FINAL EXAM - SCI Flashcards
(108 cards)
1
Q
Paraplegia
A
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
Q
Etiology of spinal cord injuries– Four
A
Number one. MVA
Number two. Falls
Number three. Acts of violence
Number four. Sports
3
Q
Nontraumatic spinal cord injuries most common cause – 6
A
- Cancer/tumors
- Spinal stenosis
- Transverse myelitis/infections
- Motor Neuron disease. (Guilin Barre syndrome, CIDP)
- MS
- Spinal stroke
4
Q
Life expectancy for spinal cord injuries varies based on – three
A
- Age at time of injury – longus at 20 years of age, shortest at 60 years of age
- Level of injury – longest if paraplegic, shortest if tetraplegic
- Completeness of injury – longest if incomplete, shortest is complete, shorter if ventilator dependent
5
Q
Cause of death for spinal cord injuries – two
A
- Pneumonia
2. Septicemia
6
Q
The vertebral column is made up of how many cervical, thoracic , lumbar, sacral and, coccygeal vertebrae?
A
Seven cervical 12 thoracic Five lumbar Five sacral Four coccygeal
7
Q
Flexion load versus extension load refers to
A
The position of the head and neck during injury. This mechanism of injury is unstable
8
Q
Flexion load versus extension load characteristics – three
A
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
Q
Tetraplegia
A
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
Q
Hi velocity versus low velocity characteristics – two
A
- Hi velocity injuries generally cause more damage to the spinal cord (gunshot wound, MVA, some sports)
- Low velocity injuries associated with less damage and a brighter prognosis (Falls, some sports, tumors) – usually an older population due to falls
11
Q
Other mechanisms of injury – two
A
One. Infection
Two. Disease
12
Q
The key to reducing risk of paralysis at time of injury is to reduce
A
Inflammation
13
Q
AIS (American spinal injury Association impairment scale)classification
A
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
Q
AIS motor testing tests key muscle groups graded on 0 to 5 MMT scale the key groups are
A
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
Q
AIS sensory testing
What does it test?
How does it test?
Grading
A
Sensation tested by dermatomes With a light touch and pinprick Grading: 0= absent 1= impaired 2= normal NT= not testable
16
Q
axial load refers to
A
bone shards penetrate the cord. this mechanism of injury is generally stable
17
Q
Characteristics of Axia Load (3)
A
- result in burst fractures
- frequently considered orthopedically stable
- often result in significant neurological damage due to splintering of vertebral body into spinal cord
18
Q
ASIA A - Most Impaired
A
Complete. No motor or sensory fxn preserved at sacral segments S4-S5 (Anal sphincter)
19
Q
ASIA B
A
Incomplete. Sensory but not motor fsxn is preserved below the neurological level and includes the sacral segments of S4-S5
20
Q
ASIA C
A
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
Q
ASIA D
A
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
Q
ASIA E Least impaired
A
Normal
23
Q
Neurological level is the lowest level at which there is
A
normal motor AND sensory fxn
24
Q
Motor level
A
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
