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MedCon Rehab II > SCI Part II EXAM 1 > Flashcards

SCI Part II EXAM 1 Flashcards

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1
Q

Laundry list of 2* Complications of SCI

A
  • press sores
  • HO
  • Osteoporosis
  • syringomyelia
  • autonomic dysreflexia
  • RSD
  • OH
  • altered thermoreg
  • DVT/PE
  • pain
  • Resp dysf.
  • contractures
  • spasticity
  • B&B dysf.
  • altered sexual function
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2
Q

Single greatest factor leading to INC in hospital LOS and $$$

A

Pressure sores aka Decubitus Ulcer

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3
Q

Pressure Sores…. aka what?

due to what?

A
  • Decubitus ulcers
  • combo of anasthesia w/ pressure/and shearing forces
  • ****MAJOR SOURCE MORBIDITY AND MORTALITY
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4
Q

Pressure Sores

What can cause them?

A
  • Poor B&B control
    • skin maceration (like pruny fingers)
  • Hypertonia
    • shearing– skin breakdown
  • trauma
    • # tapeburns
  • Nutritional deficiencies or comorbidities delay healing

***See O’Sullivan table 20.3***

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5
Q

Pressure sores… what is @ risk?

A

ANY WBing part of body

* calcaneous

* lat. malleolus

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6
Q

Pressure sores…. the best tx is…

A

PREVENTION

*pos changes q hour

NOTE: q= every

* Sitting pressure releases q 15mins

*need entire rehab team on this!!!!!

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7
Q

Heterotopic Ossification (HO)

What is it?

A
  • Abnormal dev. of BONE below lvl of SC lesion
    • ​usually in soft tissues
      • ​surrounding joints
        • ​w/ SCI–> hips/knee
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8
Q

HO is….

A

Extraarticular

Extracapsular

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9
Q

HO typ. occurs where?

A

@ hips/knees

MAY also occur shoulders, elbows, paravertebral area

*functional limits 20% pts

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10
Q

Predisposing Factors for HO

A
  • COMPLETE lesions
  • pressure sores
  • hypERtonicity
  • C/S–mid T/S lesions
    • *Males 2x likely to dev. HO
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11
Q

Early s/s of HO may mimic what?

A
  • Thrombophlebitis
    • ​warm, erythema, swelling, reduced ROM
  • NO X-ray findings
  • elevated Alkaline Phosphates significant clinical finding
    • ​***New bony growth blood marker***
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12
Q

HO and ROM

acute vs. later phases

A
  • Early research discourages ROM—> proven wrong!!!
    • Acute phase== rest/gentle PROM
    • Acute phase OVER== PROM and mobilization
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13
Q

HO @ its WORST….

A

Prevents safe and normal siting posture, transfers, interferes w/ preserved ROM and worsens hygiene problems due to B&B issues

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14
Q

Pharmacologic interventions HO

A
  • Prophylaxis—-beforehand
    • ​Indomethacin (NSAID) OR refecoxib (COX-3 inhibitor)
      • ​reduce risk of developing HO
    • radiation tx’s
  • For Tx:
    • ​Etidronate—- halts progression after dx
      • early admin is key!!!
    • radiation— slow/stop HO progress.
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15
Q

Osteoporosis due to changes in……..

A

Ca metabolism

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16
Q

INC risk of THIS w/ Osteoporosis

also INC risk of _____ and ________

A
  • INC risk patho fx
    • no support
    • no trauma
    • just happens
  • INC risk renal stones
    • INC conc. of Ca in urinary system
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17
Q

Osteoporosis commonly tx’d w/

A

Biphosphates

Ex’s: Fosamax or Didronel

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18
Q

EARLY TX for Osteoporosis

A

Wt. Bearing Ex!!!!

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19
Q

Osteoporosis due to what?

Tx?

A
  • due to immobility and disuse from lack of WBing BUT
  • WBing w/out mm contraction USELESS
    • ​Spasticity can prevent this
  • Tx to INC mm contraction prevents this
    • FES reasonable tx
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20
Q

Syringomyelia aka

A

Posttraumatic Cystic Myelopathy

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21
Q

What is Syringomyelia aka Posttraumatic Cystic Myelopathy?

A
  • Dev. of fluid filled cyst in SC—-typ near lvl of injury
    • ​sx’s WORSE as cyst ENLARGES
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22
Q

Syringomyelia aka Posttraumatic Cystic Myelopathy s/s:

A
  • Sx’s include:
    • PAIN
      • local/radicular
        • diff vs. deafferent dysesthesia
    • sensory changes
    • weakness/mm atrophy
    • hypOreflexia
  • NOTE: develops in 3% all SCI pts
    • ​8% incidence in comp. tetraplegia pts
      • ​can occur ANYTIME post injury
        • ​mo’s—-decades
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23
Q

Dx of Syringomyelia?

A

History THEN MRI

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24
Q

Tx Syringomyelia:

A
  • Surgical
    • laminectomy/drainage
    • syringoperitoneal OR syringosubarachnoid shunting
  • outcomes mixed
    • some surgeons NO operate if only sensory symptoms w/out motor changes
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25
What should you remember about **Autonomic Dysreflexia/Hyperreflexia???**
IT IS A MEDICAL EMERGENCY!!!!!!!!!!!!!!!
26
Autonomic Dysreflexia is a syndrome that affects indiv's w/ what kind of SCI?
T6 or higher SCI\*\*\*\*\*\*
27
Autonomic Dysreflexia occurance?
* Affects indiv's w/ T6 or higher SCI * occurs due to **uncontrolled autonomic outflow** * **​Causes:** * **​**SEVERE HTN * HR changes * severe sweating and flushing * severe HA * piloerection (gooseys) * shivering * **Consequences can be lethal!!!** * **AUTONOMIC DYSREFLEXIA IS A MEDICAL EMERGENCY**
28
MASSIVE, **uncompensated**, CV rxn of the **sympathetic NS** to a noxious stimulus **below the lvl of the SCI lesion resulting in marked HTN**
Autonomic Dysreflexia \*They have **sensory loss,** so cannot feel noxious stim but still get the signals that it's there
29
What is going on w/ Autonomic Dysreflexia why can pt not feel the **normal signals?**
Normal signs from the **carotid sinus** and to **lower peripheral resistance** are unable to pass the **injured area of the SC**
30
Persistence of HTN assoc'd w/ Autonomic Dysreflexia can be **Fatal** ## Footnote **causing....**
Stroke Cardiac Arrest Seizures
31
Autonomic Dysreflexia What to do if it's happening?
* have the pt **Sit UP** * **​**Remember....they have HIGH BP so this will REDUCE BP * Search for the **offending noxious stimulus** * **​**The **trigger** * **​**pain stimulus **below SCI** person cannot perceive * blocked catheter (often) * bedsore * restrictive clothes * Take (and note) BP
32
Why should we TAKE and NOTE BP in someone w/ Autonomic Dysreflexia?
People w/ SCI can have **normal systolic pressures of 90-100** so a BP of 140/80 **could indicate significant HTN for them!**
33
Autonomic Dysreflexia What to do if you try to remove the stimulus but this does not work?
* IF BP does NOT come down after this.... * catheterization * IF still no drop in BP * medical or surgical intervention
34
Address Autonomic Dysreflexia IMMEDIATELY
MEDICAL EMERGENCY!!!!
35
Complex Regional Pain Syndrome (CRPS) OR aka
Reflex Sympathetic Dystrophy (RSD) \*\***P. nerve injuries mostly\*\***
36
CRPS or RSD occurance
small # SCI pts
37
CRPS or RSD likelihood?
INC's in **neurological lvl is at or near lvl of injury** **\*\*HIGHER injury==more likely** MAY cause INC in **abnormal sensory discharge/responsiveness**
38
CRPS/RSD where is pain? what is spared?
* Typified by PAIN @ **fingers or hand WITH shoulder or scapular pain** * Forearm or elbow **spared**
39
CRPS or RSD ## Footnote **Sympathetic vasomotor changes**
Red, taut, glossy skin and **trophic nailbed changes**
40
CRPS or RSD **pain cycle**
leads to cycle of **immobilization and stiffness** ## Footnote **demineralization of bone**
41
When will we normally see OH? (Orthostatic HypOtension) What pos changes?
Supine --\> sit Sit---\> stand
42
OH results from loss of what?
Loss of **SNS influences** that control **vasoconstriction** Basically....not enough volume of blood to maintain BP
43
\_\_\_\_\_\_\_\_\_\_\_\_ combined w/ __________ and _________ leads to __________ w/ OH
LE vasodilation combined w/ loss of mm pump and prolonged bed rest leads to **venous stasis (**stoppage or pooling of blood)
44
What interventions can we use for OH?
Pressure garments like **TEDS and Abdominal binders** Teach the **Valsalve Maneuver** **\*\*ALL preventative measures\*\***
45
OH and early PT tx
* resumption of upright is very difficult in early tx * judicious BP monitoring * patience!!! * **Graded standing via tilt table ==== PT intervention of choice!!!** * **​**@ 80deg they'll feel "upright" * @ 90deg falling forward feeling
46
Altered thermoreg is **limited thermoreg where?**
BELOW LESION LVL
47
Why does altered thermoreg happen?
Connect. b/w **ANS and SC interrupted** ## Footnote **\*normal thermoreg may not happen\***
48
Altered thermoreg s/s
* Pt unable to **sweat when warm** or **shiver when cold** * **​****HIGHER the lesion===GREATER proportion of body that is unable to maintain safe temp!**
49
Being mindful of altered thermoreg
\*People w/ SCI should ICE after strenuous act. to cool down OR dress warmly in cool weather
50
DVT and PE What are they?
* DVT * clot in the venous system or blockage * PE * clot that breaks loose and travels into the **pulmonary aa circulation** into **lungs** * **LIFE THREATENING**
51
DVT/PE risks
INC risk due to DEC LE mvmt Loss of LE mm pump (gravity pulls blood DOWN)
52
Pharmacologic **prevention** and **Tx DVT/PE**
1. Coumadin--**anticoagulant** 2. Heparin-- **intravenous**
53
DVT/PE prevention
Compression garments (TEDS or intermittent SCDs) SCDs==\> Sequential Compressive Device---**these have timers and inflate to squeeze the limbs (mimic mm pumps)** **\*\*PT for daily mobilization\*\***
54
MAJOR problem experienced by those w/ SCI
PAIN
55
PAIN assoc'd w/ SCI can come from a variety of causes what are they?
* Overuse * Mm imbalances * Reverse action use\*\*\*GOOGLE * Trauma * Radicular pain * Dysesthesias (prickling, burning) * Phantom pain\*\* * feeling of limb being in place after amputation
56
Lesions above ________ result in **paralysis of the diaphragm**
lesions **above** C4 \***this means person w/ C1-C3 tetraplegia req's artificial ventilation\*\*\***
57
Lesion of ________ spares diaphragm
C5-T12
58
C5-T12 lesion **spares diaphragm BUT limits what?**
Limits use of **intercostals and accessory mm's** ## Footnote **\*still leads to Resp Dysfunction**
59
Compensations for Resp Dysfunction occur over time BUT
Diminished functional resp capacities present
60
People w/ lesion above ________ have abdominal weakness and limited **expiratory capacity**
T10
61
People w/ lesion ABOVE T10 have \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ results in what?
Abdominal weakness and **limited expiratory capacity** This results in **diminished cough and inability to expel lung secretions** **#PNA**
62
Flexibility is the cornerstone to.....
Mobility!!!
63
Marked loss of FLEX
Contractures
64
Contractures occur due to:
* Occur due to: * lack of mm opposition * hypERtonicity * lack of norm. positioning **Significantly limit ability to participate in OR perform ADLs** **Tenodesis!!! ---\>** passive insufficiency where multi joint long finger flexors are pulled tight when wrist moves into pos of ext
65
Spasticity is \_\_\_\_\_\_\_\_
Velocity dependent \*velocity dependent INC in resp. to PROM
66
Spasticity and using PROM
PROM can **prevent secondary complications** UNLIKELY that any type of handling tech. can "cure' spasticity may DEC it temp.
67
Spasticity Tx: **medical**
* Medical Tx: * **antispasmatics** * **​Baclofen** * **Klonopin** * **Tizanidine**
68
Spasticity Tx: **surgical**
* Surgical Tx: * IT (intrathecal) Baclofen * Phenol block * **dorsal spinal N. root injection** * **Botox (botulinium toxin)** * **​**paralytic INTO muscle and paralyzes that muscle * Temporary (few mos) * reduces resting tension * **if pt does receive this...we can mobilize and stretch to restore ROM**
69
Role of Urinary System?
make urine in kidneys store it in bladder remove it from bladder via urethra NOTE: **bladder composed of smooth mm and can stretch to accommodate 500cc (2cups)**
70
Successful mgmt bladder comps ====
PRIMARY reason for DEC morbidity and mortality in people w/ SCI
71
What controls flow of urine from bladder?
* Sphincter mm's * sphincters relax---\> urine flows
72
Bladder innervated....
Sacral N. segments \***Detrusor muscle**
73
2 Syndromes assoc'd w/ bladder
1. Spastic or reflex bladder==**hyperreflex** 2. Flaccid bladder== **hyporeflex**
74
Spastic Bladder
* Detrusor hypERsensitivity * usually occurs w/ SCI @ or above T12 * external catheter req'd
75
Detrusor hypersensitivity aka Spastic bladder what happens?
* Bladder empties **as a reflex to a certain lvl of filling** * Rxn may be triggered by **exercise OR removal OR kinking of indwelling catheter**
76
Spastic bladder
@ or ABOVE T12 SCI
77
Flaccid Bladder
* Sphincter remains CLOSED and bladder fills w/out emptying==distended * occurs w/ lesions BELOW T12 * Tx either by indwelling (stays in place) OR intermittent (changed t/o day) catheter
78
Flaccid bladder: sphincter remains closed what happens?
urine backs up into kidneys==**urosepsis**
79
Flaccid bladder occurs
BELOW T12
80
Loss of neurologic control of the **intestinal tract** causing loss of **control of defication**
Neurogenic bowel
81
Neurogenic bowel lose control of intestinal tract==lose control of defication===
DEC gastric motility and loss of voluntary control **anal sphincters**
82
After all is said and done.... w/ neurogenic bowel what is the result?
Stool retention
83
Stool retention as a result of **neurogenic bowel interventions:**
* Includes: * digital stimulation (exactly what it sounds like) * suppositories * enemas * manual disimpaction * manually remove feces * PT and B&B * transfers, balance, limb mvmt
84
Sexual disturbances in SCI
physiologic dysf. S and M disturbance psychologic and sociologic distress
85
Why should PTs understand issues related to sex and sexuality???
Rapport VERY close proximity w/ pts they are COMFORTABLE w/ you
86
Sexuality in men after SCI these 3 things are **different phenomena**
1. Erection 2. Ejaculation 3. Orgasm \*\***depending on type of lesion, all three may be affected in some way**
87
**Organs** of MALE repro. and sexual anatomy supplied by:
T10-S4
88
Somatic supply controlling **ejaculation in men** comes from:
S2-S4 to the **pudendal nerve**
89
Normal Erections have 2 separate components:
1. Psychogenic 2. Reflexogenic
90
Psychogenic Erections
* **erotic ideation---\> Endocrine function** * Structures involved supplied by **T10-L2** * **NOT EXP'D BY INDIV'S W/ LMN LESIONS\*\*\***
91
Reflexogenic Erections \***UMN thing**
* result of **internal or external stim of genitals** * **MOST common in men w/ lesions ABOVE T12** * Structures involved arise from **S2-S4** * **​Erectile reflex center\*\*\***
92
Somatic supply controlling ejaculation comes from....
S2-S4 segments to the **pudendal nerve**
93
Ejaculation 3 stages:
1. emission of seminal fluid from urethra 2. closing of bladder sphincter 3. **antegrade ejaculation**
94
Three stages of ejaculation coordinated by
diff. nerves and mm's \***far less common occurence than erection** **retrograde ejaculation may occur (goes back into urethra into bladder)**
95
Sterility after SCI: due to
* Ejaculatory dysf. * **genital duct blockage** * **​**recurrent UTI and non-drainage of repro tract * DEC spermatogenesis due to INC testicular temp * issues maint. temp * repro often artificial insemination
96
50% of men w/ SCI report they can have orgasms
Hallelujah!!!! \***unrelated to lvl of injury**
97
These control **vaginal secretions and clitoral tumescence**
Parasympathetic nerves S2-S4
98
Control the smooth muscle of the Fallopian Tubes and Uterus
Sympathetic Splanchnic nerves T5-T12
99
Innervates Pelvic floor musculature
Somatic pudendal nerves S2-S4
100
What is the PRIMARY sexual impairment in women w/ SCI
Lack of lubrication!! buy some lube!!! NOTE: **intercourse can contribute to INC UTI's** **\*post-coital catheterization**
101
This is very common in women post-SCI \*relates to sexuality
disruption of menstrual and ovulatory cycles NOTE: generally resumes to prior status w/in a yr.
102
Long term repro capacity in women w/ SCI
* NOT impaired, but complications * Autonomic dysreflexia---EMERGENCY!!! * thromboembolism--DVT * resp. diff's * **if lesion is cervical OR high thoracic** * **risks can be mg'd and not insurmountable barrier to preg.**
103
Risks assoc'd w/ Sexuality and SCI
* pregnancy possible regardless of whether male or female * STD's * realities of the disability.... * fall off bed * skin breakdown from vigorous love making * pathologic fx's
104
Counseling for Sexuality and SCI
see slide 52
105
Current concepts in SCI rehab
* FES---mm stim for **functional mvmts** * **BWS TM/Gait training** * **​robotics**
106
Use of electrical stim to aid in **physical functioning of persons w/ phys disablity** **and 2 types**
FES 1. FES-based **cycle ergometry** or FES-based **orthotics** 2. **Implanted** FES units for UE's and LE's
107
BWSTT/BWSGT 3 types
1. Litegait---PT assists in moving legs 2. Lokomat---robot legs kindof 3. Alter G--high tech \*pt needs to be able to move limbs
108
Robotic ADs
ReWalk

MedCon Rehab II (5 decks)

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