Slide 1. Slide 2. Slide 3. Introduction CHAPTER 10:CLIENTS WITH SPINAL CORD INJURY PART I. Introduction - page 252(pathophysiology)

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1 Slide 1 CHAPTER 10:CLIENTS WITH SPINAL CORD INJURY PART I PT 151 Slide 2 Introduction - page 252(pathophysiology) Traumatic SCI occurs when an external force, such as fracture of the vertebrae or penetration of an object, causes stretching, bruising, laceration, or compression to the vulnerable spinal cord. Slide 3 Introduction Primary Injury: due to the mechanical injury to neurons. Secondary Injury: due to multiple biochemical and histological changes, which occurs over days and weeks following an injury.

2 Slide 4 Introduction pg. 252 PT begins in acute hospital setting, once injury is stabilized and continues throughout the inpatient and outpatient rehabilitation settings. Slide 5 Introduction Role of PTA: assisting PT in providing select interventions, performing tests and measures appropriate and providing patient and family education in all types of practice settings until client has reached his or her maximal functional abilities. Slide 6 Incidence pg cases per million population or 11,000 new cases per year Approximately 240,000 in US with SCI. Primarily affects young Caucasian males Average age 41 y/o Males 80.6% of all SCI s

3 Slide 7 Causes pg. 252 Most common cause: MVA (41%) Followed by falls and acts of violence, primarily gun shot wounds. MVA s/sport s injuries/falls = cervical Violence = thoracic/lumbar/sacral Slide 8 Life Expectancy pg. 252 Life expectancy has increased in recent years, but still somewhat lower than for people who have not had a SCI. Mortality rates are higher in first year following injury. (especially with severe injuries or high tetraplegia) Most common cause of death was renal failure, now pneumonia and septicemia Slide 9 Describing the Neurological Injury: Level and Extent of Injury pg 253 A lesion to the spinal cord affects the transmission of sensory information to the brain and motor information to the periphery. Each spinal nerve root innervates a precise area of skin called: dermatome

4 Slide 10 Page 253 Cont And a group of muscles called: myotome By documenting sensation and muscle strength, the clinician can identify whether and injury is complete or incomplete and establish the neurological level of injury. Specific criteria described by the American Spinal Injury Association (ASIA) Slide 11 Purpose of ASIA Classification p Provides common language for those providing care for patients with spinal cord injuries 2. Outcomes of research will be comparable 3. Functional predictors can be developed. Slide 12

5 Slide 13 Complete Vs. Incomplete Injury pg 254 An incomplete SCI is defined by the presence of sacral sparing, which is partial or complete preservation of motor function, sensory function or both in the S4 and S5 spinal segments of the cord. (anal sensation and voluntary contraction of the external anal sphincter indicate sensory and motor incomplete injuries). Slide 14 Complete Vs. Incomplete - p. 254 Based on sensory and motor evaluation, 1 of 5 ASIA impairment scales is assigned (A, B,C D, or E) With an incomplete injury, motor function below the injury can vary, depending on the severity of the injury. Muscles a few levels below the level of injury can be weak or less than fair (+) but this is not considered incomplete unless the lowest sacral segments are also spared. Slide 15

6 Slide 16 Level of Injury pg. 255 Describes the patient functionally; it refers to the segmental neurological level of the spinal cord where function remains, rather than to the vertebral level affected. For example, the radial nerve innervates the triceps brachii and is composed of nerves from C7 and C8 roots. C7 nerves innervate a sufficient number of motor units so that a person with a C7 lesion has Fair (F) strength in triceps. Slide 17 Level of Injury pg. 255 Motor level of injury is determined by the last nerve root that innervates key muscles at Fair strength, providing that the muscles innervated at the levels above are of Normal (N) strength. Sensory level of injury is determined by the last nerve root at which sensation is normal for both light touch and sharp/dull. Slide 18 Neurological Level of the Injury The most caudal segment that has both normal motor and sensory grades Example: pt s motor level is L3 and sensory level L4; NLI = L3 WHY?

7 Slide 19 Zone of Partial Preservation (page 254) Complete SCI ZPP = Zone of partial preservation Most caudal segment with SOME sensory or motor function Example: C5 ASIA A, impaired sensation to T1 T1 = ZPP Slide 20 Tetraplegia Vs. Paraplegia - p255 A person with SCI and all four extremities affected is tetraplegia, but more commonly called QUADRIPLEGIA The extent depends on what level. At C8 a person may just have a loss of finger motion while a person with C1-C4 have significant loss of UE. Slide 21 Tetraplegia Vs. Paraplegia - p 255 Paraplegia: T2 and below injury in which the UE s are not affected at all.

8 Slide 22 Reflexic Vs. Areflexic Injury pg 255 Most SCI are considered to be reflexic or upper motor neuron lesions. SCI is apart of the CNS. Symptoms: spasticity, hypertonicity, and pathologic reflexes Slide 23 Reflexic Vs. Areflexic Injury -p.255 Areflexic injuries, or lower motor neuron injuries are seen with the damage is to peripheral nerves (ex. Cauda equina) or following infarct to the cord. Symptoms: flaccidity, atrophy, and absence of reflexes. Can also occur transiently during spinal shock Slide 24 Special Categories of SCI p. 255 Brown-Sequard Syndrome: Results from hemisection of the spinal cord. Because various sensory and motor tracts cross at different levels of the cord, a characteristic clinical picture is seen: contralateral loss of pain and temperature, and crude touch, ipsilateral loss of proprioception, vibration, fine touch. Ipsilateral spastic motor paralysis below the level of injury.

9 Slide 25 Special Categories of SCI p. 255 Central Cord syndrome: primarily seen in older pts. with cervical spondylosis and hyperextension injuries: has greater involvement of UE s than LE s. (UE tracts are more central). Slide 26 Central Cord Syndrome /12/756/F1.large.jpg Slide 27 Special Kinds of SCI pg. 255 Anterior Cord Syndrome: The most dorsal tracts that carry proprioception are spared, while anterior tracts which carry motor function are affected. Cauda Equina Syndrome: Injury to lumboscacral nerve roots within the neural canal. Because the cauda equina is part of the peripheral nervous system, an areflexic motor injury is seen.

10 Slide 28 Pop Quiz Name that SCI Syndrome (assignments) A. B. C. Slide 29 Slide 30 Clinical Picture of SCI pg 257 Motor Loss Below the level of injury may be complete or partial. ASIA has chosen key muscles to represent each of the neurological levels. All MMT can be completed in supine. A PTA may have to complete follow up testing during individual s rehab.

11 Slide 31 Respiratory involvement pg. 257 Involvement of Respiratory Muscles: With injuries above L1, some or all of the respiratory muscles will be affected. Remember!! C3, 4, 5: keep the body alive(diaphragm). The intercostal muscles are innervated by T1-11. Abdominal muscles are T8-T12. Therefore forced breathing and coughing may be difficult. Slide 32 Clinical Picture of SCI pg 258 You may need to aid with manual assistance for coughing and clearing secretions. The patient may also require suctioning or mechanical ventilation if diaphragm is involved. Pneumonia is one of the leading causes of death for SCI pts. Slide 33 Clinical Picture of SCI pg. 258 Sensory Loss Occurs in dermatomal pattern. For ASIA testing, includes light touch, pinprick (sharp/dull), and is tested in specific areas. Graded: Normal, impaired or absent. Absent = can t differentiate between sharp and dull

12 Slide 34 Clinical Picture of SCI pg. 258 Proprioception also tested, helps predict functional outcomes With a complete injury, all sensation is lost. PTA may have to repeat selected sensory testing with an incomplete SCI. Slide 35 Clinical Picture of SCI pg. 259 Spasticity: A majority of people with SCI have spasticity after spinal shock, which can last a variable amount of time after injury. It affects skeletal muscles as well as muscles of bowel, bladder, and sexual organs. Extent varies: May be minimal or it may interfere with function and sitting position. Some may use their spasticity to assist their function. Slide 36 Clinical Picture of SCI pg. 259 Bowel, Bladder, and Sexual Dysfunction Lose total or partial voluntary control. Will have to retrain their bladder. May have to learn voiding compensations: including indwelling, condom, or suprapubic catheter; intermittent catheritization; or performing crede, which is pressing on bladder to force urine out.

13 Slide 37 Clinical Picture of SCI pg. 259 Will have to retrain bowel function and elimination: may experience incontinence. Males with reflexive motor function are able to achieve a reflexive erection but are unable to ejaculate. Males with areflexive (LMN) injuries can t achieve erection or ejaculate. Women s normal cycles usually return and they are able to become pregnant following a SCI. Slide 38 Autonomic Dysreflexia or Autonomic Hyperreflexia pg. 259 Autonomic Dysreflexia (AD): total body sympathetic nervous system response to noxious stimuli which may be observed in people with SCI above T6. Triggers: bladder distention, bowel impaction, pressure sores, catheter irritation, LE hamstring stretching, tight clothing, a restrictive leg bag strap, or medical tests Slide 39 Autonomic Dysreflexia or Autonomic Hyperreflexia pg. 259 Signs and symptoms: increased BP, pounding headache, restlessness, bradycardia or tachycardia, cardiac arrhythmias sweating, flushing, or blotchiness of face, chills, nasal congestion, and blurred vision T6 or above are prone

14 Slide 40 Autonomic Dysreflexia or Autonomic Hyperreflexia pg. 259 Considered a medical emergency. Immediate treatment by PTA: would include: monitor BP, loosen tight clothing, get patient to sitting position, make sure urine flow is not impeded, and notify PT, nurse and MD. Slide 41 Psychological Reaction to Loss p. 261 Adjustment phases of loss and grieving similar to those described by Kubler-Ross for people who are dying. May include anger, depression, withdrawal, and having unrealistic expectations. Slide 42 Psychological Reaction to Loss p. 2 Personnel can support the pt by understanding this process and helping him or her move through these phases by gaining independence and continuing to modify goals as progress is achieved.

15 Slide 43 Pain pg 261 Common finding and can be a barrier to rehab 65% have pain, 30% have severe pain 2 types 1) Nociceptive 2) Neuropathic Slide 44 Pain pg Nociceptive pain: musculoskeletal pain is an example related to mechanical instability, inflammation, muscle spasm and overuse of muscles and joints and is described as dull, aching, and movement related. TENS can be effective in reducing this type. Slide 45 Pain pg Neuropathic pain: located above, at, or below level of injury. Described as sharp, stabbing, burning, or electrical pain. Thought to be related to damage to neurons within the spinal cord. Combo of meds and modalities may be required.

16 Slide 46 Complications pg. 261 Orthostatic Hypotension: drop in BP that can occur the first time the patient with SCI tries to sit or stand, will complain of dizziness. Loss of LE muscle pump. An abdominal binder or corset and elastic stockings are used to substitute. Slide 47 Complications pg. 261 Usually resolves over time, but usually takes weeks. Use of tilt table, recliner W/C, or medication may be required to help patient adapt to upright position. Slide 48 Complications pg. 261 Deep Vein Thrombosis: (DVT): a blood clot in a vein, associated with being inactive or on bed rest. Medical concern and contraindication to treatment because clot could travel. Treated with anticoagulants

17 Slide 49 Complications pg. 262 Concomitant injuries (occur at the same time as the SCI): Include fractures of extremities, brachial plexus, abdominal and brain injuries. Brain injuries occur in 50% of people with SCI. Can complicate the person s ability to rehabilitate and learn to deal with complex emotional adjustments placed on him or her after SCI Slide 50 Complications pg. 262 Heterotopic Ossification: (HO) an abnormal overgrowth of bone in the joint space and around the joint which occurs in 10-20% Common signs and symptoms: decreased ROM, localized swelling and pain. Slide 51 Complications pg. 262 HO usually occurs within first 3 months, and is associated with spasticity and most often affects the hip, then knees, shoulders, and elbows Treatment is ROM to affected joint and use of medication, possible surgery.

18 Slide 52 Complications Decreased bone mineral density (BMD) occurs following complete SCI and in people with paraplegia/tetraplegia. BMD declines during first 3 months, 37% loss by 16 months. WHY? Slide 53 Complications After 37% BMD loss, increased risk for fractures Precaution when working with these people. Fractures can occur during transfers, as a consequence of fall, unusual movement, or LE PROM Slide 54 Complications Impaired temperature regulation: due the SNS dysfunction. The patient may complain about being cold and require warmer clothing

19 Slide 55 Complications In the heat, however, the patient will be unable to sweat below level of injury and can be at risk for heat stroke due to inability of body to cool. Slide 56 Complications Problems associated with normal aging (musculoskeletal and cardiovascular) are magnified. Injury above T6 = greater risk for CV compromise. WHY?