OTA 103 Quiz 4

Spinal Cord Injury

(For this section it is very important that you use the table in the Early text book (Figure 27-1, page 536) that illustrates what muscles and what function becomes available at different levels of injury.) The spinal cord is a part of the central nervous system and, like the brain, the cells of the spinal cord do not regenerate. Therefore, injuries to the spinal cord are permanent. Injury to the spinal cord results in tetraplegia (previously called quadriplegia), which is any degree of paralysis to the four limbs and trunk; or paraplegia, which is paralysis of the lower extremities and some involvement of the trunk. This loss of motor control includes the loss of bowel and bladder control and can include the loss of postural control and paralysis of the muscles required for breathing. The amount of paralysis will depend on the LEVEL of injury to the spinal cord. Trauma is the most common type of injury to the spinal cord and motor vehicle accidents are the most frequent cause of SCI. In some accidents the person will sustain both a spinal cord injury and a trauma injury. Trauma can occur when there is a sudden blow to the spine that fractures or crushes the vertebrae and causes damage to the spinal cord. Other causes include falls, acts of violence (gunshot and stab wounds to the back), and recreational sporting accidents. The most common type of sport injury that results in SCI is diving accidents. Surfing and body surfing are also common causes of SCI in areas where those sports are prevalent. In addition to trauma, INJURY to the spinal cord can occur as a result of other factors. CANCER, INFECTIONS, spinal stenosis, ARTHIRITS and inflammation are non-traumatic causes of spinal cord injury. Spinal cord injury is much more common with MEN (75 to 80% of injuries occur to men), young ADULTS and SENIORS and people who are ACTIVE in SPORTS. In terms of prevalence it is estimated that there are approximately 250,000 people living with spinal cord injury in the United States. Review the areas of the spinal cord and the major areas of the body that the spinal nerves supply on the illustration below. The names of the various spinal vertebrae should already be familiar.

ASIA - A

Complete: No SENSORY or MOTOR function is preserved in sacral segments S4-S5

Sexuality and SCI - Erections

For men who have a complete SCI at level T11 and above it is usually possibly to have a reflexogenic or SPONTANEOUS erection, which are controlled by the spinal segments S2-4. However, they usually cannot have a psychogenic erection. For these men, ejaculation is possible but RARE. For men who have a complete SCI at level T12 or below a psychogenic erection is usually POSSIBLE but a reflexogenic erection is usually not possible. For these men ejaculation is not usually possible, especially if the sacral NERVES are involved. In order to conceive a CHILD most men with SCI will need to involve a fertility specialist. Women who have a SCI have an easier time returning to sexual ACTIVITY although they have the same issues with autonomic dysreflexia and BOWEL and BLADDER care. A lubricant may needed and can be used to maintain skin INTEGRITY and prevent any friction. The ability to CONCEIVE a child is usually not impaired and menstruation usually RESUMES approximately 6 months after injury. Since they are able to conceive, BIRTH control does become an issue. Condoms are frequently the BEST choice. Birth control pills may be prescribed but are used with CAUTION as both the pills and the SCI can cause vascular COMPLICATIONS. IUDs are usually a poor choice as they can cause PELVIC inflammatory disease that may not be felt. Attitude toward returning to sexual ACTIVITY and willingness to experiment can be beneficial to the experience. Partners should consider things that may add to their PLEASURE. Adding pleasure to the experience is really a personal preference and partners should discuss what they find desirable. Having a SCI does not mean the end of have a fulfilling sex life. It is IMPORTANT for the person who sustains this type of injury to know what is possible.

Sexuality and SCI

Sexual function is an important part of LIFE for and often a concern for people who have DISABILITIES. It is a significant concern for people who have PARALYSIS from a spinal cord injury. Facilities that have SCI PROGRAMS usually have someone, often a psychologist, who counsels clients about sexual function. It is important for the COTA working in SCI to understand sexual FUNCTION for this population as the client may ask QUESTIONS regarding this issue. In order to be effective, the COTA must be able to DISCUSS these issues that may not be comfortable to talk about. To start, there are many things that are a part of an intimate relationship in addition to sexual intercourse. Intimate CONVERSATION, sharing FEELINGS, TENDERNESS and AFFECTION are a significant part of this type of relationship. People seek companionship from their PARTNER Sexual identity contributes to social ROLES and self-evaluation. There are numerous concerns that a person with a spinal cord injury typically has regarding sexual function. With limited MOVEMENT not being able to fully participate and please their partner is a common FEAR. The ABILITY to have an orgasm and to become a AROUSED are also concerns. There is also the problem of lack of BLADDER and BOWEL control - people who have a spinal cord injury are on a SCHEDULE for their BLADDER and use a catheter for their BALDDER. Despite being on a SCHEDULE and preparing by being sure the bladder is EMPTY, accidents can happen. Liquid INTAKE should be limited PRIOR to sexual activity. The other issue with this is the need to REMOVE the catheter, which is much more difficult for the person who doesn't have HAND use and requires assistance to remove it. There is a possibility that sexual activity can TRIGGER an episode of autonomic dysreflexia. If this should happen, the activity needs to STOP and 911 should be called. To DECREASE the chance of this happening rough stimulation of the genital area and the use of VIBRATION should be avoided. Having an INFECTION or inflammation can also be a trigger to autonomic dysreflexia.

SCI - OT treatment

The OT will evaluate range of motion, muscle strength, sensation, postural control, hand function and ability to perform self-care tasks. Goals are then established to utilize the MOTOR skills that the client has to maximize independence in FUNCTIONAL activity. Treatment can include the following: • ROM EERCISES, SPLINTING and POSTIONING • Strengthening innervated MUSCLES • Increasing ENDURANCE • Training in SELF-CARE, MOBILITY, HOME MANAGEMENT, AND COMMUNITY SKILLS, WITH ADAPTIVE TECHNIQUES AND EQUIPMENT • Exploration and training IN LEISURE AND VOCATIONAL INTEREST • Caregiver training TRAIN CLIENT ON HOW TO TRAIN OTHER PEOPLE IN THEIR CARE

Sacral Sparing

The presence of SENSORY or MOTOR function at the anal-mucocutaneous junction When sacral sparing occurs, the spinal cord is only PARTIALLY compressed, not FULLY severed. This allows one or more NERVES to continue sending and/or receiving SIGNALS though the sacrum. The practical EFFECT is that people with sacral sparing retain some SENSATION and CONTROL though the extent varies depending upon the SEVERITY of the injury.

Spinal cord injury complications - autonomic dysreflexia - prevention - overfull bladder, UTI

follow your bladder management program

Spinal cord injury complications - autonomic dysreflexia - prevention - overfull bowel or constipation, Gastrointestinal problems such as gallstones, stomach ulcers, or gastritis

follow your bowel management program. Eat fiber and consume fluids as your doctor suggests.

Spinal cord injury complications - orthostatic hypertension

his is a decrease in blood PRESSURE that occurs when the person is moved from a SUPINE to UPRIGHT position. It is common with people who have a SCI because of the lack of muscle TONE. When this happens the person becomes DIZZY, nauseous, and may LOSE consciousness. When this happens the person should be RECLINED until the symptoms go away. This problem usually diminishes as activity TOLERANCE increases but it is a continued problem for some people. Abdominal BINDERS and compression garments can be helpful for some people.

Spinal cord injury complications - decreased vital capacity

his is caused by WEAKNESS or PARALYSIS of the diaphragm and of the intercostal and latisimus dorsi muscles from lesions in the CERVICAL or high thoracic area of the spinal cord. This results in a DECREASED ability to have a productive COUGH and a tendency to develop respiratory INFECTONS. Manually assisted COUGHING and deep BREATHING exercises help with to maintain vital capacity.

Complete spinal cord injury

injury means that there is a complete lesion with a TOTAL lack of either SENSORY or MOTOTR function below the level of injury.

Sexuality and SCI - Erections - Spontaneous

internal stimuli, like having a full bladder

Clinical syndromes that occur with incomplete lesions - brown-sequard syndrome

ipsilateral upper MOTOR neuron paralysis and loss of PROPRIOCEPTION, as well as contralateral loss of TOUCH, PAIN and TEMPERATURE sensation.

Main sign of sacral sparing

the retention of some SENSATION or function BELOW the site of the injury, particularly along the anus. There may be some SENSATION of needing to ELIMINATE or even being able to eliminate without ASSISTANCE some or all of the time. Sensory function is EVALUATED by testing for LIGHT touch and PIN PRICK (being able to tell the difference between the SHARP and DULL side of a safety pin). To begin the evaluation the therapist will often start by evaluating sensation on the face to determine a baseline of NORMAL sensation. For the evaluation there are 28 key SENSORY dermatomes that are each TESTED separately.

Spinal cord injury complications - Heterotopic ossifcation

this is BONE that develops in abnormal places, usually around the HIPS, KNEE, shoulder or ELBOW. It can cause PAIN and limit joint ROM and is usually treated with MEDICATION and maintenance of ROM.

Spinal cord injury complications - autonomic dysreflexia

this is a medical EMERGENCY and can be life threatening. Autonomic dysreflexia is a SYNDROME in which there is a sudden onset of excessively high BLOOD pressure. It is more common in people with spinal cord injuries that involve the thoracic nerves of the spine or above (T6 or above). It is caused by REFELX action of the autonomic nervous system in RESPONSE to some stimulation which can include a distended BALDDER, fecal MASS, urinary TRACT infection, SKIN breakdown, tight CLOTHING or PAINFUL stimulus. These situations TRIGGER an automatic reaction that causes BLOOD pressure increase, heartbeat to SLOW and become irregular. The client's body cannot restore their blood PRESSURE to NORMAL because of the spinal cord DAMAGE.

Spinal cord injury complications - autonomic dysreflexia - symptoms

¥ POUNDING Headache. ¥ A flushed FACE and/or red blotches on the SKIN above the level of spinal injury. ¥ SWEATING above the level of spinal injury. ¥ Nasal STUFFINESS. ¥ Nausea. ¥ A slow HEART rate (bradycardia). ¥ Goose BUMPS below the level of spinal injury. ¥ Cold, CLAMY skin BELOW the level of spinal injury. The only way to REVERSE symptoms is to CHANGE the situation-for example, by removing TIGHT clothing or EMPTY the bladder.

Spinal cord injury complications - autonomic dysreflexia - prevention - Broken bones or other injuries, Tight clothing or devices Extreme temperatures or quick temperature changes

• Be aware that these can cause the condition. Discuss this with your doctor. -Make sure all clothing and devices fit correctly.

Spinal cord injury complications - autonomic dysreflexia - prevention - • Pressure sores, Ingrown nails, Other skin problems

• Check your skin daily. -Make sure all clothing or devices fit correctly.

SCI - OT treatment - expected functional outcomes - L2-S5

• Good TRUNK control and partial CONTROL of LOWER extremities • Able to ambulate with forearm crutches or cane and KAFO or AFO • Independent with all daily living

SCI - OT treatment - expected functional outcomes - C7-8

• Movement includes ELBOW extension, ulnar WRIST extension, WRIST flexion, finger FLEXION and EXTENSION • Continued DECREASED vital capacity • Weak TRUNK control • Able to assist with BOWEL and BLADDER management • Independent self-feeding, GROOMING, upper body DRESSING & BATHING • Some assist required for LOWER body dressing & BATHING • Independent for level TRANSFERS and some uneven transfers • Able to do light MEAL preparation and HOMEMAKING

SCI - OT treatment - expected functional outcomes - C6

• Movement includes SCAPULAR protraction, FOREARM supination and radial WRIST extension. The WRIST extension is important because it allows for the use of a tenodesis SPLINT with use of a splint. • Continued DECREASED vital capacity • May be independent for some level TRANSFERS • Independent with self-FEEDING and upper BODY dressing with adaptive EQUIPMENT • Independent with a MANUAL wheelchair INDOORS • Independent DRIVING in a modified VAN with a lift

SCI - OT treatment - expected functional outcomes - T1-9

• Movement includes intact UPPER extremities and limited upper TRUNK stability BLADDER management • Independent with all SELF-CARE • Independent with all MANUAL wheelchair and all TRANSFERS • Independent DRIVING a car with HAND controls • Assisted with HEAVY housecleaning

SCI - OT treatment - expected functional outcomes - C5

• Movement includes shoulder FLEXION, abduction and EXTENSION, elbow FLEXION (but no active extension) and SUPINATION, and SCAPULAR adduction and abduction • No ventilator but DECREASED vital capacity and may need help to clear SECRETIONS • Able to do PRESSURE relief with equipment • Able to SELF-feed and do some GROOMING and upper DRESSING dressing when set up with SPLINTS or universal cuff • Can use a POWER wheelchair with hand CONTROL and can push self in a MANUAL chair on a level surface for SHORT distances • May not require 24 hour ATTENDANT with sufficient PERSONAL and home care

SCI - OT treatment - expected functional outcomes - C1-4

• Movement possible includes neck FELXION, extension, and ROTATION and at C4 scapular ELEVATION and inspiration • Requires a VENTILATOR for breathing at C1-3 but may be able to BREATHE without a ventilator for C4 • Suction needed to CLEAR secretions • Totally DEPENDENT for all CARE • Independent in POWER chair with CHIN or breath control • Participation in functional ACTIVITY is with mouth STICK, high tech EQUIPMENT and environmental CONTROL units.

Spinal cord injury complications - decubitus ulcers

• PERSON WITH SPINAL CORD INJURY LACKS SENSATION. DON'T FEEL DISCOMFORT SO YOU DON'T MOVE. These most often occur in areas where there are BONEY prominences. Skin breakdown and pressure SORES can be very difficult to heal and often there is more damage BELOW the level of a sore that is visible. Therefore it is very important for the person with the SCI to be knowledgeable about SKIN inspection and the need for WEIGHT shifting and repositioning. Methods to relieve PRESSURE include routine turning in BED, specialized MATRESSES and wheelchair SEAT cushions, and performing WEIGHT shifts when sitting in the WHEELCHAIR.

SCI - OT treatment - expected functional outcomes - T10-L1

• Respiratory FUNCTION is now intact • Fair to good TRUNK stability • May AMBULATE with forearm crutches or WALKER and KAFO

Spinal cord injury complications - autonomic dysreflexia - if it happens during OT treatment

• Sit up STRAIGHT or raise the HEAD so they are looking straight ahead. If possible lower the LEGS. The client needs to be sitting upright until their blood pressure is back to NORMAL • Loosen or TAKE OFF any tight CLOTHING or accessories. This includes BRACES, catheter TAPE, socks or stockings, SHOES and bandages. • Empty the BLADDER by draining the Foley catheter or using the catheter. • The client can use digital stimulation to EMPTY the bowel. • Check the skin for red spots that indicate a PRESSURE sore. • If possible, check the BLOOD pressure every 5 minutes to see if it improves. • Call the doctor, even if SYMPTOMS go away and blood pressure is DECREASING. • If the symptoms return, repeat the above steps and go to the emergency ROOM or call emergency SERVICES. The OTA should stay with the client while getting medical help. The following are some frequent causes of autonomic dysreflexia and how they can be prevented.

Spinal cord injury complications - autonomic dysreflexia - prevention - Sexual activity

Be aware that sexual activity can cause the condition. Discuss this with your doctor.

Initial medical management of a person with a spinal cord injury

Early medical treatment is focused on restoring NORMAL alignment of the spine, decompressing the spinal cord and maintaining stabilization of the INJURED area. Rotating kinetic beds are used to provide SKELETAL traction and immobilization. The person frequently has surgery for open reduction with internal fixation and SPINAL fusion. Portable immobilization devices are used during the healing process. These include a halo vest for tetraplegia or a thoracic body jacket for paraplegia.

ASIA - C

Incomplete: MOTOR function is preserved BELOW the neurologic level, and most key MUSCLES below the neurologic LEVEL have a muscle GRADE of less than 3

ASIA - D

Incomplete: MOTOR function is preserved BELOW the neurologic level, and most key MUSCLES below the neurologic level have a muscle grade that is GREATER than or equal to 3

ASIA - B

Incomplete: SENSORY, but not MOTOR, function is preserved BELOW the neurologic level and extends through sacral segments S4-S5

Clinical syndromes that occur with incomplete lesions - Central cord syndrome

It is marked by a disproportionately GREATER impairment of MOTOR function in the UPPER extremities than in the LOWER extremities, BLADDER dysfunction and SENSORY loss below the level of INJURY.

Treatment considerations when working with people who have had a SCI

It is very important to consider the PSYCHOLOGICAL adjustment the person has to make. Use of ACTIVE listening and client-centered TREATMENT is so important to understanding the needs of the client. Questions about sexuality are also frequently a concern. In most FACILITIES there is a specific person or discipline assigned to do sexual counseling and EDUCATION. The OT practitioner should be prepared to answer QUESTIONS about sexual FUNCTION and make referrals to the appropriate person for sexual counseling. Caregiver TRAINING is also an important part of treatment and this should include TRAINING that the OT practitioner provides as well as training the CLIENT to verbally INSTRUCT caregivers.

ASIA - E

Normal: SENSORY and MOTOR functions are NORMAL

SCI - OT treatment - splinting

Splinting is an important part of TREATMENT and it is essential that any splint fits well to PREVENT the possibility of SKIN BREAK down. People with SCI may be ABLE to use a tenodesis GRASP if they have WRIST extension. With this GRASP, wrist extension is used to facilitate tenodesis action of the long FINGER flexors. For these clients it is good to have some TIGHTNESS of the wrist extensors. This is achieved by ranging FINGER flexion with WRIST extension and finger EXTENSION with wrist FLEXION. It is important that the THUMB is in opposition and the web SPACE is maintained to use this GRASP. There are SPLINTS used to enhance the tenodesis grasp and you can see a picture of one at this web site: http://www.360oandp.com/orthotics-101-tenodesis-splint.aspx It is also important that ELBOW flexion contractures do not develop. This is because the client who does not have ACTIVE triceps can maintain balance during STATIC sitting and transfers by fully EXTENDING the elbows to lean on the ARMS See your textbook for a picture of this on page 544, Figure 27-7.

ASIA

The American Spinal Injury Association (ASIA) has a standard impairment SCALE classification in which injuries are classified into one of five levels. Note that with a complete spinal cord injury there is no MOTOR or SENSORY function preserved in the sacral segments S4-5. Clinically a person is considered to have a COMPLETE lesion if they do not have FUNCTION below the LEVEL of the lesion. The ASIA classification brings this to the LOWEST level of the spinal cord when looking at COMPLETE lesions. Therefore if a client does not have any MOTOR or SENSORY function in the anal and perianal area, which is represented by S4-5, then they would be classified as having a COMPLETE lesion.

What happens when a person has a injury to the spinal cord?

When a person has an injury to the spinal cord there is loss of SENSATION and MOTOR function BELOW the level of the injury. The level of the SCI designates the last fully FUNCTIONAL neurological segment of the cord. For example, ????

Clinical syndromes that occur with incomplete lesions - anterior spinal cord syndrome

a LESION affecting the anterior two-thirds of the spinal cord with loss of MOTOR control and loss of PAIN, TEMPERATURE and TOUCH sensation below the lesion with intact PROPRIOCEPTION.

Clinical syndromes that occur with incomplete lesions - cauda equina

a serious condition caused by COMPRESSION of the bundle of NERVES in the lower portion of the SPINAL canal called cauda equina (Latin for horse's tail). Symptoms include low BACK pain, numbness and/or tingling in the buttocks and LOWER extremities (sciatica) weakness in the LEGS, and incontinence of BLADDER and/or bowels.

Dermatome

an area of SKIN that is innervated by the sensory axons within each segmental nerve root. Review the website below for a sample evaluation sheet that includes information on the ASIA levels.

Tetraplegia

any degree of paralysis to the four limbs and trunk

Incomplete spinal cord injury

means that SOME function of the spinal cord may be PARTIALLY or COMPLETELY intact below the level of the lesion.

Paraplegia

paralysis of the lower extremities and some involvement of the trunk

Sexuality and SCI - Erections - Reflexogenic

physical touch, can also happen when putting in or taking our a catheter, grooming or bathing

Sexuality and SCI - Erections - Psychogenic

seeing or thinking about something erotic

Clinical syndromes that occur with incomplete lesions - conus medullairs syndrome

the most common symptoms include: severe back PAIN, sensations in the back, such as BUZZING, TINGLING, or NUMBNESS, WEAKNESS or TINGLING in the lower limbs.

Spinal cord injury complications - osteoporosis

this can develop because of DISUSE of the long bones, especially of the LEGS. Osteoporosis can lead to FRACTURES which are most common in the legs. Standing FRAMES can be used to slow the onset of osteoporosis.

Spinal cord injury complications - spasticity

this is common following spinal cord injury. Some spasticity is helpful to maintain MUSCLE mass and to facilitate blood CIRCULATION. However, severe SPASTICITY can be a problem and it is frequently treated with MEDICATION. More information on spasticity can be found at this website: http://www.spasticityalliance.org/about-spasticity/spinal-cord-injury-and-spasticity/