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Flashcards in FINAL EXAM - SCI Deck (108)
1

Paraplegia

Impairment or loss of sensory and/or motor function in the Thoracic, lumbar, or sacral segments of the spinal cord. Affects lower extremities and trunk. Upper extremities are spared

2

Etiology of spinal cord injuries– Four

Number one. MVA
Number two. Falls
Number three. Acts of violence
Number four. Sports

3

Nontraumatic spinal cord injuries most common cause – 6

1. Cancer/tumors
2. Spinal stenosis
3. Transverse myelitis/infections
4. Motor Neuron disease. (Guilin Barre syndrome, CIDP)
5. MS
6. Spinal stroke

4

Life expectancy for spinal cord injuries varies based on – three

1. Age at time of injury – longus at 20 years of age, shortest at 60 years of age
2. Level of injury – longest if paraplegic, shortest if tetraplegic
3. Completeness of injury – longest if incomplete, shortest is complete, shorter if ventilator dependent

5

Cause of death for spinal cord injuries – two

1. Pneumonia
2. Septicemia

6

The vertebral column is made up of how many cervical, thoracic , lumbar, sacral and, coccygeal vertebrae?

Seven cervical
12 thoracic
Five lumbar
Five sacral
Four coccygeal

7

Flexion load versus extension load refers to

The position of the head and neck during injury. This mechanism of injury is unstable

8

Flexion load versus extension load characteristics – three


One. Estimated 90% of injuries are flexion load
Two. Significant bone and ligamentous disruption as well as Neurological injury
three. Often require surgical stabilization

9

Tetraplegia

Impairment or loss of sensory and/or motor function in the cervical segments of the spinal cord. Affects upper extremities, lower extremity's, trunk and possibly respiratory systems.

10

Hi velocity versus low velocity characteristics – two

1. Hi velocity injuries generally cause more damage to the spinal cord (gunshot wound, MVA, some sports)
2. Low velocity injuries associated with less damage and a brighter prognosis (Falls, some sports, tumors) – usually an older population due to falls

11

Other mechanisms of injury – two

One. Infection
Two. Disease

12

The key to reducing risk of paralysis at time of injury is to reduce

Inflammation

13

AIS (American spinal injury Association impairment scale)classification

ASIA impairment scale previously known as a just scale. Uses key muscles for motor level classification, key points for sensory level classification, can be different levels for motor versus century, and can be different levels for left versus right

14

AIS motor testing tests key muscle groups graded on 0 to 5 MMT scale the key groups are

C5 – elbow flexors
C6 – wrist extensors
C8 – flexion of middle distal phalanx
T1 – abduction of fifth finger
L2 – hip flexors
L3 – knee extensors
L4 – ankle Doris flexors
L5 – great toe extensors
S1 – ankle plantar flexors

15

AIS sensory testing
What does it test?
How does it test?
Grading

Sensation tested by dermatomes
With a light touch and pinprick
Grading:
0= absent
1= impaired
2= normal
NT= not testable

16

axial load refers to

bone shards penetrate the cord. this mechanism of injury is generally stable

17

Characteristics of Axia Load (3)

1. result in burst fractures
2. frequently considered orthopedically stable
3. often result in significant neurological damage due to splintering of vertebral body into spinal cord

18

ASIA A - Most Impaired

Complete. No motor or sensory fxn preserved at sacral segments S4-S5 (Anal sphincter)

19

ASIA B

Incomplete. Sensory but not motor fsxn is preserved below the neurological level and includes the sacral segments of S4-S5

20

ASIA C

Incomplete. motor fxn is preserved below the neurological level, and more that half of key muscles below the neurological level have a grade less than 3

21

ASIA D

Incomplete. Motor fxn is preserved below the neurological level, and at least half of the key muscles below the neurological level and a muscle grading great than or equal 3/5

22

ASIA E Least impaired

Normal

23

Neurological level is the lowest level at which there is

normal motor AND sensory fxn

24

Motor level

Level at which strength is great than or equal 3/5 with the level about it being 5/5

25

sensory level

Level at which the sensation is intact for both pinprick and light touch

26

Complete

the absence of sensory or motor function in the lowest sacral segment (S4-5)

27

Zone of Partial Preservation (ZPP)

used only with complete injuries. Refers to those dermatomes and myotomes caudal to the neurological level that remain partially innervated

28

Incomplete

partial preservation of sensory &/or motor function in the lowest sacral segment (S4-S5)

29

5 clinical syndromes of SCI (all incomplete)

1. central cord syndrome
2. brown sequard syndrome
3. anterior cord syndrome
4. conus medullaris syndrome
5. Cauda equina syndrome

30

Central Cord Syndrome is commonly caused by

falls

31

Central cord syndrome characteristics (7)

1. Most common incomplete injury
2. cervical lesion on the neck
3. produces sacral sparing
4. greater weakness in UEs than in LEs (can walk around but can't use arms)
5. may also produce bladder dysfunction
6. various forms of sensory loss below the level of the lesion
7. Outcomes: 75% walk, 50% regain bowel and bladder control, 25% regain UE fn

32

Brown Sequard Syndrome common cause

gun shot wounds

33

Brown sequard syndrome (6)

1. occur in 2-4% of all SCI
2. lesion that damages 1/2 of spinal cord (hemisection)
3. Ipsilateral proprioceptive and motor loss (one side of the body)
4. contralateral loss of sensitivity to pain and temperature (other side of the body)
5. patient presents with hemiparesis
6. Outcome: Generally expected to be positive

34

Anterior cord syndrome can be caused by

disrupted blood flow to the part of cord "anterior spinal artery syndrome)

35

Anterior Cord Syndrome characteristics (5)

1. injury affects anterior 2/3 of spinal cord
2. loss of motor fn below level of injury
3. loss of sensitivity to pain and temperature
4. preservation of proprioception, light touch, and deep pressure (prevents ulcers and fx)
5. outcome: 10-20% chance of muscle recovery

36

Conus Medullaris Syndrome(3)

1. Injury of the sacral cord (conus) and lumbar nerve roots within the spinal canal
2. Presents with lower motor neuron deficits of anal sphincter and bladder
3. Areflexic (flaccid) bladder and lower extremities

37

Cauda Equina Syndrome (5)

1. injury to lumbosacral nerve roots within the neural canal
2. Below L1
3. Lower motor neuron injury
4. Areflexic bladder and bowel
5. Flaccid lower extremities

38

Posterior Cord Syndrome (Rare) (5)

*no longer recognized as a standardized clinical syndrome of SCI
1. occurs in

39

Comorbidities at time of SCI ( 7)

1. Fx
2. amputations
3. loss of consciousness
4. TBI
5. Pneumothorax
6. Hemothorax
7. burns

40

Surgical management following SCI (6)

1. Goal is to align spinal column and canal, and to remove pressure on the spinal cord
2. most often done with an anterior approach
3. bone graft may be taken from ASIS for fusion
4. Wiring of vertebral bodies
5. plates and screws
6. Rods

41

Orthotic Management: Halo

1. not as common
2. able to be mobile but head and neck won't move
3. only used until spine heals post surgery. Generally 3 months

42

Orthotic Management:Cervical Orthoses

1. Most common
2. each limits movement and provides stability to a different extent
3. Rarely comfortable

43

Orthotic Management: Thoracic and Lumbar orthoses

1. frequently taken off in bed as long as person lays with head of bed

44

Jewitt Brace

places spine in slight extension: tends to be uncomfortable

45

Complications and Impairments : Neuromuscular System (5)

1. paralysis or paresis of skeletal muscle,
2. hyperactivity of stretch reflexes
3. spasticity and/or spasms (misconstrued as movement)
4. muscle atrophy with cellular degeneration and increased fibrosis
5. muscle cells physiologically change into slow twitch fibers with slow contraction speeds.

46

Complications and Impairments : autonomic dysreflexia (noxious stimuli event)
MEDICAL EMERGENCY - homeostasis is out of wack
(4)

1. occurs in T6 injuries and above
2. Acute, life threatening, syndrome of uncontrolled, massive reflex sympathetic discharge
3. usually caused by noxious stimulus below the level of the injury (frequently bladder{full cath bag}, bowel, pressure sore, electrical stimulation, ingrown toenails.)
4. Parasympathetic system is not responding properly

47

Symptoms of Autonomic dysreflexia (7)

1. severe headache - pounding - Act Immediately
2. sweating above injury level
3. slow pulse
4. goose bumps
5. extremely high BP - 300/160
6. Pallor
7. blurry vision

48

Treatment of Autonomic dysreflexia (3)

1. sit person up to decrease cerebral BP (blood out of brain)
2. Try to remove noxious stimulus
3. Obtain medical assistance - Send to ER if can't resolve, give BP medication

49

Clonis

beating of the foot

50

Spasms are no use to the Pt but

keep muscle tone and blood flowing

51

Complications and Impairments : Autonomic Dysfunction - thermoregulation

1. decreased ability to regulate body temperature
2. inability to sweat below the level of injury (complete injuries)
3. occasionally, excessive sweating is noted

52

Precautions for Autonomic Dysfunction

1. tetraplegics should try to remain in cool places during hot weather
2. keep warm in cold weather

53

Complications and Impairments : Skeletal System - Osteoporosis and bone demineralization (2)

1. up to three-fold decrease in load to failure
2. high incidence of pathological bone fx (stretching, lean on femur to tie shoes)

54

Complications and Impairments : Skeletal System - Ligamentous changes at joints (2)

1. joint instability
2. up to 40% decrease in load to failure

55

Complications and Impairments : Skeletal System - degenerative joint disease (1)

1. overuse syndromes, particularly in UEs

56

Normal muscle pull on bone keeps the bone strong. Therefore, if there is a decrease in spasticity then what occurs?

demineralization ( due to lack of muscle pull on bone)

57

Complications and Impairments : Postural deformities(3)

1. scoliosis seen due to poor sitting posture and muscle imbalances
2. kyphosis/ posterior pelvic tilt seen due to poor sitting posture
3. requires wheelchair seating assessment/revision

58

Complications and Impairments : Joint contractures

1. due to loss of antagonist muscle contractions
2. prolonged sitting and or supine positioning
3. leads to skin issues and fn mobility/transfer issues

59

Complications and Impairments : HO (5)

1. occurs in neurologically impaired segments; hips knees, ankles, elbows
2. Peak incidence = 4-12 wks post injury
3. can severely impair ROM and Fn
4. may present with sudden onset of redness & swelling near joint, joint effusion and pain
5. differential diagnoses = DVT, septic arthritis, fx, osteomyelitis, impending pressure sore, cellulitis

60

HO Diagnosis (3)

1. elevated serum alkaline phosphatase levels always precedes radiological evidence in HO
2. routine xrays are of no value in early states
3. 3 phase bone scans used to determine presence of and maturity of HO

61

HO treatment

1. medication management
2. ROM once inflammation diminishes
3. Forcible stretching and mobilization may worsen stimulation
4. Splinting may be needed if total joint ankylosis(stiffening and immobility of the joint due to fusion of the bones) is expected

62

HO surgical intervention

1. best 12-18 months post onset or when bone formation is mature
2. excision usually followed by irradiation of the area to prevent recurrence
3. post-op complications: delayed wound healing, excessive bleeding, infection, fx, and recurrence

63

Complications and Impairments : Integumentary system

1. pressure sore development
2. increased risk of burns: lean against radiator, heated car seats, sun burn, coffee on lap (no hot packs even if requested)

64

Complications and Impairments : Cardiovascular System (7)

1. peripheral circulatory clamping of vessels
2. Circulatory and lymphatic stasis
3. venous thrombosis and risk of pulmonary embolus
4. cardiac muscle atrophy
5. reduced volumes of whole blood and plasmas
6. decreased cardiac output
7. unstable heart rate and bp
8. Orthostatic hypotension

65

Management of orthostatic hypotension (6)

1. abdominal binder
2. bilateral LE support stockings
3. medication
4. gradual acclimation to position changes
5. reclining wheelchair
6. tilt table

66

Complications and Impairments : Gastrointestinal (3)

1. paralytic ileus lasts approx 5-7 days post injury (oral feedings held until bowel sounds are heard)
2. abdominal distention - lack of muscular support and GI complications
3. Bowel dysfunction and incontinence - controlled at level of conus medullaris

67

Bowel dysfunction and incontinence care (3)

1. begin bowel program to promote regular bowel elimination and to prevent impaction
2. includes dietary and medication management (suppositories, enemas, stool softeners)
3. psychological impact

68

Complications and Impairments : Genito-Urinary

1. use of catheters to manage incontinence
2. high risk for UTI

69

Catheters (3)

1. indwelling
2. external
3. intermittent catheterization

70

Complications and Impairments : Sexual Fn and Sexuality (5)

1. psychological impact/body image
2. Male and female sexual functions controlled t12 through s4
3. women can become pregnant and give birth normally
4. men can father children but often require medical interventions to do so
5. Bowel regimen plays into sexual activity

71

Complications and Impairments : pain syndromes(2)

1. nociceptive pain
2. neurogenic pain

72

Nociceptive Pain

One. Caused by noxious stimuli to the normal innervated body part, usually at or above the level of injury .
2. Degenerative joint changes
3. Nerve entrapment
4. Myofascial
5. Trauma
6. Disease
7. Overuse syndrome

73

Neurogenic pain (5)

1. Related to injury at nerve roots, cauda equina, and spinal cord, usually at or below level of injury.
2. 48% to 94% incidence and SCI
3. severity is variable
4. if develops months/years post-injury, should investigate via MRI to rule out syrinx formation

74

Types of neurogenic pain syndromes (4)

1. radicular pain
2. segmental pain
3. deafferentation central pain
4. reflex sympathetic dystrophy

75

Syrinx Formation (Syringomyelia) (5)

1. Cavity forms within the spinal cord
2. Maybe primary cause of spinal cord injury enter
3. May develop after traumatic injury.
4. Causes changes in motor or sensory function.
5. Most pain symptoms.

76

Respiratory System Triad of normal Ventilation(3)

1. Diaphragm is the major muscle of passive inspiration. Innervated at c3 - c5, lesions above sea for result and paralysis of diaphragm and require artificial ventilation.
2. Abdominal muscles innervated at T5-L1, needed for efficient cough/expiratory function.
3. Intercostal muscles are innervated at t1 - t12, stabilizes the rib cage and provide additional expansion of the chest. Needed for controlled exhalation and speech

77

Complications and Impairments : Respiratory System (8)

1. Respiratory complications are common.
2. Diaphragmatic, accessory, and intercostal muscle paralysis or paresis.
3. Decreased chest expansion, vital capacity, and tidal volume
4. Reduced ability to cough efficiently and to clear secretions.
5. 80% to 85% of people with sei show signs of acute or chronic pulmonary disease (atelectasis, pneumonia, respiratory failure)
6. Decrease in lung capacity equals can't get enough air
7. C4 vent may come off
8. C 4 to C 5 may only need vent at night

78

Vital Capacity-5

1. normal = approx 4L
2. c1-c2 expect 5-10% of normal (vent depend.)
3. c4-c6 expect 50% of normal (vent free maybe at night)
4. C7-T4 expect 60-70%
5. T5-S5 expect relatively normal

79

Artificial airway tracheostomy

1. Passes the upper airway and laryngeal structures
2. Used to relieve airway obstruction
3. Facilitates artificial ventilation
4. Facilitates suctioning

80

mechanical ventilator-2

1. Automatic cycling devices that generate air pressure to assist or take over breathing function
2. Tracheostomy or mouthpiece

81

Pulse oximeter -2

1. Measures percentage of oxygen in hemoglobin
2. Only truly indicative of hemoglobin levels are WNL

82

Abdominal binder (2)

1. Assist with venous return
2. Provides mechanical leverage for respiratory mechanisms

83

Endotracheal suctioning devices (2)

1. Invasive procedure to remove secretions, mucus plugs, & foreign objects from respiratory system
2. Generally described as uncomfortable for recipient

84

Mask (3)

1. Used often for sleep apnea
2. Ventilation well at night
3. Doesn't require tracheostomy

85

mechanical in-exsufflator (Coughalator, MI-E) (8)

1. Works like a vacuum
2. Apply gradual pressure to the airway then rapidly shift to negative pressure thereby stimulating a cough
3. Get deeper than Main brochi
4. Is not invasive
5. Used via tracheostomy, face mask, or mouthpiece
6. Cannot be used with individuals who have chest injuries or who have fragile cardiac status
7. Tends to be well received by patients when compared to use of endotracheal suctioning
8. Reluctance among medical community to use due to lack of exposure and lack of comparative outcomes research

86


Phrenic nerve stimulation / pacing advantages -5

1. Increase mobility
2. Improve speech
3. Decrease nursing care
4. Decrease anxiety
5. Overall decrease in cost

87


Phrenic nerve stimulation/pacing disadvantages


1. Both phrenic nerve must be intact capable of being stimulated
2. Risk of phrenic nerve injury due to surgical dissection
3. Requires thoracotomy or laparoscopic surgery
4. Expensive
5. Mixed outcomes

88

ROM of the shoulder

in the absence of active or strong elbow extentinon, greater than normal elbow extension combined with shoulder external rotation is required

89

ROM of Elbows (2)

Full extension is needed for stability
occassionally, slightly great than extension is needed

90

ROM of forearm

full supination is essential to assist in locking elbows into extension while wt bearing

91

ROM of wrists -3

1. full wrist flexion and extension must be preserved
2. if active wrist extension is

92

Tenodesis - natural kinematics of wrist and hand movement (3)

1. wrist extension results in finger flexion
2. wrist flexion results in finger extension
3. allows for functional grasp and release of objects in the absence of active finger movement

93

Finger tenodesis

1. fn grasp and release accomplished with tenodesis
2. DO NOT over stretch long finger flexors!
3. perform ROM by flexing wrist while extending fingers, and extending wrist while flexing fingers

94

Wt bearing activities on the hand should be performed in a

fisted position

95

ROM of neck

after cevical injury, ROM should be obtained through gentle active exercise

96

ROM TMJ(3)

1. hypomobility of TMJ noted in literature due to halo immobilization
2. may cause discomfort with chewing
3. headaches

97

ROM lower back (2)

1. prevent over-stretching in order to increase trunk stability in sitting
2. mild tightness will allow transmission of head and shoulder motions to body and will enhance

98

ROM Hamstrings (3)

1. flexibility will facilitate long sitting, dressing, mat mobility, and floor trasfers
2. straight leg raises should ideally be 110* - 120* once orthopedically stable
3. perfrom SLR stretch in supine to avoid over-stretching low back

99

ROM Ankles (3)

1. Dorsiflexion to neutral is needed for proper placement on wheelchair
2. Insufficient dorsiflexion will result in excessive pressure on metatarsal heads
3. normal dorsiflexion is needed for ambulation

100

Functional Expectations following SCI: C1-C4 (3)

1. dependent in all fn positioning
2. independent POWER wheelchair mobility
3. independent in giving instructions for self-care and transfers

101

Functional Expectations following SCI: C5 (4)

1. moderate assist bed mobility with bed rails
2. moderate (occ min) assist pressure relief
3. mod/max assist sliding board transfers
4. independent propulsion in power wheelchair; short distance in manual

102

Functional Expectations following SCI: C6 (4)

1. independent in bed mobility (hospital bed)
2. Independent in pressure relief
3. minimal assist/ independent sliding board transfers
4. independent wheelchair mobility for basic skills, assist on uneven surfaces

103

Functional Expectations following SCI: C7, C8, T1 (4)

1. independent bed mobility and pressure relief
2. independent transfer wc-bed, car
3. min assist floor transfers
4. independent wheelchair mobility basic skills, some assit with advanced skills

104

Functional Expectations following SCI: T2-T6 (2)

1. indep. in wc level skills
2. may begin ambulatino (household)

105

Functional Expectations following SCI: T8-T10 (2)

1. best candidates for ambulation with bilateral KAFOs
2. independent in fn mobility and ADLs

106

Functional Expectations following SCI: Caudal to T10 (2)

1. Indep. in wheelchair level skills
2. Indep. in all fn mobilitiy an adls

107

Pressure relief weigth shifts - power tilt wheelchair

1. Tilt and recline in combination produces the most pressure relief
2. Tilt angle of 25-65 degrees provides pressure relief
3. Recline - maintain constant seat angle with respect to the ground
4. elevating leg rests used with recline position helps relieve pressure

108

Pressure relief weight shifts - manual wheelchair

1. lean form side to side
2. lean forward
3. independent push ups (C7 and below)
4. Proper training needed
5. Cross leg over other and lean back
6. cross leg with ankle on other knee lean forward
7. lean against tables