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S6- Neuro 2 > Week 4- SCI Treatment Considerations Pt 1 > Flashcards

Week 4- SCI Treatment Considerations Pt 1 Flashcards

1
Q

PART 1: INTRO, SKIN INTEGRITY

A

PART 1: INTRO, SKIN INTEGRITY

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2
Q
  • ASIA ______ = Compensation
  • ASIA ______ = Compensation and Restoration
  • ASIA ______ = Restoration
A
  • ASIA A and B = Compensation
  • ASIA C = Compensation and Restoration
  • ASIA D = Restoration
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3
Q

Goals of SCI Rehabilitation.

A

Functional Mobility

  • Bed Mobility
  • Transfers
  • WC Mobility
  • Ambulation
  • WC Trials
  • Equipment Requisition
  • Sitting Balance Training
  • Skin Management
  • Strengthening
  • Aerobic Training
  • Respiratory
  • Home Modifications
  • Community Reintegration
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4
Q

Goals For All Levels of SCI Injury:

  • Upright tolerance: ___-___ hours/day
  • Utilize appropriate seating position and/or mobility devices to support posture and maximize function
  • Maintain _____ integrity
  • ___________ for all direction of care as needed
  • Caregiver becomes independent with all aspects of care as needed
  • Maintain healthy habits, minimize body habitus
  • MAXIMIZE _____________
A
  • 10-12 hours
  • skin integrity
  • Independent
  • MAXIMIZE INDEPENDENCE
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5
Q

Skin Integrity After SCI:

  • Wheelchair Pressure Relief __-__ minutes every ___-___ minutes. (Pushup method only needs to be held 30-90s)
  • Bed rolling schedule every ___ hours.
  • _____ check daily, may need adaptive equipment.
A
  • 2-4 minutes every 15-20 minutes
  • 2 hours
  • Skin checks
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6
Q

What are the 2 main reasons SCI patients are at high risk for skin breakdown?

A
  • Less mobile on WC all day.

- Likely lost majority of sensory that lets us know when we’ve been sitting so long.

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7
Q

What are 4 ways a patient can relieve pressure from sitting too long in WC?

A
  • Side bending
  • Knee crossover and pull
  • Flexion to toes
  • Push up method (not recommended)
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8
Q

What is the difference with pressure relief with powerchair users?

A

-It is easier because the chair does all the work for them.

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9
Q

PART 2: RESPIRATORY CONSIDERATIONS

A

PART 2: RESPIRATORY CONSIDERATIONS

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10
Q

What is the number 1 cause of death after a SCI?

A

-Pneumonia

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11
Q

What things do we examine in regards to our respiratory function? (5)

A
  • RR, breathing pattern, chest excursion
  • Cough
  • Posture
  • Breath support w/ speech
  • May need Pulmonary Function Testing
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12
Q

An effective _______ is crucial for a patients ability to clear secretions.

A

cough

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13
Q

Functional Cough:

  • Sound?
  • Number of coughs per exhalation?
  • Functional significance?
A
  • Sound = loud and forceful
  • Number of coughs per exhalation = 2 or more
  • Functional significance = Independent in respiratory secretion clearance.
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14
Q

Weak Functional Cough:

  • Sound?
  • Number of coughs per exhalation?
  • Functional significance?
A
  • Sound = soft, less forceful
  • Number of coughs per exhalation = 1 per exhalation
  • Functional significance = Independent for clearing throat and small amount of secretions. Assistance needed for clearing large amount of secretions.
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15
Q

Nonfunctional Cough:

  • Sound?
  • Number of coughs per exhalation?
  • Functional significance?
A
  • Sound = sigh or throat clearing
  • Number of coughs per exhalation = no true cough; attempt
  • Functional significance = Assistance needed for airway clearance.
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16
Q

Why is a posture examination in their WC important?

A

-To make sure components being added to chair are not impeding but rather promoting activity of respiratory muscles.

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17
Q

What is a way to measure breath support with speech?

A

-Inhale and have them count out load to see how loud/strongly they can speak.

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18
Q

What are the main ways to increase respiratory strength and endurance? (3)

A
  • Diaphragmatic Breathing
  • Upper Chest Strengthening
  • Respiratory Inspiratory Muscle Trainers
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19
Q

Diaphragmatic Breathing:

  • Ideal for _______ breathing.
  • “______ breathing”
  • How can we help a patient with this when in supine?
  • Instructing the patient to sniff can encourage diaphragmatic breathing.
A
  • quiet breathing
  • “belly breathing
  • Place a large, light object (ex: box of tissues) on abdomen and instruct patient to watch themselves breathe. (Progression = active resistance on abdomen)
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20
Q

Upper Chest Strengthening:

  • ↑ inspired air to enhance coughing, improve breath support for speech, or during ↑’d activity.
  • How can we help a patient with this?
  • Quick stretch to ______, _________, and _________ by pushing the upper chest in and caudally just before asking patient to inhale.
A
  • Therapist places hands on upper chest and ask patient to push against them while breathing deeply.
  • SMC, Pec major, and Scalenes
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21
Q

Respiratory Inspiratory Muscle Trainers:

  • Useful alternative to diaphragmatic breathing and upper chest strengthening.
  • Shown to improve strength & endurance in muscles of ventilation, improved PFT results, encourages slower and deeper breathing, reduces use of __________ muscles, and increases activity tolerance.
A

-accessory

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22
Q

Other Respiratory Interventions. (8)

A
  • Eccentric Control of Exhalation
  • Chest Wall Mobility
  • Posture Considerations
  • Glossopharyngeal Breathing (tetra)
  • Abdominal Binders (tetra)
  • Assisted Cough Techniques
  • Self Cough Techniques
  • Vent Weaning (tetra)
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23
Q
  • ________ control of exhalation is required for normal speech production.
  • How do we instruct a patient to perform this?
  • Goal = __-__ seconds before inhalation
  • Can further promote by adding _____________ or __________.
A
  • Eccentric
  • Patient inhales maximally and then counts or says, “ah” or “oh” for as long as possible before taking another breath.
  • 10-12 seconds
  • manual vibration or resistance
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24
Q
  • Very often we see chest wall _________ problems due to pain and other injuries from accidents.
  • What are some things we can do to increase this?
A
  • mobility

- Deep breathing exercises, passive stretching, joint mobilizations, intermittent positive-pressure breathing.

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25
Q

Anterior pelvic tilt, erect trunk, adducted scapulae, and neutral head and back alignment are all _________ considerations for enhanced respiration.

A

-postural

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26
Q

____________ breathing involves the use of the tongue and pharyngeal muscles to help with respiration. Involves forcing air in the lungs through a series of “_____”.
-Can also help with what?

A
  • Glossopharyngeal (tetra), “gulps”

- chest wall mobility

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27
Q
  • ________________ can also be used with higher paraplegic injuries to contain abdominal contents in sitting and better position diaphragm.
  • Why?
A
  • Abdominal binders (tetra)
  • Patients with paralysis of abdominal muscles are higher paras or tetras and can see a difference in ability to breathe in lying down vs sitting up due to mechanical shift of contents in abdomen.
28
Q
  • _________ cough techniques are crucial in preventing complications like pneumina.
  • When is it used?
  • What is the technique?
A
  • Assisted Cough Techniques
  • When patient does not have a normal functional cough.
  • 2 coughs per 1 breath while pressing into patients abdomen.
29
Q

List the steps to performing a self-cough technique.

A
  • Breathe in as deeply as possible. (If possible, combine with trunk and neck extension as well as shoulder flexion or scapular adduction.
  • Hold breathe deeply.
  • Cough. (If possible, combine forced exhalation with trunk and neck flexion as well as shoulder extension or scapular abduction. (If patient can control it they can even fall into a folded position))

If adequate UE strength and balance, can self-apply Heimlich-like maneuver to stomach

30
Q

Vent Weaning (Tetra):

  • ___ or lower can usually regain capacity to breathe independently. What are some factors that will reduce this potential?
  • Even if unable to complete wean from vent, can still make goal towards developing capacity to breathe independently for brief periods of time. What can this assist with?
  • Gradual reduction of patients dependence on ventilator. (Progressive Ventilator Free Breathing)
A
  • C3 or lower. Respiratory or other medical complications, pre-existing respiratory conditions, >50 years old, VC<1000, max negative inspiratory pressure <30cm H2O, hx of smoking.
  • Reduces safety concerns from electronic failure and can help with ease of transfers, bathing, or trach care.
31
Q

PART 3: ROM

A

PART 3: ROM

32
Q

Why is it common to see ROM impairments and soft tissue contractures? (2)

A
  • UMN Injury, lose descending drive from cortex because it cant get past spinal cord injury to muscles to modulate tone.
  • From injury itself we will see mismatch in working muscles vs non-working muscles. (Ex; C5 tetras will have biceps but no triceps)
33
Q

What are some prevention strategies to maintain ROM?

A
  • Daily ROM exercises, proper positioning, WB activities
  • Adequate spasticity management
  • Splinting
34
Q

_______ cast is used for legs to make it removable when we want to perform functional activities.

A

-Bivalve casts

35
Q

What are (3) ways we will manage contractures if our main conservative measures do not work?

A
  • Serial Casting
  • Medication
  • Surgical Interventions
36
Q
  • What is serial casting?
  • What is the worst thing about serial casting?
  • It can be used for both _________ and ____________ of contractures.
  • With patients with spasticity (without clonus), this can help prevent what would otherwise be an inevitable contracture formation.
A
  • Bring shortened muscle into stretch and cast it. Maintained for few days to a week. Gradually increase ROM.
  • Can interfere with functional mobility.
  • treatment and prevention
37
Q
  • What are the two main medications used in the management of contractures?
  • Which can be used in conjunction with serial casting?
A
  • Baclofen and Botox Injections

- Botox Injections

38
Q

What surgical interventions may be used to manage contractures? (3)

A
  • Joint manipulation under anesthesia
  • Arthroscopic vs open release
  • Rotational osteotomy (physically move things around in joint, commonly done at femur)
39
Q

Particular Considerations:

  • With weakened or paralyzed elbow extensors, shortening of elbow _______ is a common problem.
  • __________ and other scapular muscles should be monitored closely for contractures. (decreased muscle length significantly impacts force production)
  • Patients with incomplete tetraplegia or complete/incomplete paraplegia who are walking candidates require _______ ROM throughout the entire LEs. What are some common troublemakers here?
A
  • flexors
  • Rotator cuff
  • normal ROM, common trouble makers are hip flexors, hamstrings, and DFs
40
Q

Adaptive Shortening:

  • What is adaptive shortening?
  • With intact innervation of ___ = wrist extension preserved. This means we can use the wrist to achieve _______ which can help with what task?
  • Patients with __ or __ SCIs must avoid overstretching their finger flexors during activities and functional tasks to maintain tenodesis capabilities.
A
  • With specific levels of SCI, allowing adaptive shortening of particular muscles is recommended to enhance the achievement of certain functional skills.
  • C6, Tenodesis which can allow passive shortening of finger flexors to help with grasping activities.
  • C6 or C7
41
Q

Adaptive Lengthening:

  • Combination of lengthened ________ + adaptive shortening of ____________ can provide stability in short- and long-sitting positions.
  • Need to maintain ____-____ SLR without overstretching back muscles.
A
  • lengthened hamstring + shortened back extensors

- 110-120 degrees SLR

42
Q

PART 4: STRENGTHENING

A

PART 4: STRENGTHENING

43
Q

UE and LE Strengthening:

  • Should we target key muscles with MMT testing?
  • Monitor patients closely for _______ response when initiating new strengthening activities. (Blunted responses with autonomic dysfunction)
  • Combination of _____-_____ exercises as well as ______ movements.
  • Are closed-chain or open-chain more beneficial?
A
  • No, further MMT should be completed for all intact spinal nerve roots.
  • hemodynamic
  • multi-joint as well as isolated movements
  • Both open and closed chain are beneficial (If MMT ≥3/5, try to find positions/techniques to prioritize closed-chain, functional based activities.)
44
Q

Injury prevention is key, what is a common site of MSK breakdown with these patients?

A
  • Shoulder common site and are extremely important to functional independence!
  • STOMPS Trial (2011)
45
Q

UE Restoration and Maintenance:

  • UEs become primary mode of locomotion, this means increased load, especially on the shoulder joints. It is the number 1 site for orthopedic pain and injury following SCI.
  • We should focus on strengthening what key muscles to prevent injury to UE? (5)
  • Also focus on teaching strategies to _______ UE use.
  • Big focus on shoulder ergonomics: WC MOBILITY
A
  • Serratus anterior, Lats, Pec major, Rotator cuff, Tricep

- minimize

46
Q

Why is core strengthening important?

A

-Important for balance, stability during functional movement, and respiratory function.

47
Q

What are some helpful equipment used to help strengthening with SCI? (6)

A
  • Powder board
  • Skates
  • Air splints
  • Inclined board
  • Mobile arm support
  • Thera-Band
48
Q

Supine Benefits:

  • ______-_______ position for many UE/LE muscles.
  • Easy to facilitate _____ ______.

Supine Considerations:
-Can be compromising position for _________ muscles. May need to consider propping on wedge or pillows to improve _________ function during exercises.

A
  • Gravity-eliminated
  • rest breaks
  • respiratory
  • respiratory
49
Q

Side Lying Benefits:

  • ______-_______ position for many UE/LE muscles.
  • Can be more comfortable than supine if vertebral _________ present.

Side Lying Considerations:

  • Need to be aware of not over-_______ trunk which can compromise respiration.
  • Difficult to incorporate LE _______-_____ exercises.
  • More so able to implement some functional-based tasks.
A
  • Gravity-eliminated
  • fractures
  • over-flexing
  • closed-chain
50
Q

Prone Benefits:

  • Great way to extend back, hip flexors, even knee flexors.
  • Allows for full pressure relief of _______.
  • Can progress position in variety of ways (prone on elbows, prone with elbows extended).
  • Can allow for neck _________ strengthening.

Prone Considerations:

  • Be cognizant of _____ ROM - need to be able to move freely to allow for comfort and breathing.
  • If neck ROM limitations - may consider use of towel rolls to prop chest and head.
  • Primarily a position used to target ___s when considering strengthening interventions.
A
  • buttocks
  • extension
  • neck ROM
  • UEs
51
Q

Quadruped Benefits:

  • Great functional position, closed-chain UE/LE.
  • Challenges ________ muscle.
  • Incorporates _______ muscles and _______stabilizers.
  • Can allow for neck _________ strengthening.

Quadruped Considerations:

  • Challenging position - but variety of ways therapist can assist and facilitate to allow even patients with tetraplegia to achieve this position!
  • Consider use of equipment to help maintain position.
A
  • proximal
  • trunk muscles and pelvic stabilizers
  • neck extension
52
Q

High Kneeling Benefits:

  • If intact, great position for glutes, pelvic muscles, low back stabilizers.
  • If higher level, targets intact ______ muscles and can incorporate balance strategies.

High Kneeling Considerations:
-Be careful of leg position, be sure pelvis, hips are neutral to avoid inappropriate load through hip/knee joints.

A

-trunk

53
Q

Sitting Benefits:

  • _____ stabilization.
  • _______-chain UE exercises.

Sitting Considerations:
-Great position to incorporate ____-____ balance activity while strengthening targeted muscles.

A
  • core stabilization
  • closed-chain

-dual-task

54
Q

(Assisted) Sitting:

  • Great functional position, closed-chain UE/LE.
  • Challenges _________ muscles.
  • Incorporates trunk muscles and pelvic stabilizers.
  • Can allow for neck extension strengthening.

(Assisted) Standing:

  • Challenging position - but variety of ways therapist can assist and facilitate to allow even patients with tetraplegia to achieve this position.
  • -Consider use of equipment to help maintain position.
A

-proximal

55
Q

Upright Tolerance:

  • _____ is a VERY COMMON problem in acute stages.
  • What are the S/Sx of this?
A
  • Orthostatic Hypotension
  • hypotension + tachycardia, dizziness, pale skin, sweating, slurred speech, fogginess, blurred vision, nausea and/or vomiting
56
Q

What are some strategies to manage and progress upright tolerance?

A
  • Slow transitions
  • Compression garments (abdominal binders, TED stockings, ACE wraps)
  • Equipment (tilt’n space w/c, tilt table, ERIGO, active standing frame)
57
Q

Regardless of level on injury or prognosis, incorporating standing into your POC has a multitude of benefits. List some. (8)

A
  • Socialization
  • Mood
  • Respiratory and Cardiovascular function
  • Aids in digestion
  • Bone health
  • ROM maintenance
  • Strengthening
  • Skin integrity
58
Q

Assisted Standing Considerations:

  • Monitor _______ closely during each session.
  • Incorporate _______ or ____ strengthening into session as tolerated.
  • Incorporate _______ or small range LE strengthening as able and as device allows.
  • Consider use of _____ while in standing.

-Goals are typically __________-based (“Pt can tolerate 10 minutes of assisted standing frame with stable hemodynamics and minimal report of fatigue”) but can incorporate strengthening goals as well!

A
  • vitals
  • trunk or UE strengthening
  • isometric
  • FES

-tolerance-based

59
Q

PART 5: BALANCE

A

PART 5: BALANCE

60
Q

What 3 things are we focusing on in regards to balance with tetraplegic injuries?

A
  • Achieving Balance
  • Maintaining Balance
  • Reaction to LOB
61
Q

Tetra UE Prop Positions for Sitting Balance:

  • What are the (3) primary positions for UE support when in short or long sitting from easiest to hardest?
  • What are some important ROM to achieve these positions?
  • This is often a part of ____-______ for patients with mid-low level tetraplegic.
A
  • Posterior Prop, Lateral Prop, Anterior Prop
  • Shoulder extension, abduction, and ER
  • goal-setting
62
Q
  • _______ are an important muscle when relying on closed-chain BUE support in sitting.
  • What is a compensation for weakness of this muscle?
A
  • Triceps
  • If triceps are impaired (C6 injury), can still achieve closed-chain UE support if anterior deltoid and shoulder ER are functional.
63
Q

C6/C7 needed to maintain finger flexion whenever WBing through UEs during sitting balance task, why?

A

-To protect tenodesis grasp.

64
Q

Reactionary Techniques (Tetra Static Sitting):

Normal:

  • Small perturbations = ______, _____/____ muscles
  • Large perturbations = reaching reaction with UEs

With Loss of trunk and variable UE strength:

  • Small perturbations = _____/_____, upper ______ and upper ______ muscles
  • Large perturbations = difficult to be successful

What is the “sweet spot”?

A
  • trunk, pelvic/hip
  • head/neck, upper shoulder and upper trunk
  • Sweep Spot = Every patient has a “sweet spot” that their COM lands perfectly over their BOS and they can briefly hold balance without UE support despite inadequate trunk strength.
65
Q

Dynamic Balance Considerations for Paraplegic Injuries:

  • _______ Balance + ______ Control + _____ and _____ Strengthening.
  • Focus on quickening _________ strategies.
  • Higher paraplegia may benefit from head/neck reactionary techniques for smaller LOBs.
A
  • Dynamic Balance + Trunk Control + UE and Core Strengthening.
  • reactionary
66
Q

__________ positions are key positions to promote strength, balance, and functional independence.

A

-Therapeutic Positions

67
Q

What are the (4) main therapeutic positions?

A
  • Long Sit
  • Short Sit
  • Ring Sit
  • Prone

S6- Neuro 2 (18 decks)

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