -Consider: Patient's weight, strength, edema, footwear, skin condition, and willingness to accept device

Mechanical devices that can help with airway clearance - MIE

-Consists of insufflation of the lungs with positive pressure followed by an active negative-pressure exsufflation that creates a peak and sustained flow high enough to provide adequate shear and velocity to loosen and move secretions toward the mouth for suctioning or expectoration

Acute-Care PT Intervention Priorities - Respiratory management

-Deep Breathing exercises -Glosso-pharyngeal Breathing -Forced Expiratory Strengthening Exercises -Assisted Coughing -Abdominal Support: abdominal binder -Stretching

Acute-Care PT Examination Priorities - Muscle tone and DTRs

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

Acute-Care PT Intervention Priorities: ROM and positioning

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

Orthostatic Hypotension

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

CV training in acute rehab and parameters

-Endurance training can improve aerobic fitness in the SCI population. -UE-based exercises such as arm ergometry, w/c propulsion, and swimming are the most common. -In people with incomplete SCI, consider locomotor training on a treadmill with and without body-weight support (BWS) -Consider FES-induced cycling, walking. ACSM recommendations: endurance training 3 to 5 days/week, 20-60 min/day, at 50%-80% of peak heart rate. -Systematic Review by Van Der Scheer et al on the Effect of Exercise on Fitness and Health in SCI is posted in full pdf in Session 3.3. Abstract linked here.

"Typical" Functional Outcomes for People with Motor COMPLETE SCI --> C6

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

"Typical" Functional Outcomes for People with Motor COMPLETE SCI --> C8

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

Acute-Care PT Examination Priorities: Respiratory

-Function of respiratory muscles -Chest Expansion -Breathing Pattern -Cough -Vital Capacity

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

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

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

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

Active rehabilitation phase - PT intervention priorities

-Interventions focused on respiratory management, ROM, and positioning will continue. -Expanded program of resistive exercises and a neurorecovery program to induce neuroplasticity → includes use of FES bikes, robotics such as the Erigo, Lokomat, exoskeletons etc. -Development of motor control and muscle re-education techniques directed towards appropriate muscles (based on lesion level) -Emphasis on regaining postural control by substituting upper body control and vision (due to loss of proprioception) -Emphasis on improved cardiovascular response to vertical and exercise via aerobic training.

Cervical orthoses - philadelphia collar

-It is a reinforced-type collar -Not used in SCI Indications: → Used to immobilize → Quick drying → Good triage collar → Comes with or without a tracheostomy opening → Multiple sizes (height)

Strengthening in acute rehab and parameters

-Key UE ms to strengthen - Serratus Anterior, Latissimus Dorsi, Pectoralis Major, Rotator Cuff muscles and Triceps Brachii -These muscles are important for independent transfers -Strengthening of all innervated muscles should be performed daily during early rehab then 2-4x/week, performing 2 to 3 sets of 8-12 reps at 60%-80% of one rep max. -A variety of strengthening methods is best: pulley systems, free weights, elastic bands, and weight cuffs. -Depending on MMT grades, consider gravity-reduced positions on a powder board and/or with "skate", AAROM. -Consider strengthening in functional postures as well such as prone-on-elbows, supine-on elbows, quadruped, high-kneeling etc.

SCI life expectancy

-Life expectancy for persons with SCI remains significantly below life expectancy of persons without SCI -Mortality rates are significantly higher during the first year after injury. -Primary Causes of death in those with SCI = Pneumonia and Septicemia -Mortality rates have declined for cancer, heart disease, stroke, PE, urinary diseases, digestive diseases and suicide -Mortality rates have increased for endocrine, metabolic, nutritional diseases, accidents, nervous system disease, mental disorders and musculoskeletal disorders -There has been no change in mortality rates for septicemia in the past 47 years and only a slight decrease in mortality from respiratory diseases

Cervical orthoses - aspen collar and aspen vista collar

-Lighter than the Philly collar (plastic frame with thinner foam) -Cooler , and comes in multiple sizes and has changeable pads -Indications: used to immobilize -Often accepted by pts better than the Philly due to being lighter, cooler and feels less claustrophobic -The front and back have open areas -helpful if patient has a surgical wound.-The fit of a cervical collar in order to provide cervical stability is very important in that 3%-25% of spinal cord injuries occur AFTER the initial spine injury. ASPEN VISTA: -Is adjustable -Comes in one size, but it is adjustable for fit with 6 height adjustments -Considered more stable for upper C-spine fx than the regular Aspen or Miami J collars

Drop locks (most common) for KAFOs vs Bail locks

-Locks drop when knee is extended for gait -either by gravity or done manually -Unlocks for sitting -Most durable and most simple knee joint -Causes a stiff-legged gait -Patient/Client needs to be able to lock and unlock it which can be done in sitting or standing -requires full ROM into extension at the knee to easily lock it -Ball Lock Retainers/Retention Button - can be added to allow the drop ring to stay up and allow for gait with knee flexion or to make unlocking easier for patient's with one functional UE and balance deficit (e.g. can unlock lateral lock, get balance, then lean back down to unlock medial lock without the other one falling back down) -Sit < > stand issues -Knee flexor contractures: impeding locking of the drop lock Bail lock = A horizontal lever placed from the uprights around and behind the knee joint -When lifted, the knee joint unlocks

Robot Assisted Gait Training (e.g. The Lokomat System) - can also stand with BWSGT with Biodex System or Lite-Gait BWS system!

-Locomotion therapy supported by an automated gait orthosis on a treadmill = effective intervention for improving over-ground walking function caused by neurological diseases and injuries. -The Lokomat is the first driven gait orthosis that assists walking movements of gait-impaired patients and is used to improve mobility in individuals following stroke, spinal cord injury, traumatic brain injury, multiple sclerosis or other neurological diseases and injuries Advantages of Lokomat® based therapy: -A driven robotic gait orthosis guides the patient's legs on a treadmill offering a wide range of training possibilities -Faster progress through longer and more intensive training sessions compared to manual treadmill training -Physical strain on therapists is relieved, single operator mode -Patient walking activity is easily monitored and assessed -Improved motivation through visualized performance feedback -Gait pattern and guidance force are individually adjustable to the patient's needs -The concept of "task-specific learning" based on neuroplasticity suggests that activities of daily living may be trained and improved through numerous repetitions and intensive training

Active rehabilitation phase - PT intervention priorities - mat programs

-Major component of intervention during the rehab phase -Used for retraining of Function as well as for Strengthening and ROM -Sequence typically progresses from achievement of Stability within a posture and advances through -Controlled Mobility to Skill in Functional Use -Early Activities - Bilateral and Symmetrical -Progression to Weight-Shifting and Movement within a posture -A gradual emphasis is placed on Timing and Speed (e. g.Motor Control) -Often individual components of more complex functional skills (Part-Task Training) are included. -Functional Re-training including bed mobility, transfer training -Strength Training Program of innervated muscles -Cardiovascular Training -Neuro Recovery Program initiated including: Gait training for Tetraplegia with Hocoma brand BWSGT in people with AIS C or D classification if appropriate, RT 300 FES Bicycle, Erigo -Prescriptive Wheelchair -Basic and Advanced Wheelchair Skills -Doning/Doffing orthoses and/or directing others -Independent in recognizing signs and symptoms of Autonomic Dysreflexia and takes appropriate action. -Para-Gait Training if appropriate

Active rehabilitation phase - PT examination priorities

-More in-depth examination of muscle performance, ROM, and functional skills can usually be done as patient is permitted greater mobility First day: CVP, FUNCTION so you can determine level of assistance with bed mobility, OOB, W/C seating, splinting → History → Premorbid factors → Precautions → Skin integrity → Sensory integrity → ROM → Muscle tone → Muscle performance

Zone of partial preservation

-Motor ZPP is recorded in Incomplete injuries with absent motor (no VAC) If VAC present there is no ZPP and NA is marked -Sensory ZPP is recorded in absence of sensory function in lowest sacral segments S 4-5 (LT and PP0 as long as DAP is not present. -Dermatomes and myotomes caudal to sensory and motor levels that remain partially innervated -With presence of DAP there is no ZPP and NA is marked -In the absence of DAP, Sensory ZPP can be recorded if there is absence of LT and PP sensation at S4-5, while it should be noted as "not applicable (NA)" if there is presence of LT or PP sensation at S4-5

Spinal Precautions

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

Spinal precautions

-No excessive bending or twisting -Maintain logroll at all times → spine in neutral alignment for all mobility -No lifting > 10 pounds or what is indicated by surgeon -Rigid cervical collar braces to be worn at all times other than hygiene (or per MD order) -Typically on for ~12 weeks, but depends on surgical method

Autonomic Dysreflexia

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

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

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

IMPORTANT CONCEPT in bracing: "three-point pressure systems"

-One principal force acting in one direction and two counter-forces acting in the opposite direction located proximal and distal to the principal force -Too much pressure in any one spot can cause skin and/ or circulatory issues. Distributing pressure over larger areas help with comfort and tolerance. -These three-point pressure systems are present in AFO's, KAFO's, HKAFO's and spinal orthoses -A three-point pressure system applies two forces to a certain segment of the body with a third counterforce between the two -Most orthoses apply force(s) to the body in such a way as to limit range of motion, prevent pain or assist movement -Forces are usually distributed over a wide area instead of a point

When do I use a specialty mattress? What are the types?

-Patient has impaired mobility -Patient has impaired ability to perform pressure relief due to weakness/ cognition -Patient has impaired sensation in buttocks/ lower back area SPECIALTY MATRESSES UltraCare -Alternating pressure -Good for people with reduced mobility and sensation Lateral Rotation -Not FDA approved for anyone other than those who have cardiac/pulmonary impairments -Rotates you 40 Degrees to each side Clinatron -Good for people who have skin breakdown and are unable/ refuse to reposition -Makes mobility very challenging How do I decide what cushion and mattress to use? -Use clinical decision making flowsheets!

Potential for Recovery

-People with a complete injury often regain 1 or 2 levels of injury. This means you often regain control of 1 or 2 levels of muscle movement. -People with an incomplete injury are more likely than people with a complete injury to regain control of more muscle movement, but there is no way to know how much, if any, will return. -As long as you are seeing some improvement, like regaining muscle movement, your chances for improvement are better. -The longer you go without seeing improvement, your chances for improvement are lower.

Recovery of walking/function and what affects it

-People with a complete injury often regain 1 or 2 levels of injury. This means you often regain control of 1 or 2 levels of muscle movement. -People with an incomplete injury are more likely than people with a complete injury to regain control of more muscle movement, but there is no way to know how much, if any, will return. -As long as you are seeing some improvement, like regaining muscle movement, your chances for improvement are better. -The longer you go without seeing improvement, your chances for improvement are lower.-Grossly ½ of AIS B recover ambulatory function, but may be with devices and limited distances -Preserved pin pick sensation is positive prognostic indicator for this group. -Why might this be? -Better for AIS C than AIS B (sensory incomplete)-grossly 75% -Age is strong prognostic indicator: those older than 50 have 30-40% chance vs 80-90% in those younger than 50 -AIS D have excellent potential for walking with almost all patients younger than 50 ambulating at a year -Lower extremity motor score, presence of pinprick sensation and younger age have been correlated with better outcomes in several studies Van Middendorp et al developed clinical prediction rule for ambulation outcomes at 1 year. Identified age (<=65), Motor score of L3 and S1, light touch score of L3 and S1 as prognostics indicators for walking independently Other Factors that Influence Functional Outcomes -Muscle tone -Comorbidities -Body weight and proportions -Arm length to trunk length for example -Age -Premorbid activity level -Access to and quality of medical and rehab services

Counter-rotation assist

-Position patient in side-lying -The therapist begins by following the patient's breathing cycle, with hands positioned over the patient's shoulder and pelvis -Rotate the upper chest out during inspiration and in during exhalation by moving the shoulder out during inhale and hips/pelvis in during exhale

Benefits of FES/Standing

-Prevent atrophy, increase muscle bulk and strength. -Slow down the process of osteoporosis -Prevent contractures -Decrease incidence of pressure sores -Decrease spasticity -Improved bowel and bladder function -Improve cardiovascular health -Improve circulation -Last 3 are standing glider, ERIGO, BWS harness -The Erigo* combines gradual verticalization with robotic movement therapy to ensure the necessary safety for the stabilization of the patient in the upright position. -Due to the unique afferent stimulation provided by the Erigo and the flexible harness, patients can be trained intensively and safely already in a very early stage of rehabilitation. -Even with severely impaired neurological patients (e.g. vegetative state) the training with the Erigo can be induced efficiently within a few days after onset.

Functional Electrical Stimulation (FES)

-Provides muscle contraction and Functionally useful movement -Allows SCI individuals to maintain muscle viability and promotes cardiovascular health -Used to counteract secondary complications -Can be applied via a FES unit for shoulder subluxation and/or used to assist with rowing, biking etc. -FES Bike -Exercise for people with disabilities ExPD

How do you do pressure relief in a manual chair? power chair? bed?

-Push up -Anterior + lateral leans -30 second push up -30 seconds in anterior lean followed by 30 seconds in right and left lateral leans -Bottom must lift off the chair in all positions POWER CHAIR -Tilt ALL THE WAY back (to at least 45 degrees) -Hold at least 5 min BED -Side-lying -Quantum tilt -Change sides every 2 hours

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

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

Why do pressure relief? How often?

-Restores blood flow to skin over bony area -Pressure injuries start to form after about 30 minutes and can go all the way down to the bone in 3 hours -15-20 minutes in ALL chairs

Acute rehab Prevention, Health Promotion, Fitness, and Wellness and also education/prescriptive WC seating

-Shoulder pain - age, level of injury, body weight, transfer technique, and number of repetitive transfers in a day are predictive of shoulder pathology* -Consider taping, FES, supports for UE's when in the w/c (Tetraplegia). Education - What for? With whom? -Should begin early after injury, continue throughout rehab phase, and cover extensive impact of SCI such as: skin care, AD, self-directing care, W/C mobility and maintenance, sexuality, bowel and bladder care etc. -Peer mentoring - can provide education, support, and assistance with rehab process. -Discharge and Community Re-Integration is critical - e.g. accessible housing, nutrition, transportation, finances, maintaining functional skills and fitness, employment or further education. (Case Management in Inpatient Rehab -Materials are posted in Pre-Class Resources for this Session) Prescriptive wheelchair and seating -A wheelchair acts as a mobility base and provides postural support -Postural alignment affects: respiration, bowel and bladder function, skin integrity, and mobility -In SCI, a w/c is used exclusively so it should be custom measured and ordered for each individual Outpatient Programs -Journey Forward is a local gym designed for people with SCI, but some controversy as there are no PTs, only exercise physiologists or trainers → FES bike → Standing Frames → Pool Therapy → Gait training → Nautilus → Accessible gyms: The YMCA Partnership Program, Journey Forward → Adaptive sports - See Optional Resources for Resources Wheelchair fitness training resource -Adapt To Perform (ATP) - You Tube Channel with excellent Videos for Cardiovascular and Stengthening programs for w/c-dependent clients. https://www.youtube.com/c/AdaptToPerform/videos -Facebook - https://www.facebook.com/AdaptToPerform/

Cervical orthoses - cervical soft collar

-Supportive -Provide little stability to the C-Spine -Not for unstable fractures -Have been shown to provide up to 10% restriction to cervical motion in all planes -Generally one size fits all -Washable but takes long time to dry Indications: -Can serve as a reminder to a patient to limit exaggerated neck movements -May be useful for: minor whiplash, cervical spondylosis, or as a post-operative adjunct with a stable spine -May be used after coming out of a more rigid cervical collar for an unstable fracture after 12-16 weeks; for comfort only

Mechanical devices that can help with airway clearance - Intrapulmonary percussive ventilation

-The patient breathes through an IPV® accessory device -Delivers rapid, high flow, mini-bursts (percussions) of Air or Oxygen into the lungs while simultaneously delivering therapeutic aerosols -IPV® loosens and helps propel deep retained airway secretions upward from the lungs where they can be more easily expectorated

Anterior chest compression

-This technique is called anterior chest compression assist because it compresses both the upper and lower anterior chest during the coughing maneuver -This is the one technique to address the compression needs of the upper and lower chest in one maneuver therapist puts one arm across the patient's pectoralis region to compress the upper chest, while the other arm is placed parallel on the lower chest (avoiding the xiphoid process) or the abdomen or is placed as in the Heimlich-type maneuver -Because of the direct manual contact on the chest, inspiration can be easily facilitated first, followed by a "hold.'' -Thus, the therapist can readily enhance the first two cough stages. The therapist then applies a quick force with both arms to simulate the force necessary during the expulsion phase. -The directions of the force are (I) down and back on the upper chest, and (2) up and back on the lower chest or abdominal -This technique is more effective than the costophrenic assist for patients with very weak chest wall muscles because of the added compression of the upper anterior chest wall

Heimlich - type of abdominal thrust assist

-This technique requires the therapist to place the heel of their hand at about the level of the patient's navel, taking care to avoid direct placement on the lower ribs -After appropriate positioning, the patient is instructed to "take in a deep breath and hold it." -Manual facilitation of inhalation is not feasible with this technique. -As the patient is instructed to cough, the therapist quickly pushes up and in, under the diaphragm with the heel of his or her hand, as in a Heimlich maneuver. -The patient is instructed to assist with appropriate trunk movements to the best of his or her ability. -This procedure is very effective at forcefully expelling the air as in a cough, but it can be extremely uncomfortable for the patient because of: (1) its concentrated area of contact (2) its abrupt nature, which may elicit an undesired tonal response, and 3) the force may cause gastrointestinal dysfunction -Should be used only when the patient does not respond to other techniques and the need to produce effective cough is high -Both costophrenic assist and Heimlich assist can be used in side-lying simultaneously -One upper extremity is used to perform the Heimlich-type of assist while the other does a unilateral costophrenic assist

SCI age at injury

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

Urinary Tract Infections (UTI's)

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

Craig-Scott KAFO's

-Used only with pts with paraplegia appropriate for para-gait training -Has T-shaped foot plate for medial/lateral stability -Ankle joint with ant/post adjustable stops(generally set in 10 degrees of Dorsiflexion) -Double uprights -A Pre-tibial band -Posterior thigh band -Knee joint with bail locks -Orthotic stabilization of the knee and ankle is provided as well as passive (or ligamentous) stabilization of the hip without recourse to orthotic components at and above the hip -The fixed ankle with adjustable joints, combined with specially reinforced shoes, provides a solid base of support -Careful adjustment of the ankle into a slightly dorsiflexed attitude, combined with the locked knee mechanisms and therapy training to teach the patient to extend the hips and hang on the hip ligaments (Y ligament), results in hands-free balance -This posture is suggested for adult use and not for children as the Y ligament is not fully developed -Ambulation for limited distances is possible using crutches, at least for the young or vigorous individual

Acute-Care PT Examination Priorities Muscle Performance and ROM:

-Using MMT - Palpation is KEY due to common muscle substitutions used! (e.g. can look like the patient is actively flexing their knee with the hamstrings in prone when they are really flexing and externally rotating their hip with the Sartorius, which will bring the knee along with it when in prone). -Besides testing the "key muscles" identified in the International Standards for Neurological and Functional Classification of Spinal Cord Injury (ISNCSCI), other muscle groups should be tested throughout the myotomes with intact innervation -Use extreme caution when performing MMT and examining PROM around the neck and shoulders in tetraplegia, and lower trunk and hips in paraplegia -Work with OT in facilitating and maintaining a Tenodesis Grasp in people with mid- to high- Cervical injuries (above C6).

Cervical orthoses - Miami J collar

-Washable -Comes in a variety of sizes -Very common and favorite by MDs but more recent studies state the newer Aspen Vista Collar stabilizes better than the Miami, especially in high C-Spine fx -Indications: Used to immobilize

Self assisted cough techniques

1) Long sitting self assist 2) Short sitting self assist 3) Prone on elbows self assist 4) Hand-knees rocking self assist 5) Standing self assist

Types of LE resting splints

1) Static -Stays in one static position - cannot change over time → #1 called a Prevalon Heel Protector Boot (we call them moon boots!) - Help more with skin as heel floats inside, does not provide a stretch to the foot/ankle → # 2 is called a Multipodus type with an outrigger that can be repositioned to help with hip position (e.g. to reduce the amount of internal or external rotation 2) Dynamic -Provides a dynamic stretch that changes with the patient 3) Adjustable -e.g. Turnbuckle brace, Plantar Fasciitis night splint (blue and green) -Static but able to be set at different angles as patient changes.

Level of lesion from most to least common

1. Incomplete tetraplegia (47.4%) 2. Complete paraplegia (19.9%) 3. Incomplete paraplegia (19.7%) 4. Complete tetraplegia (12.4%) Over the last 20 years, the percentage of persons with incomplete tetraplegia has increased while complete paraplegia and complete tetraplegia have decreased.

SCI incidence, prevalence, gender, maritial status, occupational status, employment, ethnicity, cause, acute care stay

18,000 cases/yr, 300,000 persons, more than 1/2 single/never married, 1 year post 13% persons are employed, 30%$ individuals employed 20 years post injury, mostly white, mostly MVA and falls, In 1970s acute care length of stay was an average of 24 days, today it is an average of 11 days

ASIA levels

A = Complete. No sensory or motor function is preserved in the sacral segments S4-5. B = Sensory Incomplete. Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-5 (light touch or pin prick at S4-5 or deep anal pressure) AND no motor function is preserved more than three levels below the motor level on either side of the body. C = Motor Incomplete. Motor function is preserved below the neurological level**, and more than half of key muscle functions below the neurological level of injury (NLI) have a muscle grade less than 3 (Grades 0-2). D = Motor Incomplete. Motor function is preserved below the neurological level**, and at least half (half or more) of key muscle functions below the NLI have a muscle grade > 3. E = Normal. If sensation and motor function as tested with the ISNCSCI are graded as normal in all segments, and the patient had prior deficits, then the AIS grade is E. Someone without an initial SCI does not receive an AIS grade.

Basic orthotic functions

Alignment -Anywhere from foot to spine -- alignment of 1 joint affects the joint above and below! -When alignment is the goal -you need to decide what forces will need to be applied to correct the alignment and is that tolerable? Stability - due to decreased ms strength or control -Consider if the stability provided then blocks other planes of movement that you might want? -Trunk stability is great but not at the cost of not being able to breath! → Eg pt in a collar who's claustrophobic Preventing deformity -From ms imbalance: lack of sensation, that can occur over time such as hyperext at knee, tone reduction, contracture prevention Contracture reduction -Through resting splints, dynamic splints

What are the most common causes of bed wounds and chair wounds?

Bed → Sacral and coccygeal wounds Chair → Ischial wounds

Benefits of pressure mapping and what does it not assess

Benefits of pressure mapping -SCI leads to decreased number and size of capillaries that feed muscle fibers due to hypotension leading to ischemia sooner than in non SCI patients Assists in education -Real time visual feedback allows patients to see the importance of weights shifts and pressure relief Pressure injury prevention -Allows clinicians a comparison between cushions and different seating systems personalized to individual patient needs Pressure mapping does not assess: -Shearing and friction -Temperature/moisture -General tissue health ***The above all needed to be considered when selecting appropriate seating choices for pt skin health!

Pt education and what to avoid in a PT session if a wound is present

Education -Pressure relief -Smoking → decreases circulation making it easier to get a wound and harder to heal -Drinking → impairs judgment -Clothing for people with SCI = Dignity by Design, Endless Abilities, IZ adaptive Clothing -Shoes → Different sized shoes for winter and summer, 1-2 sizes bigger dependent on swelling -Recommending Out of Bed (OOB) schedule -Recommending turning schedule -Recommending mattress What to avoid in a therapy session (if a wound is present) -Sitting on a RoHo when doing sitting balance on the mat (unless they have IT wounds) → This will place a patient in a posterior pelvic tilt, putting more pressure on the sacrum and coccyx -Shearing activities (although all can be modified to fit your patients' needs!) Sliding board -Can be used with people who have sacral and coccygeal pressure injuries as long as they are leaning forward and lifting up vs sliding -Should be avoided with people who have IT wounds Stationary bike -OK to use with people who have sacral and coccygeal pressure injuries, as long as they have a backrest that is not shearing their skin -Avoid with people who have IT wounds → there is a lot of shearing on the ITs when biking Showers - Depending on where you work, as a PT you may end up showering patients. It is important to understand what wound can and cannot get wet -It is OK to shower a patient who has a pressure injury as long as you have the appropriate bathroom DME -You can take the dressing off to shower if it is a stage 2 or 3 -Speak to the medical team if there is bone exposed in a stage 4 pressure injury -The water can help debride the wound -DOES NOT APPLY TO SURGICAL WOUNDS! Commode and shower chairs -Should be considered even with patients who have wounds → If they have a wound on the coccyx or sacrum you can use a posterior cut out commode/shower chair → If they have an IT wound you can use a lateral cut out commode/shower chair

Acute-Care PT Examination Priorities: Integument

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

Respiratory infections and failure ***This is life-long risk, not just in acute-care of acute rehab! A variety of sequelae of SCI contribute to the high risk of retained secretions, atelectasis, pulmonary infections, and respiratory failure, including:

Expiratory muscle weakness, which results in an ineffective cough Altered levels of consciousness from concomitant head trauma or sedating medications Ileus, with increased diaphragmatic excursion and an increased risk of aspiration of gastric contents Failure to spontaneously sigh Bronchial mucus hypersecretion - occurs in approximately 20 percent of acute cervical level SCI patients, possibly from impairment of the peripheral sympathetic nervous system Associated rib fractures or thoracoabdominal surgery Dysphagia and aspiration associated with tracheostomy and/or cervical spine surgery using an anterior approach. -Patients with SC injury above T4 are at risk to develop restrictive lung disease -This occurs five to 10 years following SCI and can be progressive in nature -The quadriplegic individual should have pulmonary function studies at yearly or every-other-year between five and 10 years post injury

"Typical" Functional Outcomes for People with Motor COMPLETE SCI --> C7

Extensor pollicus longus and brevis, extrinsic finger extensors, flexor carpi radialis, triceps

Hyperextension TLSO vs corset TSLO

Hyperextension Indications: spinal fracture or injury where you need to block or prohibit forward flexion Jewett Hyperextension TLSO - blocks forward flexion and lateral flexion while still allowing active hyperextension Corset Indications: to immobilize, support for pain control, or to help with structural alignment -Many types such as DonJoy brand TLSO or Spinal Tech Pre-Fab SpinaLoc

Air cusions

Ideal for patients who are at high risk for skin breakdown, require max - dependent assist for pressure relief -Constantly adjust to an individuals body movement -Excellent for pressure relief -Lightweight -Decreased stability and positioning -High maintenance -Requires skill for proper inflation Roho -smart check -high profile -enhancer -quadtro

Hybrid cushions

Ideal for patients who need increased stability but still require the benefits of gel or air inserts -Low to no maintenance - depending on air vs. Gel -Stable -Optimal pressure relief -Advanced positioning - Can be heavy - Proper inflation may be necessary if using air insert FOAM/AIR -Ottobock Terra -Flair -Jay Fusion Air -Jay 3 Air -Varilite

Mattresses in the hospital and at home - what are the different groups and what is best?

In the hospital -This is important to know, especially if you are working in any kind of hospital, long term care, or rehab setting -As PTs, it is within our scope to recommend a mattress that we think is appropriate -For people with reduced mobility and sensation, a hospital will usually provide a **group 2** mattress Group 1 -Overlays for use of prevention of pressure sores in people with limited mobility Group 2 -Specialized mattresses for treatment of active pressure sores. -Low air loss/alternating pressure mattresses -Immerse (adjusts pressure based on position) Group 3 -Pressure relieving beds for those who have failed with other mattresses. -Ex. clinatron, envella At home Inner spring -Each inner spring is a pressure source Memory foam -Good pressure relief -Retains heat -Forms to body impairing mobility Air -Good pressure relief -Adjustable air control improves mobility Water -Best pressure relief -Poor postural support

Indications and contraindications for KAFOs

Indications -Little to no voluntary control at the knee and foot with some voluntary control of the hip and trunk musculature -Malignment of the knee: such as genu valgus or varus or to a lesser degree, knee flexion contractures, severe genu recurvutum Contraindications -Unable to meet energy demands -Lack of adequate strength (esp. in the trunk &UE) a) to control standing balance or to use assistive devices b) decreased hip/trunk strength to allow swing phase -Open wound in the area of the orthosis

Cervicothoracic and Cervicothoracolumbar Sacral Orthoses (CTO's and CTLSO's)

Indications: -Minimally unstable fractures from C3-T2 -After internal fixation from C3-T2 -POOR flexion control C1-C5, best from C5-C7 Types: 1. Minerva CTO (newer style) -Cervical orthosis consisting of a rigid posterior section extending from the head to the thorax, and an anterior section extending from the mandible to the thorax, held in place by a forehead band -Can add these to a rigid body jacket/clamshell TLSO which makes it a CTLSO ***Minerva CTO is the most effective method for immobilizing C1-2, and has been shown to limit flexion-extension by ~ 79%, axial rotation by 88%, and lateral bending by 51% -VERY challenging to immobilize the Cervicothoracic area since it is a transitional area between the very mobile and lordotic cervical spine and the kyphotic thoracic spine 2. A CTO added to a Clamshell TLSO = CTLSO 3. S.O.M.I. CTLO -S.O.M.I. = Sternal-Occipital-Mandibular-Immobilizer-The Minerva CTO, the SOMI, and a custom-molded CTO can be used for conditions extending as far caudally as T5 -Increasing the length of the orthosis down the trunk enhances its capabilities

Thoracolumbar Sacral Orthoses (TLSO's)

Indications: -Recommended treatment for significant fractures of the thoracolumbar junction being treated conservatively -Can be used to manage fractures from T6 to L4 -Often used after spinal decompression and fusion after burst fractures -Spinal weakness or painful pathology requiring immobilization of the thoroco-lumbar spine -Types = clamshell TLSO and body jacket TLSO → In one study by Buchalter et al., a custom thermoplastic TLSO showed 94% restriction in lateral bending and 69% restriction of flexion-extension in the L-spine → In the Thoracic spine, there was 49% restriction of flexion-extension and 38% restriction of lateral bending, and a 60% reduction in total rotation of the T-spine

Important values in pressure mapping - maximum pressure (mmHg), sensing area (in2), coefficient of variance (%), regional distribution (%)

Maximum pressure (mmHg) → The highest amount of pressure over any one sensor, ideally this number should be below 80mmHg Sensing area (in2) → The area that the pressure is distributed over, the larger the value the better. Use the value shown in blue Coefficient of variance (%) → A percentage/ratio that refers to how evenly the pressure is spread out over the sensing area, the smaller the value the better Regional distribution (%) → Percentage of pressure from the sensing area (blue square) compared to the pressure under the ITs and sacral area (green square) -Research has shown a value >50% would be high risk for a pressure injury -Use the value shown in green

Treatment a PT can provide for pressure injuries - moisture assoc skin damage and pressure relief, improving blood flow/muscle bulk

Moisture-associated skin damage -No wearing of an adult brief in bed -Timed voiding -Remove wet clothes -Fully dry after a shower Pressure relief -Should be performed every 15-20 minutes -In a power chair - tilt back for at least 5 minutes (fully tilted!) -Tilt and recline are NOT the same → recline causes more shearing and should be avoided -In a manual chair - push up for 30 seconds or lean forwards, and laterally for 30 seconds each -Stance - stand for at least 30 seconds A therapist can help... → Improve blood flow to damaged area → Improve muscle bulk → Improve posture → Appropriate seating → Appropriate mattress → Education Improve blood flow/muscle bulk -Pressure relief! -Maintain blood pressure → encourage pressure garments -Electrical stimulation→ not as effective as pressure relief, however can increase peak blood flow to gluteals and significantly reduce pressure on ITs -NMES can also maintain muscle bulk in the gluteal area decreasing risk of pressure injuries -When used in sitting increased load on front of legs vs. buttocks -Improved blood flow → improved oxygenation → improve healing times -Use of NMES with people who are unable to move their own limbs can improve healing times by 74% due to improved blood flow!

PT considerations for posture/seating

Posture -People with chronic injuries tend to be more kyphotic and have a more posteriorly tilted pelvis → increased interface pressures on all cushions with pressure mapping, IT deformity over time/increased risk pressure sores -Not only does kyphosis tend to make people sit with a more posterior pelvic tilt, it also puts direct pressure on a few vertebrae when sitting (vs. dispersing the pressure through several vertebrae -This makes someone at high risk for getting pressure injuries on their vertebrae when sitting in a wheelchair! Seating -Ideal posture is sitting all the way back in the chair with a slight anterior pelvic - Knees and hips should be in the same line and feet should rest flat on the footplate Cushion considerations Airflow → allows for ventilation and decreased moisture Weather → hardening/softening of cushion depending on temperature, air pressure in air cushions depending on temperature Pressure distribution → how well does cushion accommodate clients shape Weight → postural support (laterals, lap tray , chest and pelvic straps, help or hinder posture ***These are some important aspects to consider when you are trialing cushions with patients. Cushions are not one size fits all. Each patient will need a cushions specific to them that address their environments and lifestyle!

How can you tell pressure vs moisture and how can you avoid moisture injuries?

Pressure -Circular or oval shaped -Periwound may feel firm -Over a bony area only -Can be deep Moisture -Thin even slit (usually in gluteal cleft) -Uneven superficial open areas (can be confused with a stage 2 wound!) -Periwound will be red Moisture injuries -Limit use of diaper , especially in bed -Timed voiding -Ensure seating is not wet (unless it is a shower chair) -Ensure that clothing is not wet from sweat -Take wet towels out from underneath pts after showers -If a pt is incontinent they must be cleaned and placed in dry clothes ASAP

Proper seating and poor WC posture

Proper seating -Straight back with slight anterior pelvic -Hips, knees and feet at 90-degree angles -Feet flat on footplate -Shoulders are in a neutral position What causes poor wheelchair posture -Wheelchair backrest height and firmness -Wheelchair legrest height -Cushion -Patient's trunk control

Wheelchair and shower chair seating considerations

Seating considerations Wheelchair, PT -Perform in upright and tilted positions -Appropriate lumbar support-Appropriate armrest and leg rest height -Lateral supports-Dump and/or backrest angle -Thigh guides for proper LE positioning Showerchair, OT -Appropriate leg rest height -Appropriate pelvic positioning -Cut out orientation -Appropriate lumbar support -Padded vs specialty cushion (ROHO)

How do you determine the ASIA sensory, motor, and overall neuro levels>

Sensory = last level with 2-2, motor = first level of a 3 or 4 with a 5 above it or the same as sensation for C1-4, T2-L1, S2-S5, neuro = highest SC level/worst prognosis of the sensory and motor for both sides

ASIA sensory and motor exams

Sensory Exam -28 key dermatomes from C2-S4/5 bilaterally -Examines: Pin prick (sharp vs. dull) and light touch -Graded: 0=absent; 1=impaired; 2= intact Motor exam -10 key muscle groups, if no key muscle group for that level use sensory data -C5=elbow flexors -C6=wrist extensors -C7=elbow extensors -C8=finger flexors -T1= 5th finger abductor -L2=hip flexors -L3=knee extensors -L4=ankle dorsiflexors -L5=long toe extensors -S1=ankle plantarflexors

PT interventions for impaired skin integrity

Skin inspection: with use of assistive devices as appropriate -Patient gradually to assume responsibility and be independent in directing others in their skin inspection/care/pressure relief -Emphasis that skin inspection and care MUST become a regular and lifelong component of the patient's routine! Impaired skin integrity -Patients with absent or impaired sensation are at risk for pressure ulcers -Patients at high risk of skin breakdown are placed on a low air loss mattress -This is set by nursing and should always remain with a maximum of 3 bars showing -If deflating for transfers, remove at plugs- do not touch the buttons to change the firmness -Many secondary factors that predispose them: -Paralysis, incontinence, obesity, edema, spasticity, joint contractures and poor nutrition -Document Patient and Family education regarding the frequency of pressure relief in the chair and bed positioning. -Every 2 hours in bed (rolling side-back-side) -At least every 15-20 minutes in ALL Wheelchairs - re-distribute pressure for at least 30 seconds in each direction in manual w/c and 5 min in power w/c! -Pressure map within the first three days of admission on specialty cushion -Establish an out of bed schedule or if the patient is only allowed to lie in certain positions to avoid pressure on wounds -In Tilt-in-Space (TIS) wheelchair - pts should be sitting upright majority of time and during pressure relief should be tilted back at least 45 degrees - then returned to upright -Manual chair techniques - lateral lean, anterior lean, depression push up

When do I use a specialty cushion? What are the types?

When do I use a specialty cushion? -Patient has impaired mobility -Patient has impaired ability to perform pressure relief due to weakness/ cognition -Patient has impaired sensation in buttocks/ lower back area -Use the flow sheet! -It is OK to trial several cushions -Pressure map after each cushion change SPECIALTY CUSHIONS Air → A+ for skin → D for posture Foam → B for skin → B for posture Gel → B for skin → A for posture Hybrid ***Usually the best choice for skin and posture