Expected Functional Outcomes-Tetraplegia Flashcards
(65 cards)
1
Q
Expected functional outcomes determined by…
A
Level and completeness of injury (consider zones of partial preservation)
- Impacted by additional factors:
- Patient goals
- Previous level of function
- Age
- Comorbidities
- Body type
- Support system
- Complications
2
Q
Conversion of AIS A to B or C
A
20-30%
Tetra > para
Penetrating < burst fx
3
Q
Conversion of AIS B to C
A
50-65%
Tetra > para
4
Q
Conversion of AIS score
A
- Majority occurs in the first 3 months
- ZPP of > 3 levels have increased likelihood of conversion
AIS exam performed > 72 hours, less likelihood of converting form complete to incomplete - Does not necessarily equate to walking outcomes
- By 2 years, little chance of paralyzed muscles working again
- Muscle return in first several weeks -> better chances for walking recovery
5
Q
Motor recovery in cervical SCI
A
Complete: 70% of injuries recover 1 level of motor function below the original level of lesion
Incomplete: good prognostic indicator of motor recovery
6
Q
Motor function at C1-C4
A
- Muscles supplied by cranial nerve are innervated
- Diaphragm (C3-C5)
- C4: trapezius, lev scap, partial rhomboid
Movements possible: - head turning
- mastication
- talking
- sipping/blowing
- scapular elevation
7
Q
A
8
Q
C1-C4 dependent for…
A
- Mobility
- Most ADLs (except those that can be controlled via environmental controls)
- Bowel/bladder management
- Requires FULL TIME CAREGIVER
- May require a ventilator (full time vs. part time)
C4: 80% wean off
C3: 60% wean off after 4 weeks - Unable to drive or ambulate
9
Q
Expected functional outcome goals for C1-C4
A
- Power wheelchair independently using devices such as sip and puff, head, tongue or chin controls
- independent weight shifts in power chair-tilt, recline
- direct the care provided for them
- activate the environment using environmental control unit (computer, light switches, voice activation -> brain computer interface)
10
Q
Equipment required for C1-C4 SCI
A
- adjustable bed with pressure relieving mattress
- ventilator (1&3) portable
- power wheelchair; tilt and recline option, pressure relief cushion
- mechanical lift for transfers
- shower chair
- wheelchair accessible home
- accessible van
- environmental control units
11
Q
Overview of interventions for C1-C4 SCI
A
- Respiratory care
- Upright tolerance
- FES cycling (aerobic conditioning)
- Wheelchair skills
- Verbally instructing others on care and stretching
- Patient education
12
Q
Respiratory interventions
A
- Ventilator management: speaking valve on vent/trach, emergency response training
- Trunk stretching: contraindicated in acute phase -> possible unstable fx site
- Muscle training: improve strength, vital capacity, maximal inspiratory/expiratory pressure/residual volume
- Inspiratory muscle training: incentive spirometry, resistance to epigastric area
- Expiratory muscle training: breath through device that minimizes airflow/increases resistance
13
Q
Risk of developing pneumonia
A
85% chance
And/or atelectasis within 1st month of injury
- Negative impact on respiration (gas exchange)
14
Q
Respiration intervention techniques
A
- Assisted cough
- Glossopharyngeal breathing: gulps used for emergency situations
- Diaphragmatic breathing
- Abdominal binder; increases intraabdominal pressure, diaphragm in better position
15
Q
Benefits of upright positioning
A
- Decrease risk of secondary complications:
- improve ROM
- Improve GI motility
- Cardiovascular benefits
- improve circulation
- chest expansion
- pressure relief
- psychological well-being
- delay onset of attenuate effects of osteoporosis
16
Q
Upright tolerance
A
- Upright sitting first
- Tilt table initially -> standing frame
- Use of abdominal binder, compression stockings, ace wraps, BP medication
- Monitor vitals: orthostasis defined as fall in systolic >20 or diastolic >10 for 3 min
- 5-10 degrees at a time
- Beware initial BP can now be normal at 90/60 -> not set cut-off, monitor symptoms, consider cognitive decline
17
Q
Aerobic conditioning with FES cycling: UE & LE
A
- can be used as a form of aerobic conditioning in higher level cervical spinal injuries
- beware of post exercise hypotension
- effective at improving CV conditioning
Parameters: 3-5 days/week, 20-60 min, 50-80% peak HR, RPE 13-17
18
Q
Wheelchair skills
A
- independent in power wheelchair; ramps, small curbs, home and community
- home modification to accommodate use of power chair
- if pt has to use a power chair it limits their community access; require use of accessible van, use of ramps for restaurants and more
19
Q
Verbally instructing others on care C1-C4
A
- independent with verbally instructing others (stretching program of all major muscle groups)
Considerations: shoulder flexion/abduction <90 degrees if unstable fx site (acute phase)
Care plan involves: mechanical lift, assisted cough, transfers/bed mobility, w/c management into and out of van
20
Q
Patient education for C1-C4
A
- Pressure relief
- Autonomic dysreflexia
- Concern for hypotension
- Initiate stretching program
- Postural alignment in w/c management into
- Power wheelchair skills
21
Q
Muscles innervated at C5 LOI
A
- biceps
- brachialis
- brachioradialis
- deltoid
- Supra/infraspinatus
- rhomboids
- some supination
- shoulder external rotation, abduction and elbow flexion *
22
Q
Expected outcomes for C5 SCI
A
Mobility:
- dependent transfers with mechanical lift (some can transfer with transfer board and assist)
- dependent or with significant assist with bed mobility
- gait unable to
- dependent bowel/bladder
Requires PART TIME CAREGIVER, able to direct
- assistance or set up assistance for ADLs
23
Q
Wheelchair mobility for C5 SCI
A
- independent power chair with joystick/hand support
- independent pressure relief in power
- may be indecent with manual wheelchair on level indoor surfaces with plastic coated rims, rim extensions, power assist, assist with pressure relief
- uses environmental controls
24
Q
Driving and C5 SCI
A
Patient may drive independently with adaptive controls
25
Equipment required for C5 SCI
- power or specialized manual wheelchair
- pressure relief cushion
- accessible van
- adjustable bed with pressure relief mattress; bed rails/loop allows for greater independence
- adaptive equipment for ADLs
26
Interventions for C5 SCI
- assisted cough technique from caregiver
- upright tolerance
- wheel chair skills
- verbally instructing others
- patient education
- aerobic conditioning FES
- strengthening
- stretching
- seated balance with UE support -> transfers
27
Aerobic conditioning for C5 SCI
- swimming, UE ergometer, adaptive rowing, wheelchair propulsion
- surface FES is effective in improving CV conditioning
28
Strengthening for C5 SCI
- pt missing many key antagonist muscles
- resistance may be contraindicated in the acute phase
- focus on shoulder external rotation, RTC, rhomboids, biceps
Muscles to avoid; upper trap, biceps in the chronic phase
- consider closed chain shoulder strengthening (on elbows)
29
ROM for C5 SCI
- elbow flexion contractures common
- shoulder internal rotation/adduction, hip external rotation/flexion contractures
- Focus on:
- shoulder ROM in a pain free range; <90 degrees in acute phase if unstable fx present
- pec/thoracic extension
- elbow extension
- hip extensor/external rotation/adductors
- trunk
30
Muscles innervated at C6 SCI
- extensor carpi radialis
- more SITs mm
- latissimus dorsi
- pec major (clavicular portion)
- pronator teres
- serratus anterior
- teres minor
* Wrist extension, greater shoulder stability *
31
Expected functional outcomes at C6 SCI
- min assist/independent bed mobility
- adaptive equipment; loops, rails
- min assist/independent transfers (transfer board may increase independence)
- May be independent with adaptive equipment but likely needs assist for bladder/bowel
- some assistance/independent ADLs (tenodesis improves ability to grasp)
Eating: adaptive equipment, universal cuff
Upper body dressing: independent w/ equipment
Lower body dressing: requires assist and adaptive equipment
* PART TIME CAREGIVER REQUIRED *
32
Wheelchair and C6 SCI
- independent with manual wheelchair on level surfaces
- requires coated hand rims/extensions, power assist wheels, pressure relief cushion
- Power wheelchair for community
- independent pressure relief (leaning or posterior in power)
33
Driving and C6 injury
With adaptive controls
34
Equipment required for C6 SCI
- specialized wheelchair manual and/or power
- pressure relief mattress ideally, bed rails/loops
- adaptive equipment for ADLs
- van with adaptive controls
35
Interventions for C6 SCI
- upright tolerance - progress to standing frame
- wheelchair skills
- Function e-stim (cycling)
- aerobic conditioning
- patient education
- respiratory care: assisted cough, trunk stretching, incentive spirometry
- functional mobility; transfers, bed mobility, seated balance (short sit, long sit, ring sit)
- strengthening shoulder program
- stretching
36
Lock out mechanism used for C6 pts
- compensatory strategy for no triceps
- shoulder extension
- shoulder external rotation
- supination
- wrist extension
- contract anterior deltoid to extend elbow in closed chain position
- maintain finger flexion in weight-bearing positions
37
Stretching for C6 SCI
- Selective! Do not allow finger flexors to become stretched, intrinsic plus splint, consider taping fingers during early mobility training, shoulder less than 90 deg abduction/flexion until clearance, increase extension
- LE; preserve tightness in low back extensors (improves trunk stability), hamstrings (SLR 100-110) allows for passive pelvic stabilization in sitting, DF for improve seated posture
38
Muscles innervated with C7 SCI
- extensor pollicis longer and brevis
- extrinsic finger extensors
- flexor carpi radialis
- triceps
- fully innervated serratus
* greater scapular stability, elbow extension, wrist flexion, finger extension *
Note: fine motor skills still limited
39
Strengthening for C6 SCI
- 2-4x/week, 2-3 sets x8-12 reps
- push up using scap depressors (lats and low traps) serratus (stabilizer)
- wrist extensors (e-stim)
- SITS and pecs
- consider; A-AROM, gravity minimized positioning, closed chain
40
Expected functional outcomes with C7 SCI
- independent with possible loops/rails for bed mobility
- independent may require assist on uneven surfaces for transfers
- independent for most ADLs with adaptive equipment for shower, feeding, lower body dressing
- WC accessible environment
- assist with difficult household management
- independent bowel/bladder with adaptive equipment
DOES NOT NEED TO RELY ON A PERSONAL ATTENDANT
41
Wheelchair mobility and C7 SCI
- independent with manual wheelchair
- may require assist for grades/ramps/uneven terrain
- plastic coated rims d/t limited grip strength
- possible power assist
- independent pressure relief via lean, anterior WS appropriate
42
Equipment required for C7 SCI
- Manual wheelchair, pressure relief cushion
- Adaptive equipment as needed; lower body dressing, eating, shower, bowel/bladder
- able to drive with adaptive controls
43
Intervention for C7 SCI
- Functional mobility; transfers, bed mobility, seated balance
- Respiratory care; assisted cough technique
- upright tolerance; standing frame
- wheelchair skills
- functional e-stim
- patient education
- aerobic conditioning
- strengthening; triceps, depressors, serratus
- selective stretching; hamstring, lumbar spine, finger flexors
44
Muscles innervated with C8 SCI
- extrinsic finger flexors
- flexor carpi ulnaris
- flexor pollicis longus
- intrinsic finger flexors
- pecs, lats
* improved grip (finger flexors), even greater stability *
45
Expected functional outcomes for C8 SCI
- independent bed mobility
- independent with occasional assist on uneven surfaces for transfers
- may be able to perform floor to chair transfers
- independent with manual wheelchair
- independent with ADLs in accessible environment
- less adaptive equipment required secondary to improved hand function
- independent with adaptive equipment for bowel/bladder
- driving with adaptive controls
46
Intervention for C8 SCI
- Functional mobility; transfers, bed mobility, seated balance
- respiratory care; assisted cough technique
- upright tolerance; standing frame
- wheelchair skills
- functional e-stim
- patient education
- aerobic conditioning
- strengthening; triceps, depressors, serratus, grip?
- selective stretching; hamstring, lumbar spine
47
Muscles innervated from T1-T12
- Includes gradually increasing intercostal levels
- Abdominals at T7 and below
- Lower injury = improved trunk control, respiratory reserve, pec stability for lifting
48
Expected outcomes for T1-T12
- Independent transfers (including floor), bed mobility, manual wheelchair mobility (uneven terrain) & anterior pressure relief
- Increased proficiency of mobility with more caudal SCI level
- Physiologic standing and gait
- Independent with all ADLs using compensatory techniques
- Movement patterns more efficient and patient requires less adaptive equipment
49
Still consider compensatory strategies for T1-T12 SCI
- Energy expenditure
- Age
- Pain
- Time of day
50
Standing and gait T1-T12 SCI
- Motor complete:
- Static standing balance w/ LE bracing
- weight shifting
- Gait may be possible for very short distances; therapeutic, non-functional, high energy expenditure
- Requires braking and assistive device
- Swing to pattern, maybe 4 point; use upper extremities to unweight legs, hand on Y ligaments
- Sit to stand very challenging
51
Intervention for T1-T12 SCI
- Functional mobility; transfers, bed mobility, seated balance, tall kneel/quadruped positions, standing/therapeutic ambulation
- Respiratory care; assisted cough technique
- Upright tolerance; standing frame
- Manual wheelchair skills
- functional e-stim
- patient education
- aerobic conditioning
- strengthening; shoulder program
- selective stretching; hamstring, lumbar spine
- orthosis; KAFO/HKAFO)
52
ROM considerations for T1-T12 SCI
Selective stretching:
- Hamstrings 100-110
- Spinal precautions**
<60 deg SLR
<90 deg hip flexion
- Receive clearance for hip, knee, ankle
Maintain:
- ankle DR
- hip extension
- knee extension
53
Muscles innervated at lumbar SCI
- all abdominals
- all respiratory muscles
- L1-L3/L4: anterior muscles up to knee
- L4/L5-S2: distal anterior and posterior
- Cauda equina injuries: LMN
LE activation, consider impact of compensatory mechanisms
54
Expected functional outcomes with lumbar SCI
- Independent mobility
- Manual wheelchair user (L4 and above) longer distances
- Ambulation: 4 point -> 2 pint gait pattern with forearm crutches
- Driving with adaptive PF/DF control
55
Ambulation with L1-L3 SCI
- Short distance ambulation
- High energy expenditure
- Hip flexion allows for weight shifting -> 4 point or step gait pattern
- Assistive device and requires bracing
L1-L2: KAFO
L3: AFO innervation of the quad
56
Ambulation with L4-S1 SCI
- Independent community ambulation
- Full hip extension strength = S2
- Assistive devices (forearm crutches) and AFO
- articulating vs solid; working in range they have
- length of foot plate; solid and long = increased stability
57
Intervention for lumbar SCI
- Functional mobility
- Upright tolerance; standing frame
- wheelchair skills; high level
- functional e-stim (cycling)
- patient education
- aerobic conditioning
- strengthening; shoulder program
- selective stretching; caution with lumbar fx instability
- orthoses; KAFO/AFO
58
Recovery continuum for complete injuries
Emphasis on compensatory approach
59
Recovery continuum for incomplete injury
- AIS B; motor complete, more emphasis on compensatory approach
- AIS C & D; emphasis on restorative approach whenever possible
60
Mobility progression for mat/bed mobility
Rolling -> supine -> long sit -> short sit
Supine -> prone
Scooting -> quadruped -> tall kneel
61
Sitting balance progression
Ring sit -> long sit -> short sit (UE initially)
62
Transfer progression
Scooting -> transfer board -> level (no board) -> uneven -> floor
63
Wheelchair skill progression
Propulsion and management level surface -> doorway navigation -> uneven surfaces, curbs, wheelies
64
Standing progression
Gradual progression tilt -> standing frame
65
Gait training progression
For thoracic and lumbar injuries
Standing balance -> paragait in parallel bars -> assistive device -> reducing external supports and improving step pattern
