CNS class 3 (SCI, stroke, transfer techniques)

Question 1

SCI define

Answer 1

“Occurs from a direct injury to the spinal cord or indirectly from damage to the surrounding bones, tissues, or blood vessels. These events cause paralysis or a complete or total loss of the ability to move or feel sensation in part or most of the body. “
Salvo, Susan; Mosby’s pathology 5th edition

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Question 2

SCI classification

Answer 2

direct vs indirect

primary vs secndary

complete vs incomplete

Question 3

direct vs indirect SCI

Answer 3

Direct: direct trauma on the spinal cord

Indirect: damage to tissues and bones surrounding the spinal cord

Question 4

primary vs secondary SCI

Answer 4

Primary: immediate damage caused directly from trauma

Secondary: delayed damaged caused by complications after the injury

Question 5

complete vs incomplete sci

Answer 5

Complete: full lesion of spinal cord → total motor and sensory loss below lesion

Incomplete: partial lesion of spinal cord → partial loss of sensory and motor function

Question 6

sci etiology

Answer 6

trauma vs non-trauma

Question 7

trauma sci

Answer 7

Trauma: more common than non traumatic (can be direct & indirect)

Motor vehicle accidents: most common (41% in Canada) - 97% of times, patients did not wear a seatbelt

Diving: often leads to quadriplegia

Contact sports: American football & rugby (6% in Canada, 17% UK)

Violent trauma: gunshot/stab wounds (incidence increasing)

Question 8

non trauma sci

Answer 8

Spinal hematoma, infection, radiation, neoplasm

Vascular complication: cardiac arrest, aortic aneurysm, surgery

Question 9

spinal cord injuries (incomplete)

Answer 9

central cord syndrome

Brown-Sequard syndrome

Anteiror cord syndrome

Question 10

central cord syndrome

Answer 10

What: Damage to centre with periphery unaffected

Most common incomplete injury

Cause: Hyperextension or arthritic changes to c-spine

Question 11

central cord syndrome SSx

Answer 11

Upper limbs: motor and sensory abilities affected, mm weakness, flaccidity

Lower limbs: less affected

Bowel and bladder control normal or partially affected

Question 12

Brown-Sequard syndrome

Answer 12

What: Damage to one side of the spinal cord

Cause: stabbing/gunshot wound

Question 13

Brown-Sequard Syndrome SSx

Answer 13

Ipsilateral impairment: motor function, proprioception, sensation (vibration, 2-point discrimination).

NORMAL: pain and temperature perception

____

Contralateral impairment: loss of pain and temperature perception.

NORMAL: motor function

Question 14

Anterior cord syndrome

Answer 14

What: damage to anterior spinal artery/anterior spinal cord (corticospinal & spinothalamic tract injury)

Cause: Hyperflexion injury

Question 15

anterior cord syndrome SSx

Answer 15

bilateral loss of motor function, perception (pain, temperature, crude touch)

Question 16

vulnerable regions of spine

Answer 16

Most vulnerable part of the spine is C4-C6, where the spinal canal loses stability in favor of mobility.

T12-L1 also commonly injured.

Question 17

mm function vs level/severity of SCI

Answer 17

C1-C3- No function maintained from the neck down. Need ventilator to breathe

C4-C5- Diaphragm, which allows breathing

C6-C7- Some arm and chest muscles (feeding, dressing, propelling wheelchair)

T1-T3- Intact arm function

T4-T9- Control of trunk above the umbilicus

T10-L1- Most thigh muscles, allows walking with long leg braces

L1-L2- Most leg muscles, allows walking with short leg braces

Question 18

-plegia etymology & types

Answer 18

plegia = strike

.. types in following cards

Question 19

monoplegia

Answer 19

Monoplegia- paralysis of one limb

Question 20

diplegia

Answer 20

Diplegia- paralysis of both upper OR lower limbs

Question 21

paraplegia

Answer 21

Paraplegia- paralysis of both lower limbs

Question 22

paraparesis

Answer 22

Paraparesis- muscle weakness in legs

paresis = from paralysis

Question 23

hemiplegia

Answer 23

Hemiplegia- paralysis upper limb, trunk and lower limb unilaterally

Question 24

quadriplegia

Answer 24

Quadriplegia- paralysis of all four limbs

Question 25

quadriparesis

Answer 25

Quadriparesis- muscle weakness in all limbs

Question 26

autonomic dysreflexia

Answer 26

What is is? an acute exaggerated sympathetic response. People at risk generally are those with a lesion at or above T6 How? by a painful or uncomfortable stimulus in the abdomen or pelvic area eg: distention of a full bladder ... ---> muscles spasms, an extensive stretch placed on the muscle ---> a kink in the catheter bag ---> the presence of infection such as decubitus ulcers

Question 27

what happens during AD

Answer 27

stimulus sends nerve impulses to the spinal cord - they travel upward until they are blocked by the lesion at the level of injury the impulses cannot reach the brain, a reflex is activated that increases activity of the sympathetic portion of ANS. This results in spasms and a narrowing of the blood vessels, which causes a rise in the blood pressure.

Question 28

AD SSx

Answer 28

severe hypertension (300/160), bradycardia sudden pounding headache Vasospasms, piloerector response and skin pallor occur Flushed skin and sweating

Question 29

AD -- what to do?

Answer 29

It is considered a medical emergency and is potentially life threatening call for paramedic services

Question 30

MASSAGE & SCI

Answer 30

Most clients are wheelchair-bound, adapt massage to clients need and abilities Clients are generally inactive so have a larger risk to bone density and blood clots in the legs. Avoid deep pressure over bones and Forceful PROM because of risk of fractures Avoid vigorous massage techniques because of risk for clots ---> ALSO B/C DEEP TECHNIQUE IS CI'ed ON ATROPHIED MM Assess contractures Assess for potential decubitus ulcers

Question 31

stroke happens when

Answer 31

when blood flow to the brain is blocked or there is sudden bleeding in the brain

Question 32

hemiplegia

Answer 32

a non-progressive condition of paralysis on one side of the body

Question 33

stroke, result

Answer 33

insult/injury/event The range of consequences is very wide; it may cause death; it may leave a permanent state of dysfunction, it may be partially recovered from, it may be fully recovered from

Question 34

hemiplegia -- sometimes via

Answer 34

It sometimes results from a stroke It may be caused by many things: genetics, stroke, spinal cord injury, other brain injury…

Question 35

side of paralysis vs side of brain lesion

Answer 35

Paralysis occurs on the opposite side of the brain lesion

Question 36

severity of effects (stroke) duration/severity

Answer 36

Effects depend on the location and how severe the damage to the brain They can be temporary or permanent, almost imperceptible to severely disabling with profound spasticity and extreme sensory or perceptual loss

Question 37

(FYI) LEFT brain damage result

Answer 37

right side paralysis speech and memory deficits cautious and slow behaviour

Question 38

(FYI) RIGHT brain damage result

Answer 38

left side paralysis perceptual and memory deficits quick and impulsive behaviour

Question 39

hemiplegia SSx post-stroke

Answer 39

Immediately post stroke: muscles on the affected side will be weak or flaccid - acute phase gradually, flaccid paralysis leads to spastic paralysis (some flaccidity can remain) ---> lesions interfere with the brain's control over spinal cord activity = uninhibited alpha motor neuron firing

Question 40

flexor vs extensor pattern of paralysis most common pattern UE? most common pattern LE?

Answer 40

This type of paralysis can become a flexor or extensor pattern based on the uninhibited dominant reflexes ---> Most common pattern: flexor pattern in upper limbs combined with extensor pattern in the lower limb

Question 41

other SSx hemiplegia

Answer 41

Altered posture due to spasticity Altered gait - circumducted Hemiplegic shoulder - GH ADd, IR, scapular retraction Seizures, edema, pain, compensatory changes Sensory deficit Shoulder-hand syndrome - decreased ROM of GH & hand, followed with throbbing pain & edema Neglect of affected side Behavioral & emotional changes Visual impairment, speech difficulties Cognitive impairment

Question 42

more observations/clinical manifestations/SSx (hemiplegia)

Answer 42

Spasticity pattern on the affected side Circumducted gait, balance and weight shifting may be impaired Ambulatory aids - canes, walkers Muscle bulk differences between affected and unaffected sides Functional abilities will vary depending on severity of stroke and spasticity or flaccidity Postural asymmetries Neglect of the affected side

Question 43

stroke occurs when

Answer 43

A stroke occurs when blood supply to any part of the brain is interrupted, leading to the impairment of brain cells. The level of impairment depends on the location and degree of damage done.

Question 44

3 main types of strokes:

Answer 44

ischemic stroke hemorrhagic stroke transient ischemic attack (TIA)

Question 45

TIA lasts how long?

Answer 45

less than 24 hours "A transient ischemic attack, commonly known as a mini-stroke, is a temporary stroke with noticeable symptoms that end within 24 hours." "Transient ischemic attacks usually last a few minutes. Most symptoms disappear within an hour. Rarely, symptoms may last up to 24 hours."

Question 46

rare causes of stroke

Answer 46

In rare cases, an underlying condition such as a tumor, an infection, or brain swelling due to an injury or illness can cause a stroke.

Question 47

stroke risk factors (within control)

Answer 47

Unhealthy weight - hypertension (high BP) high cholesterol, diabetes, heart disease Physical inactivity Excessive alcohol & drug abuse Smoking Stress Birth control/ hormones replacement therapy (HRT)

Question 48

stroke risk factors

Answer 48

Gender Age Family history Ethnicity History of stroke or TIA

Question 49

main modifiable risk factors (stroke)

Answer 49

Blood pressure (hypertension is associated with hemorrhagic strokes) Atherosclerosis (atherosclerosis is associated with ischemic strokes)

Question 50

stroke FAST signs

Answer 50

Face – facial numbness or weakness, especially on one side Arm – arm numbness or weakness, especially on one side Speech – slurred speech or difficulty speaking or understanding Time – time is important; call EMS/9-1-1 immediately

Question 51

warning signs (stroke)

Answer 51

Sudden numbness or weakness in the face, arm or leg (especially on one side of the body). Sudden confusion or trouble speaking or understanding speech. Sudden vision problems in one or both eyes. Sudden difficulty walking or dizziness, or problems with balance & coordination. Severe headache with no known cause.

Question 52

Brunnstrom stages of recovery (stroke)

Answer 52

1. Flaccidity (immediately after the onset) No "voluntary" movements on the affected side can be initiated 2. Spasticity appears Basic synergy patterns appear Minimal voluntary movements may be present 3. Patient gains voluntary control over synergies Increase in spasticity 4. Some movement patterns out of synergy are mastered (synergy patterns still predominate) Decrease in spasticity 5. If progress continues, more complex movement combinations are learned as the basic synergies lose their dominance over motor acts Further decrease in spasticity 6. Disappearance of spasticity Individual joint movements become possible and coordination approaches normal 7. Normal function is restored

Question 53

Stage 1 - Flaccidity

Answer 53

PROM Passive stretching (gentle) Position to support upper limb, especially shoulder (subluxations common in this stage)

Question 54

Stage 2 – Spasticity develops and abnormal synergies may be present

Answer 54

Continue with PROM (very slow, gentle to not provoke spasticity) Massage for sensory stimulation

Question 55

Stage 3 – Spasticity increases

Answer 55

Continue with above techniques Increased emphasis on stress reduction Massage to relax spastic/synergistic areas May be using splints

Question 56

Stage 4 – Spasticity decreases

Answer 56

Continue with above techniques Added emphasis on using the recovering arm as much as possible with home care and ADLs PNF patterning (PROM, AROM)

Question 57

Stage 5 – Spasticity continues to decrease (minimal)

Answer 57

Continue with above Begin strengthening routine (as opposed to ROM-based exercises) PNF patterning (RROM)

Question 58

Stage 6 – Spasticity disappears and coordination reappears

Answer 58

Continue with above and focus on fine motor skills (e.g. hand and finger exercises)

Question 59

stroke hx q sample

Answer 59

goals energy levels ADLs? P? where? hm? when? rehab presentation? sensory? motor? when? stress/mental health meds

Question 60

stroke ax sample

Answer 60

palpation MMT ROM (goniometer) postural

Question 61

stroke goals sample

Answer 61

decrease SNS ---> inh ROOD, DB, heat, slow GSM decrease spasticity ---> GTO, inh ROOD increase strength of weak mm (E.g. extensors) ---> neural tapping, stim ROOD, isometric/RROM maintain jt health JM, PROM, circumduction increase ROM slow stretch, PROM

Question 62

Synergy

Answer 62

A whole series of muscles are recruited when just a few are needed. For example, when trying to reach forward, the shoulder abducts and elevates, and the wrist flexes

Question 63

synergy patterns (stroke)

Answer 63

5 patterns 1 (AKA Flexor synergy (spastic?) pattern) = IR, add (GH) = flexion (HU) = supination (RU) = flexion (RC) 2 = same as 1, except wrist = extension 3 = same as 1, except forearm/wrist are neutral 4 = same as 1, except forearm = pronation 5 (AKA extensor synergy (spastic?) pattern) = IR, retroversion (GH) = extension (HU) = pronation (RU) = flexion (RC) ---> Looks like waiter's tip

Question 64

E.g. Ax

Answer 64

Palpation / postural ROM Sensory testing

Question 65

E.g. goal

Answer 65

Promote relaxation Decrease pain Addressing postural changes/ muscle imbalances Decrease edema Decrease spasticity Maintain joint health Full body integration

Question 66

Tx/goals rationale

Answer 66

Relaxation and stress management because stress makes spasticity worse PROM and stretching are important to prevent neglect of the affected limb, to maintain sensory mapping of the area, and to prevent contracture formation Trying to lower the tone of spastic or overused muscles is important to decrease contracture formation Decreasing edema is important for tissue health Trying to stimulate muscles outside of synergy or opposite to spasticity PROM and joint play to maintain joint health Full body integration for overall wellbeing