Descibe the levels of Spinal Cord injury.
Quadriplegia (Tetraplegia)
- Involvement of all 4 limbs
Paraplegia
- Involvement of LEs and trunk (depending on level)
Level of SCI
- Complete
- Designated by the region of injury and the last fully functioning neurologic segment in that region
- Example: C5= fifth segment of the cervical region is last level of full function
Partial
- Incomplete lesion results in partial function and partial preservation of the sensory or motor pathways below the level of the lesion
What is Spinal Shock?
Spinal Shock
- Occurs within 24 hrs, Lasts 4 to 6 weeks
- No reflexes below level of injury
- Deep tendon reflexes decrease
- Sympathetic function decrease
- Constriction of blood flow, low blood pressure, decreased heart rate, no perspiration below level of injury
- Bowel/ Bladder= atonic
- No reflexes below level of injury
What is spasticity?
Spasticity
- Follows Spinal Shock
- Develops because the monosynaptic reflex arc is intact but separated by the higher inhibitory influences
- Effects Deep Motor Reflex, Bowel/bladder, Sympathetic function
- Spinal reflex activity: mass muscle spasms below level of injury
- Effects LE muscle/abdominals
Bladder infections
- Catheters/Delayed or incomplete elimination
What are the secondary symptoms?
Decubitus ulcers
respiratory infections
osteoporosis
orthostatic hypotension
automonic dysreflexia
spasiticity
what are Decubitus ulcers?
Decubitus ulcers
- Kinetic bed, weight shifts, sensory education, proper transfers (no shearing), proper positioning, frequent repositioning, proper w/c cushions
- Stages
- Red
- Blanches when pressed
- No blanching when pressed
- Skin (tip of a cone)
What are respirtory infections and what can be done?
Respiratory infections
- Strengthening of SCM and diaphram
- Manual assisted cough, deep breathing exercises,
What are osteoporosis and orthostatic hypotension?
Osteoporosis
- Disuse of long bones
Orthostatic Hypotension
- Decreased BP when changing position
- Pooling of blood due to lack of muscle tone (LE and Abs)
- Sx: Dizziness, nausea, LOC with transitions from supine to sit
- Treatment
- Adjusting position
- Recline patient: Tip back chair
- Tilt table
- Abdominal binder
- Compression garments
- Medication
- Adjusting position
What is hyperreflexia?
Autonomic Dysreflexia (hyperreflexia)
- Occurs with SCI at or above T6
- Reflex action of the ANS to a stimulus (distended bladder, bladder infection, fecal mass, viceral distention, pain)
- Sx: Immediate pounding headache, anxiety, blurred vision perspiration, flushing, chills, nasal conjestion, paroxysmal hypertension and brachycardia
- MEDICAL EMERGENCY (Can lead to stroke – seek medical attention)
- Sit patient upright, remove restrictive clothing /abdominal binders/compression stocking to decrease blood pressure
- Drain bladder/check for obstruction in urine bag
- Monitor blood pressure
Autonomic dysreflexia?
What is spasticity?
Spasticity
- Gradually increase the first 6 months
- Plateau after first year
- Moderate spasticity
- Maintains muscle mass, increases circulation, can assist with bed mobility/transfers
- Sudden increase in spasticity can alert pt to a medical problem
- Bladder infection, fever, decubitus ulcer
- Severe treated with meds, botox, nerve blocks
- Moderate spasticity
- Decreased thermo regulation
- Difficulty swallowing
- Deep Vein Thrombosis (DVT)
- Heterotrophic Ossification
- Bone develops in abnormal anatomic locations
- Sx: warm, swollen, decreased ROM
- May limit hip ROM, lead to pelvic assymetry, scoliosis, skin breakdown
Describe the levels C1-C5 muscles function and limitations of injury.
Describe C6-C8 level of injury
Describe T1-S5 level of injury
What are the key muscles of function for C1-S5?
Key Muscle Function
C1-3: Head and Neck
C4: Diaphram
C5:Elbow flexors, Deltoids
C6:Wrist extensors
C7:Elbow extensor
C8:Finger flexion
T1-T8: Chest muscles
T9-12:Abdominal muscles
L1-5:Leg muscles
L2: Hip flexors
L3:Knee extensors
S1-5: Bowel, bladder, and sexual function
Describe C1-C4
C1-3
Require Assist with almost all ADLs
Vent Dependent
Electronic Assistive Devices
- Mouth stick, voice activation
Sip and Puff Controls
Animal Assisted Therapy
C4
ADLs: Same as above
Can wean from vent
Increased head/neck control
Describe C5-C6
C5 (biceps/delts)
With use of wrist support and universal cuff can perform feeding and grooming tasks
Use a power w/c with hand controls or manual with rim projections
Require Assist with LE dressing, transfers, bladder/bowel care
Electronic Assistive Devices : phone, computers, lights, TV
Driving an adaptive van may be possible
C6 (Wrist extensors)
Feeding, grooming, bathing, bed mobility with
Adaptive Equipment and Tenodesis
I with UE dressing, LE with Assist
Bowel/Bladder with Assist
Can transfer using slide board (some become I, others require A)
- Bed to chair
Maunual w/c with rim projections/enhancement
Can drive using hand controls, custom lift and other adaptations
IADLs – phone, turn pages, write/type with assistive devices
Describe C7-C8
C7(triceps)
Can live Independently
Independent with feeding, UE dressing, bed mobility, transfers (may need A with uneven surfaces)
Use Assistive Devices for LE dressing, grooming, bathing, bowel care
IADLs :Independent with or without Assistive devices
Manual wheelchair (may need Assist with curbs)
Can drive using adaptive vehicle with hand controls
C8(Finger flexion)
Independent withmost ADL/IADLS
Manual wheel chair
Drive using adapted van /hand controls
Descibe T1-T12
Thoracic Paraplegia ( T1-12)
Independent with all Self Care including bowel/bladder
Can perform light housekeeping/meal prep
Independent with all wheelchair mobility
Advanced w/c training: curbs, ramps, wheelies, uneven surfaces
Can transfer from floor to chair
Drive with hand controls
Describe what will be in an assessment chart.
Assessment
Comprehensive
Chart
- PMHx- pass medical history
- PLOF- Prior level of function
- All secondary dx
- PRECAUTIONS
- Medications
- Discharge destination
- Motor function-manual muscle test
- Sensation
- ADL
- COPM or similar
- Pain
- Cognition
- Perception
What are the treatment objectives for SCI?
Treatment Objectives
- Maintain or Increase joint /soft tissue integrity
- ROM, Orthotics, positioning, patient education
- Increase Strength of all innervated/partially innervated muscles
- Increase Endurance
- Maximize Independence in ALL areas of occupation
- Assist with Psychosocial adjustment
- Assess Adaptive equipment needs
- Home Adaptations: safety, accessibility recommendations
- Patient/Caregiver Education
What is the acute intervention phase?
Intervention: Acute Phase
- Body Positioning
- Prevent decubitus/contractures
- Environmental Controls
- Orthotics/Hand Splinting
- Ex: C5 (no hand/wrist)
- Splint : maintain wrist neutral/extension and thumb web
- C6 (wrist extensors)
- Splint: wrist extension/ or short opponens: digits flex naturally: train for tenodesis
- Ex: C5 (no hand/wrist)
- Appropriate ROM/Strengthening
- Muscle Re-ed
- ADLs
- Feeding, hygiene
- U-Cuff for feeding
- Pt/Caregiver Education
What Orthotics are used for what SCI?
Orthotics
- Palmar splints (C1-4)
- Futuro (dorsal) wrist splints (C5)
- Tenodesis (wrist driven or externally powered) (C6)
- Short opponens (C6)
- Thumb web space (All)
What is intervention at the Rehab/ active phase?
Intervention: Active/ Rehab Phase
Sitting tolerance
Pressure relief training
A/PROM and Strengthening
- Proximal Stability
- Wrist extension: tenodesis
- Triceps: pressure relief/transfers
- Prevent elbow contractures (full extension essential for mobility)
- Allow finger flexion tightness for functional tenodesis
Adaptive Equipment: Balance with Functional Independence
ADLs: feeding, hygene, bathing, bowel/bladder care, Dressing, Transfers, Commincation, tenodesis splints
Wheelchair Seating:Proper cushions
Psychological Support
Pressure Relief
- Every 15 minutes
- 1-2 minutes a side
- Work up tolerance
Prevention of Pressure Sores
- Cushion
- Pressure relief
- Skin care and hygiene
- Transfers
- Nutrition
What happens at the discharge phase?
Discharge Phase
- Home adaptation
- Community re-entry
- Mobility
- Driving Evals
- Transportation
- Assertiveness training
- Home health or outpatient therapy
- Leisure
- Return to work/school
- DME- durable medical equipment
- Follow-up care-tendon transplants, etc.
