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Primary And Secondary Implications Of SCI Flashcards

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1
Q

Primary implications of SCI impairments

A
  • Motor & sensory impairments
  • Autonomic dysfunction
  • Cardiovascular impairments
  • Abnormal tone
  • Pulmonary/respiratory impairment
  • Bowel/bladder/sexual dysfunction
  • Pain
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2
Q

Motor and sensory impairments

A
  • Related to deficits BELOW level of injury
  • Completeness of injury
  • Clinical syndrome may be preset
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3
Q

Spastic hypertonia

A
  • Occurs after spinal shock resolves BELOW level of injury
  • Related to UMN injuries (more common in cervical spine injuries)
  • Includes: spasticity, hyperactive reflexes, clonus, high muscle tone, muscle spasms
  • Gradually increases up to 6 months post injury, plateaus at 1 years
  • 50% report negative interference w/ function
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4
Q

Functional implications of spastic hypertonia

A
  • May be helpful ie. Extensor tone during standing
  • May hinder (50%) ie. Clonus during transfers
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5
Q

Spastic hypertonia triggers

A
  • UTI
  • Pressure ulcers
  • Stress
  • Temperature
  • Pain
  • Positional changes
  • Tight clothing
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6
Q

Management for spastic hypertonia

A
  • Previous recommendation: stretching (doesn’t do much for spasticity but helps ROM)
  • Surgery ie. Lengthening tendon
  • Medications:
  • Oral muscle relaxants and spasmolytic agents; baclofen, tizanidine, diazepam, dantrolene sodium
  • Botulinum neurotoxin intramuscular injection
  • Baclofen pump; intrathecal
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7
Q

Transcutaneous spinal cord stimulation for spasticity management

A
  • Useful for complete and incomplete injuries
  • Attenuates spasticity following 30min at 50 Hz (subthreshold for muscle twitching)
  • Shows sustained improvement 2 hours post tx
  • Can be used at home with increased time -> carry-over effects up to 7 days post tx
  • Thought to enhance pre and post synaptic inhibitory mechanisms
  • Can be combined with locomotor training
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8
Q

Parasympathetic output to the heart

A
  • Vagus nerve
    Not affected in spinal cord injury
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9
Q
A
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10
Q

Sympathetic output

A

T1-L2
- Specifically concerns: above T6
- T1-T4 innervation to heart

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11
Q

C7 injury implications

A

No sympathetic innervation to heart

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12
Q

Autonomic dysfunction and cardiovascular impairments

A

Imbalance between sympathetic and parasympathetic input to the heart
- Leads to hypotension and bradycardia (no sympathetic)

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13
Q

T10 injury implications

A

More than 50% sympathetic innervation to heart

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14
Q

Spinal shock

A

The altered physiologic state immediately after a spinal cord injury
- Presents as loss of spinal cord function caudal to the level of the injury with flaccid paralysis, anesthesia, absent bowel and bladder control, temporary loss of reflex activity
- Considered over once bulbocavernosus reflex returns (pudendal nerve)

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15
Q

Neurogenic shock

A
  • Refers to the hemodynamic instability seen in these patients with hypotension, bradycardia, hypothermia (secondary to sympathetic-parasympathetic dysfunction/imbalance)
  • Occurs in injuries above T6 >50% loss of sympathetic Innervation
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16
Q

Neurogenic shock (initial weeks in above T6 SCI)

A

SBP <100 mmHg
HR <80 bpm
Parasympathetic unopposed

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17
Q

Bradycardia (initially)

A

100% in AIS A and B cervical injury

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18
Q

Hypotension (orthostatic too)

A
  • Impaired sympathetic output to the heart, unopposed parasympathetic input ->
  • Dilation of peripheral vasculature below level of injury
  • Bradycardia
  • Decrease muscle activation
  • Prolonged time in bed
    Symptoms: lightheadedness, dizziness, confusion, ringing in ears
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19
Q

The new normal blood pressure

A
  • Will likely be lower especially with higher level injuries
    Tetraplegia:
  • Average supine systolic BP: 110 mmHg
  • Average seated systolic BP: 100 mmHg
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20
Q

High/low BP should be more concerning following SCI

A

High blood pressure due to unopposed parasympathetic

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21
Q
A
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22
Q

Management for orthostatic hypotension in SCI

A
  • Gradual progression of upright position
    Head of bed up -> recliner w/c -> tilt table/standing frame
  • Abdominal binder
  • Compression stockings
  • Medication management
    As vasomotor stability returns, tolerance to vertical position with gradually improve
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23
Q

Autonomic dysreflexia

A
  • A life threatening autonomic reflex
  • Typically occurs in injuries above T6, chronic > acute (3-6 months), complete > incomplete
  • Noxious stimuli below lesion -> afferent input to spinal cord -> overactive sympathetic activity (mass reflex response) -> increased BP -> overactive parasympathetic above
    If not addressed quickly can result in:
  • Seizures
  • Cardiac arrest
  • Subarachnoid hemorrhage
  • Stroke
  • Death
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24
Q

Pathophysiology surrounding autonomic dysreflexia

A
  • Noxious stimulus occurs below level of injury, intact sensory nerves transmit impulses to spinal cord
  • Sympathetic neurons are stimulated by these ascending noxious afferent -> vasoconstriction
  • Normally, impulses stimulate receptors in cortisol sinus and aorta -> signs vasomotor center to readjust peripheral resistance
  • Following SCI -> impulses from vasomotor center cannot pass the site of the lesion to counteract the hypertension through vasodilation
  • Relatively unopposed sympathetic outflow below the level releasing neurotransmitters -> severe vasoconstriction in arteries -> sudden increase in blood pressure
  • Splanchnic vascular bed (innervated by T5-T9) sympathetic tone gets stimulated from painful response, constricting splanchnic bed (largest circulatory bed in the body and thus has a large impact on blood pressure)
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25
Causes to autonomic dysreflexia
- Bowel/bladder distention/irritation: catheter kink, distended bladder, UTI, kidney stones, irritation of urethra during catheterization - Painful stimuli - Sexual activity - Labor - Tight fitting clothes - Stretching pt too far - Fracture - E-stim below level of injury - Pressure sores
26
Signs/symptoms of autonomic dysreflexia
- HTN (systolic increase by 20-30 mmHg compared to their usual) - Bradycardia; peripheral system trying to compensate - Severe headache - Profuse sweating above LOI - Increased spasticity - Vasodilation above LOI; flushing, overactive parasympathetic activity) - Vasoconstriction below LOI; overactive sympathetic activity - Constricted pupils, blurred vision, nasal congestion, pilo-erection
27
Management for autonomic dysreflexia
- Upright position* efforts to rapidly decrease BP - Remove source of noxious stimulus - Monitor vitals - Seek medical attention is unable to resolve in about 20 min (antihypertensive meds) - Patient education n
28
2.7x greater risk in individuals with SCI
Heart disease
29
3.7x greater risk in individuals with SCI
Stroke
30
Confounding factors to cardiovascular impairments in SCI pts
- Immobility - Autonomic dysfunction - BP fluctuations
31
Impaired temp regulation and autonomic dysfunction
- Hypothalamus mediated through para/sympathetic systems cannot control blood flow or level of sweating -> loss of internal thermoregulatory responses - Tetraplegia > paraplegia - Hypothermia: loss of ability to shiver; limited ability to vasoconstrict - Hyperthermia: lack of sympathetic control of sweat glands; limited ability to vasodilate (more concerning)
32
Pulmonary impairment related to SCI
- Related to: - Level of injury - Most rostral = greater impact - Other trauma (rib fx?) - Premorbid factors - leading cause of death in early AND late stages of recovery
33
Muscles of inspiration
- Diaphragm - Scalenes - Intercostals - SCM - Serratus - Pecs - Traps - Levator scap - Abdominals
34
Muscles of expiration
- Largely a passive process - Abdominals, internal intercostals: - Maintain intrathoracic pressure for effective respiration - Support abdominal viscera, maintain position of diaphragm, push diaphragm upward during forced expiration - Lower diaphragm position -> decreased expiratory reserve
35
C1-C2 muscles
- Have SCM and upper trap - Only accessory muscles of respiration functioning - Require ventilator - Passive expiration only: airway clearance required
36
C3-C4 muscles
- Have partial diaphragm, partial scalenes, levator scap - Require ventilator acutely (part-time) - Passive expiration only: airway clearance
37
C5-C8 muscles
- Have full diaphragm, partial pec, serratus anterior - No ventilator required - Forced expiration severely impaired
38
T1-T5 muscles
- Have intercostals (innervated T1-T11) - Serratus posterior superior (innervated T1-T3)
39
T6-T10 muscles
- Abdominals (innervated T6-L1) - Intercostals (innervated T1-T11)
40
T11 and below
- Have all of the above - Missing QL & full abdominal innervation
41
Improved expiratory capacity with…
Increasing level of injury - Impacts airway clearance - Impacts risk of pneumonia/atelectasis
42
Injuries above L1 =
Pulmonary compromise
43
Endotracheal intubation
- More acute pulmonary intervention
44
Tracheostomy
- more for long term use - Permits speaking and eating - Passy Muir: speaking valve opens when breathing and closes as they exhale so air comes through the mouth, allows for speech when air passes over vocal cords - Requires learning, kids pick up quicker, adults have harder time
45
Ventilators
- Portable unit - Phrenic nerve stimulator - Diaphragmatic pacer - C-PAP for sleep disturbances - Will be trained in clinic
46
Emergency ventilation response
AmbuBag - Goes right over the tracheostomy or mouth - Manual
47
Vital capacity in SCI patients
- Greatest amount of air that can be expelled from the lungs after taking the deepest possible breath < 25% in high cervical injury 70-80% of normal in mid to low thoracic injuries
48
Functional cough
- 2 coughs with 1 exhalation Weak: 1 soft cough with exhalation Nonfunctional: no expulsive force
49
Secretion management
- Coughalator: stimulates cough via suction - Suctioning: done manually with catheter
50
Bowel/bladder and sexual dysfunction
2 main problems: 1. Failure to store urine 2. Failure to empty urine
51
UMN bladder
- Spastic/reflexive/neurogenic - Contracts and reflexively empties in response to filling pressure
52
LMN bladder
- Arreflexic or flaccid - Reflex arc NOT intact - Can’t empty by reflex
53
Pain in SCI pts
26-96% of people after SCI report chronic pain - Negatively impact function, QOL, and sleep
54
Nociceptive pain
- Associated with musculoskeletal injuries - Overuse injuries (UE injuries, shoulder pain) - Poor posture/body mechanics - Muscle imbalances
55
Neuropathic pain
- At or below level of injury: -> Injury to spinal cord or nerve roots, can result in central pain (allodynia, and hyperalgesia) pain is diffuse Above level: -> Peripheral nerves, difficult to manage; tens, massage, mental imagery, pharmacology
56
Secondary impairments implications of spinal cord injury
- Neurogenic heterotropic ossification - DVT - Contractures - Osteoporosis - Pressure ulcers - Psychosocial impact
57
Neurogenic heterotropic ossification
- Presence of bone formation in extra skeletal tissue in the context of a neurologic condition - Etiology unknown - Pathophys: induction of mesenchymal stem cells from muscles -> differentiate into osteogenic (bone cells) -> inflammation -> activates cells -> bone formation - Overactivation of osteoclast activity -> increased osteoblast activity
58
Neurogenic heterotopic ossification usually presents…
2-4 months after injury - Has been reported earlier in SCI - Can continue to develop up to 2 years after injury
59
Most common areas affected by neurogenic heterotropic ossification
- Occurs below the level of injury Hip (70-97%) > knee > elbow joints - single joint affected in 40% of cases Adults > pediatrics
60
Risk factors for developing heterotropic ossification
- Complete injury (A or B) - Trauma injury (increased inflammation) - DVT/PE (more inflammation) - Mild spasticity - UTI (more inflammation) - Pressure ulcers - Males > females - MVA and thoracic lesion
61
Symptoms of neurogenic heterotropic ossification
- Pain** - Warmth/erythema - Edema - Decreased ROM & hard end-feel (abnormal) - Low grade fever (in some)
62
Diagnosis of neurogenic heterotropic ossification
- Lab results during inflammation period: elevated phosphorus, alkaline phosphatase, erythrocyte sedimentation rate and C-reactive protein - Radiography: can be negative in beginning phases, usually shows 4-6 weeks after formation - Bone scan/CT scan: most sensitive for diagnosis and monitoring - Ultrasound: newer test to catch in early phase
63
Rehabilitation implications with HO
- Contractures - Pain - Skin ulcer development - Impaired mobility/ADLs - Nerve entrapment
64
PT specific interventions for HO
- Catch early if possible - Gentle ROM program - NO aggressive stretching - Pain -> autonomic dysreflexia - Positioning
65
Pharmacology intervention for HO
- NSAIDs early -> prevention - Biophosphonates -> post Dx (act on osteoclast activity)
66
Medical intervention for HO
- Determine implications on functional mobility to help patient determine next best course of action - Surgical excision: AFTER bone matures - Radiation therapy: so stem cells don’t transition
67
Factors associated with development of pressure ulcers
- Tetraplegia - Spasticity - Incontinence - Decreased mobility/self-care - Nutritional deficiencies (protein) - Long duration of immobilization - Smoking - Poor compliance with skin care
68
Prevention of pressure sores
- Minimize time in one position - Weight shifting/pressure relief while in bed and wheelchair
69
Protocol for bed pressure relief
- Every 2 hours sidelying -> supine -> sidelying - Pressure relieving bed (air fluidized bed)
70
Protocol for wheelchair pressure relief
- Every 15-30 min for minimum of 2 minutes - Need to allow for adequate re-oxygenation of loaded tissues - Specialized cushion is not enough
70
Protocol for wheelchair pressure relief
- Every 15-30 min for minimum of 2 minutes - Need to allow for adequate re-oxygenation of loaded tissues - Specialized cushion is not enough
71
Techniques to avoid for pressure relief
- Avoid push-up on W/C armrest - Results in increased strain on shoulders - Difficult to hold position for 2 min
72
Appropriate techniques for pressure relief
- Lateral weight shift - Anterior weight shift - Posterior weight shift of at least 65 degrees for adequate
73
Deep vein thrombosis & SCI
- Incidence varies: 5.3-64% with prophylaxis, 47-100% without - Most likely to occur during acute phase & up to 6 months: swelling, redness, tenderness to palpation - Prevention: compression, mobilization, anticoagulation meds, inferior vena cava filter
74
Contractures and decreased ROM and SCI
Related to: impaired muscle activation, impaired function and pain - Pay specific attention to areas with asymmetrical muscle innervation ie. C5 injury
75
Management for contractures
- Splinting - Positioning - ROM
76
Percent of SCI pts that have osteoporosis
100% with motor complete
77
Most rapid loss of bone mineral density
- in the first 4-6 months - continues to decrease for 2-3 years or more
78
Cause of osteoporosis in SCI pts
- No muscle activation - No loading -> bone resorption and no bone formation - Abnormal bone vascularization (sympathetic innervation)
79
Fracture risk in osteoporotic SCI pts
46% - metaphyses at distal femur and proximal tibia - can be non-traumatic ie. Stretching Risks: female, low BMI, para, increased time since injury
80
81
Standing intervention for osteoporosis
- No statistically significant difference in bone mineral density - Standing alone is not good enough for improving bone mineral density (muscles have to be working)
82
Vibration intervention for osteoporosis
Not effective
83
Pharmacological intervention for osteoporosis
- Biphosphonates within 12 months of injury (inhibit bone resorption) act on osteoclasts to slow breakdown of bone, not much affect after first year - Calcium and vitamin D
84
FES cycling and osteoporosis
- Acute phase cycling -> attenuate bone loss at distal femur and proximal tibia -> not lasting - Chronic phase -> cycling 5x or more/week could be effective in bone loss prevention 3x/wk = 1.1% reduction in bone loss 5x/week or more = 11% reduction
85
FES rowing and osteoporosis
- Increased aerobic workout -> increases blood flow to bone - Can promote new bone formation - FES sit to stand? - Implement early and high frequency
86
Psychosocial impact and SCI
- Report lower quality of life, higher levels of mental distress 25-30% experience depression and anxiety - Impacted greatly by social support Note: high incidence of re-hospitalization
87
Traumatic SCI in pediatrics
- Rare before age 15 - MVA - Sport related injuries (males) - Falls - Abuse Cervical injuries more common
88
Non-traumatic causes pediatrics
- Myelomeningocele/spina bifida - Tumor or abscess - Transverse myelitis - AV malformation - Compressive myelopathies - SC infarction due to thromboembolic disorders - Developmental abnormalities of cervical vertebrae
89
Back board considerations for stabilization of pediatrics
- Used with infants and toddlers to allow for neutral alignment of c-spine - Occiput cut out - Elevating torso pad for lack of curvature
90
Diagnosing spinal cord injury in pediatrics
- SCIWORA: spinal cord injury without radiographic abnormality - signs of acute trauma but no findings on CT or x-ray - recommend MRI; better for children - midline cervical tenderness most common sign - similar txs for anterior decompression and spinal stabilization surgeries - Halo used for younger children
91
Pediatric SCI implications
Slightly better prognosis and neurologic recovers than adults incomplete > complete - High likelihood of developing scoliosis (they’re still developing); bracing and surgical intervention (spinal fusion and growing rods used) - Muscle imbalances can cause abnormal growth and contractures; dependent on injury location - Osteoporosis w/ high fx incidence - Bowel/bladder concerns & increased risk of renal disease - Multidisciplinary rehab and family centered care!
92
Shorter or longer length of stay in acute care and inpatient care compared to 1970
Shorter! Almost/more than half shorter
93
PT role in SCI
- Education and support for patient and family - Help patients form realistic expectations for outcomes and discharge - Use of compensatory mobility strategies vs restorative**
94
Compensatory mobility techniques
Goal: teach techniques to move the body using available musculature and motor control Principles: - Head hips relationship - Momentum strategy - Muscle substitution - Task modification - Working in and out of task Consider: impact of spinal immobilization during acute phases on all mobility strategies
95
Patient history/chart review
- AIS score and level of injury, zone of partial preservation - info relevant to primary and secondary implications of SCI - social support - discharge destination/home environmental set up - patient goals: usually begins with walking but switches to bowel/bladder/sexual function
96
Neuromuscular tests and measures
- motor and sensory function (ASIA exam) - additional muscle testing (in addition to key muscles) - Tone using modified ashworth scale - Proprioception for incomplete injury only***
97
Cognitive screen for SCI patients
- LOC at accident - Fall - MVA Up to 60% of people with traumatic SCI can have TBI - Consider cognitive outcome measures
98
ROM tests and measures
- Require increased shoulder ROM eventually - Require full hip extension, hamstring length and ankle DF - Beneficial to maintain some muscle tightness in specific areas (tenodesis) Prevent contractures: splinting, positioning, ROM Goniometric measurements at appropriate joints
99
Respiration tests and measures
- Observe equipment needs: ventilator, coughalator, suction etc. - Observe pattern; normal RR 12-20 breaths/min - Paradoxical breathing; breathing movements in which the chest wall moves in on inspiration and out on expiration - Measure chest expansion: between max inhalation/exhalation; normal 2.5-3 inches - Examine functional cough - Breathing easier in supine b/c diaphragm can function better, in sitting lack of abs pulls abdominal contents including diaphragm and central tendon forward
100
Integumentary system tests and measures
- Pressure sores - Education on weight-shifting - DVT
101
Functional mobility examination
- Bed mobility - Sitting tolerance/balance - Transfers - Wheelchair parts management and propulsion - Standing/locomotion (when appropriate) - ADLs/self care - Pressure relief
102
Mental health screening
- Depression anxiety stress scales: screen for depression, stress, anxiety. 21 items; higher score = greater distress, validated in SCI - Patient health questionnaire 9: screen for depression in SCI, 10 or more = moderate depression
103
Spinal cord independence measure
- Items include: self-care, respiration, sphincter management, mobility - Total max score = 100 points - Lower score = greater disability - 30-60 min to administer - Valid and reliable for individuals with SCI - Good responsiveness to change - Includes ranges from total A, partial A, supervision, adaptive equipment
104
Capabilities of UE functioning instrument
- Tetraplegia - Self-reported - Bilateral and unilateral items - 32 items, 7 points care (unable to not limited) 32-224 - Low score = greater impairment - MDC 33.8
105
Walking index for spinal cord injury (WISCI II)
- Classification for walking ability 0-20 with increased ability receiving higher score 1 = ambulation in parallel bars, assist, and braces, 10m 15 = ambulating one cane/crutch, braces, no assist 10m - Highly recommended for AIS C/D - Floor effects for AIS A/B MDC of 1 level can be interpreted as a real diff
106
Wheelchair skills test
- examines 33 different wheelchair mobility skills - 25 skills for power - safe, pass (partial and advanced) -> unsafe, fail or “no part” (w/c does not have the part) - 30 min to implement - Fold/unfold chair, floor transfers, inclines, obstacles, stairs - Also in questionnaire form; how confident are you that you could complete this skill?
107
Craig handicap assessment and reporting technique
- Outcome measure for participation/community reintegration - Self report (0-100% for each domain) - Physical, cognitive, mobility, occupation, social integration, economic self-sufficiency - 32 items - Lower score = greater disability MDC = 53.3
108
Wheelchair users’ shoulder pain index (WUSPI)
- 15 items 4 categories: - transfers - wheelchair mobility - self care - general activities MDC: 5.10 points

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