Pulmonary Rehabilitation in Acute Spinal Cord Injury Jatuporn Jatutawanit Physical therapist, Physical therapy unit, Prince of songkla university
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
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
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
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)
Classification of SCI
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
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
Expiration phase Normally, expiration is passive In forced exhalation: exercise or coughing Abdominal wall muscle (T6-L1) Internal intercostals muscle (T1-T11)
MECHANICS OF RESPIRATION Normal respiration https://thoracickey.com/spinal-cord-injury/
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
Cough mechanism https://clinicalgate.com/airway-clearance-therapy/
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
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
Respiratory complications Most common: Respiratory failure Pneumonia Atelectasis
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
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
Changes in lung and chest wall compliance Especially in tetraplegia
Changes in respiratory control In quadriplegia, central control of respiration is effected abnormally small increase in ventitory drive hypercapnia
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
Progressive cycle of respiratory dysfunction after SCI
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
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
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
Positioning (Postural Drainage) https://www.pinterest.com/pin/763641680535547790/
Percussion & Vibration http://keckmedicine.adam.com/content.aspx?productid=117&pid= 60&gid=000051 https://clinicalgate.com/airway-clearance-techniques/
Assist cough technique http://bcrt.ca/assisted-cough/ http://www.myshepherdconnection.org/respiratory/assist-cough
Self-Assist cough technique http://downloads.lww.com/wolterskluwer_vitalstream_com/samplecontent/9780781788786_craven/samples/mod09/topic5b/text.html www.healthlinkbc.ca/healthtopics/content.asp?hwid=ug2709
Hyperinflation technique http://slideplayer.com/slide/6065224/
Mechanical insufflationexsufflation (MI-E) https://www.vitalitymedical.com/respironics-cough-assist.html https://www.youtube.com/watch?v=rovr8zkxi_m
Rib torsion http://www.firstphysioclinic.com/%e0%b8%95%e0%b8%ad%e0%b8%99%e0%b8%97%e0% B8%B5%E0%B9%88126-passive-chest-mobilization/
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
Flow incentive spirometer https://www.amazon.co.uk/triflow-incentive-exerciser-deep- Breathing/dp/B00JFRH3KE www.henleysmed.com https://www.healthproductsforyou.com/p-hudson-rci-air-ezeincentive-deep-breathing-exerciser.html
Volume incentive spirometer https://www.pinterest.com/pin/98094098109289257/
Thredshold inspiratory muscle training https://rider.in.th/article/384-power-breathe.html thailand.digitaljournals.org https://www.peanjaruan.com/products/threshold-inspiratorymuscle-trainer-imt/
Abdominal support http://www.sciencedirect.com/science/article/pii/s0003999312004339 https://quadcapable.com/quadriplegic,awareness,tetraplegia,spinal cordinjury,therapy,treatments,help/daughter/
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)
Range of Motion Exercise http://www.dinf.ne.jp/doc/english/global/david/dwe002/dwe00244.html http://acceleratedinc.net/index.php/industry-news/21-joint-movement-active-vpassive-range-of-motion https://www.google.co.th/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact =8&ved=0ahUKEwjl4I3l_ZfXAhXGKo8KHeEGCT8QjRwIBw&url=https%3A%2F%2Fakuf isio.blogspot.com%2f2015%2f05%2f&psig=aovvaw2uvx_fij2rmzfeehvmotwm&ust=15 09440373578760
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)
Bed positioning Objectives Ventilation perfusion Correct alignment of posture Prevent pressure sore and contracture Inhibit onset of spasticity
Bed positioning Supine position Foot drop and hip Ext. rotation
Bed positioning Side-lying position
Bed mobilities Full support Keep normal alignment Log rolling http://accessphysiotherapy.mhmedical.com/content.aspx?bookid=1472§ionid=8619876 0
Ambulation Up to doctor allow Orthosis Slow upright due to postural hypotension Abdominal bandage, elastic bandage, stocking
Questions?