Which nerves can be affected in SCI?
Nerves
- motor
- sensory
- autonomic
What are the implications for loss of autonomic NS function?
Implications
- Blood pressure
- Bladder/bowel
- Sexual
- Respiratory
UMN vs LMN lesions
Upper (above conus)
- Spinal reflexes
- Spastic paralysis
Lower (cauda equina)
- Loss of SC mediated reflexes
- Flaccid paralysis
What is the ASIA SCI level defined as?
Lowest intact neural segment
Motor impairment after SCI is due to:
- Damaged ascending/descending tracts
- Poor spinal/cortical reorganisation
Physiotherapy Assessment in SCI?
Ax
- Same as stroke except no dexterity training
- Fitness
- Activity Ax
What are the primary and secondary impairments in SCI?
Primary
- strength
- sensation
- spasticity
Secondary
- loss of muscle length
- disuse weakness
- cardiovascular deconditioning
What muscle innervations does a C6 Quad lack/is weak in?
No
- Elbow extensors
- Finger/thumb muscles
- Trunk or below
Very weak
- Elbow pronators
- Wrist flexors
What is the optimal functional outcome for a C6 quad?
Optimal functional outcome
- Totally independent at home alone
- Lift body weight and transfer (shoulders in locked external rotation and elbows passively extended)
- Manual wheelchair over level surfaces
- Tenodesis grip
What does a T1-4 paraplegic lack in terms of muscular innervations?
? no abdominals and erector spinae above lesion level
Research on strength training below the level? (2)
Hicks et al 2011 (systematic review)
- Mod-high intensity exercise 2-3x/week
= increased strength in chronic SCI
= unsure about functional outcome
Kloosterman et al 2009 (systematic review)
- PRE for upper limb in partially paralysed mm
- 3-5x/week (20-45 mins) for 3-6m
= increased strength and function (T/Fs, w/c)
How much training? Research (1)
van Langevelde et al 2011
- PT/OT/exercise
- Average 8.9 sessions/week at 43 mins/session
- Strength training and modified activity practice
Training function (sitting) in complete lesions (2)
Boswell-Ruys et al 2010
- Chronic thoracic paraplegia
- 1hr/3x wk/6wks
- No improvements
Harvey et al 2011
- Sub-acute thoracic paraplegia
- Usual plus 30mins task specific 3x wk/6wks
- All improved, no different
Training function in INcomplete lesions (2)
Harvey et al 2009 (systematic) = gait training to improve walking
Spooren et al 2009 (systematic) = repetitive motor task training improved UL and hand function
How can tendons be kept strong? (research)
Harvey et al 2010
- ES for keeping tendons strong before tendon transfer
Why is training function in SCI different to stroke?
Training new skills (whole, modified, part)
How frequent is spasticity in SCI and how detrimental is it?
- present in up to 80% of SCI Pts.
- more detrimental in incomplete lesion
What is the leading cause of death in long term SCI?
CV disease
Evidence for increasing ROM?
Positioning, splinting, casting, PROM and tilt table are not effective
(Rx for 30mins 3-5x/week for 4-12 weeks)
Ben and Harvey 2010
- Self-administered hamstring stretches for 30mins, 5x wk/6wks
- Average 10 deg improvement!
Rx to maintain and increase ROM
ROM Rx
- Assess accurately
- Prevent (not reverse)
- Target mm susceptible to shortening
Essential components of lying to sitting in a C6 quad
Components
- Roll onto side
- Lift upper body off bed
- Support the upper trunk
- Hook top hand under leg
- Shuffle bottom elbow around the body
- Move into upright position
Techniques to train rolling
Pre-swing phase
- Small weight
- Splints
- Arms low and close to the body
Swing phase
- Pillow behind trunk
- Cross the ankles
- Flex contralateral side knee
- Begin 1/4 off supine
Essential components of lying to sitting in a T4
- Rolling
- Walking on hands
- Lifting/pushing up trunk
- Hooking around leg and pushing to get into upright sitting
Essential components of transfers for a C6
- Move to front of w/c (cushion, slide-sheet)
- Hook under legs to sit up
- Lift first leg onto bed (feet on raised stool, strap used to help lift leg)
- Lift the second leg onto bed
- Position the hands
- Lift and shift body onto the bed (slide board)
