Pulmonary Rehabilitation in Acute Spinal Cord Injury. Jatuporn Jatutawanit Physical therapist, Physical therapy unit, Prince of songkla university
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1 Pulmonary Rehabilitation in Acute Spinal Cord Injury Jatuporn Jatutawanit Physical therapist, Physical therapy unit, Prince of songkla university
2 Causes of spinal cord injury Traumatic injury Motor vehicle crash Falls Acts of violence Sport injury Non-traumatic injury Cancer Infections Disc herniation Osteoporosis Spinal cord vascular disease Vertebral injury
3 Spinal cord injury Spinal cord injury (SCI) results in physiologic changes that affect many organ systems Pulmonary physiologic changes due to spinal cord injury (SCI) are related to the extent of neurological impairment
4 Classification of SCI The American Spinal Injury Association (ASIA) Impairment Scale is used to classify the degree of impairment that is based on strength in key muscles and on a sensory exam International_Stds_Diagram_Worksheet.pdf
5
6 Classification of SCI Grading scales for spinal cord injury: American Spinal Injury Association Scale (ASIA) A B C D E No motor or sensory function is preserved below the neurologic level through the sacral segments (Complete motor SCI ) Sensory but not motor function is preserved below the neurologic level and extends through the sacral segments Motor function is preserved below the neurologic level and the majority of key muscles below the neurologic level have a muscle grade less than 3 Motor function is preserved below the neurologic level and the majority of key muscles below the neurologic level have a muscle grade of at least 3 Motor and sensory functions are normal (no cord injury)
7 Classification of SCI
8 Normal breathing Motion of diaphragm and ribs alternate volume of thoracic cavity, a space bounded by ribs, sternum, vertebral column and diaphragm Inspiration -Space in thoracic cavity increase -Intra-thoracic pressure falls -Air move into the lungs Expiration -Space in thoracic cavity decrease -Intra-thoracic pressure rises -Air move out of the lungs
9 Inspiration phase Major muscle Diaphragm m.(c3-c5) Accessory muscles external intercostals(t1-t11) clavicular portions of pectoralis major m.(c5-c6) scaleni m.(c3-c8) sternocleidomastoids m.(c2-c3 and CN.XI) trapezius m.(c2-c4 and CN.XI) Trapzius & sternocleidomastoid m. COMPENSATORY muscle in SCI for respiration depend on high level injury
10 Expiration phase Normally, expiration is passive In forced exhalation: exercise or coughing Abdominal wall muscle (T6-L1) Internal intercostals muscle (T1-T11)
11 MECHANICS OF RESPIRATION Normal respiration
12 Normal coughing Coughing is an explosive expiration that provides a normal protective mechanism for clearing tracheobronchial trees of secretion and foreign material Coughing involve coordinated action of the glottis and muscle of both inspiration and expiration
13 Cough mechanism
14 Respiratory function Impairment in SCI Ability to breathe deeply and cough forcefully is impaired to varying degrees depending on the level and completeness of SCI Respiratory complications are a major cause of death in the early stages of spinal injury
15 Respiratory function Impairment in SCI Respiratory impairment depends upon Level of the injury: Quadriplegia or Paraplegia Severity of injury: complete or incomplete Additional trauma sustained at time of injury: rib fracture, chest trauma Premorbid respiratory status: asthma, COPD
16 Respiratory complications Most common: Respiratory failure Pneumonia Atelectasis
17 PULMONARY PHYSIOLOGIC CHANGES Pulmonary physiologic changes following spinal cord injury include: Impairment of respiratory muscle performance Changes in lung and chest wall compliance Changes in respiratory control Airflow limitation and bronchial hyperresponsiveness
18 Impairment of respiratory muscle performance Respiratory m. below level of complete SCI non-function or weakness in both inspiratory & expiratory m. vital capacity tidal volume peak cough flow
19 Changes in lung and chest wall compliance Especially in tetraplegia
20 Changes in respiratory control In quadriplegia, central control of respiration is effected abnormally small increase in ventitory drive hypercapnia
21 Airflow limitation and bronchial hyperresponsiveness Loss of postganglion sympathetic innervations in C-spine injury Parasympathetic hyperactivity -Dec. airway diameter & patency (bronchoconstriction) -Dec. mucocilialy activity - Inc. production of secretion
22 Progressive cycle of respiratory dysfunction after SCI
23 Respiratory Assessments Respiratory rate at rest Breathing pattern Chest mobility Cough Breath sound Strength of respiratory muscle Muscle test >> diaphragm, intercostals, abdominal, accessory muscles Static pressure >> MIP, MEP
24 Chest Physical Therapy Objectives Prevent lung complications: atelectasis, pneumonia Increase ventilation Respiratory muscle training By Improve bronchial hygiene Improving/ maintainance of chest mobility Strengthening of respiratory muscle Education of patients and care giver
25 Chest Physical Therapy Positioning (Postural Drainage) Percussion & Vibration Assist cough technique Hyperinflation technique Mechanical insufflation-exsufflation (MI-E) Inspiratory muscle training (IMT) Flow incentive spirometer Volume incentive spirometer Threshold IMT
26 Positioning (Postural Drainage)
27 Percussion & Vibration 60&gid=
28 Assist cough technique
29 Self-Assist cough technique
30 Hyperinflation technique
31 Mechanical insufflationexsufflation (MI-E)
32 Rib torsion B8%B5%E0%B9%88126-passive-chest-mobilization/
33 Contra-indications / precautions for manual techniques Osteoporosis # ribs / rib pathology Thoracic / cardiac surgery Pain Haemoptysis Bronchospasm Disordered coagulation Metastatic deposits Loss of skin integrity (surgery, burns, wounds) Subcutaneous emphysema
34 Flow incentive spirometer Breathing/dp/B00JFRH3KE
35 Volume incentive spirometer
36 Thredshold inspiratory muscle training thailand.digitaljournals.org
37 Abdominal support cordinjury,therapy,treatments,help/daughter/
38 Range of Motion Exercise Divide to Passive ROM Active-assisted ROM Active ROM Objectives Stimulate circulation Maintain ROM Prevent muscle shortening Strengthening muscle (Active-assisted & Active ROM)
39 Range of Motion Exercise =8&ved=0ahUKEwjl4I3l_ZfXAhXGKo8KHeEGCT8QjRwIBw&url=https%3A%2F%2Fakuf isio.blogspot.com%2f2015%2f05%2f&psig=aovvaw2uvx_fij2rmzfeehvmotwm&ust=
40 Range of Motion Exercise Cautions Extreme ROM in spinal shock phase First 6 weeks post-injury: SLR < 60º Combined flexion of hip and knee > 90º Combined flexion of wrist and fingers DVT (INR target 2-3)
41 Bed positioning Objectives Ventilation perfusion Correct alignment of posture Prevent pressure sore and contracture Inhibit onset of spasticity
42 Bed positioning Supine position Foot drop and hip Ext. rotation
43 Bed positioning Side-lying position
44 Bed mobilities Full support Keep normal alignment Log rolling 0
45 Ambulation Up to doctor allow Orthosis Slow upright due to postural hypotension Abdominal bandage, elastic bandage, stocking
46
47 Questions?
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