Spinal Cord Injury Flashcards
(34 cards)
1
Q
Describe an upper motor neuron injury
A
- UMN (Suprasegmental Control): Motor neuron that carries motor information from motor cortex or subcortical region to cranial nerve nuclei
- Interneurons that synapse with motor cell bodies in the ventral horn (LMNs)
- Intact reflex loop (sensory nerve -> spinal motor neuron -> motor nerve -> muscle activation)
- Flaccidity at the level of injury
- Hyperreflexia below level of injury
- SCIs above T12/L1
2
Q
Describe a lower motor neuron injury
A
- LMN (Segmental Control): Motor neuron that carries information from motor neuron cell bodies in anterior horn to skeletal muscles
- Includes cranial nerves and cauda equina
- Flaccid paralysis
- Hyporeflexia
- SCI’s at and below T12/L1
3
Q
Many individuals with SCIs have signs associated with both UMN and LMN pathology (True/False)
A
- True
4
Q
Spinal precautions for SCI
A
- In cases of confirmed spinal or spinal cord injury, maintain spine immobilization until definitive treatment
- Logroll the patient with a potentially unstable spine as a unit when repositioning, turning, or preparing for transfers
5
Q
Describe neurogenic shock
A
- May occur after a cervical or high thoracic (T1-T5) injury that interrupts thoracic sympathetic outflow
- Causes hypotension and bradycardia
- May not be possible to restore a pt’s BP by fluid infusion resuscitation may generate pulmonary edema
- BP can instead be restored by supplementing moderate volume replacement w/judicious use of inotropes (pressors)
- Muscarinic antagonists, such asatropine, can be used to treat hemodynamically significant bradycardia
- MAP >85 mmHg for 1st wk post-injury
6
Q
Describe spinal shock
A
- Refers to the muscle flaccidity and loss of reflexes seen after SCI.
- The “shock” to the injured cord may make it initially appear completely functionless.
- However, because the cord is usually not completely destroyed in SCI, the duration of this state is variable; recovery usually occurs
7
Q
Vital sign recommendations for SCI
A
- BP: collaborate with medical team to address hypotension (SBP <90 mmHg) prior to PT sessions; MAP goal of 85-90 mmHg for at least 1st wk following injury for adequate spinal cord perfusion
- O2 Sat: SCI pt’s typically present with impaired pulmonary function secondary to a restrictive dysfunction depending on type & level of injury; monitor SpO2 especially in individuals with ineffective cough or excessive mucus retention
8
Q
Describe treatment and effects of hypotension on SCI
A
- Hypotension may exacerbate CNNS injury
- Avoiding hypotension is paramount in early treatment to prevent secondary neuronal injury from lack of perfusion
- 1st treatment priority for hypotension is fluid resuscitation
- Goal is to maintain optimal tissue perfusion & to resolve shock
- Uncontrolled studies that used fluids and vasopressors to achieve a mean arterial pressure (MAP) of 85 mmHg for a minimum of 7 days in patients with acute SCI have reported favorable outcomes
9
Q
How can you provide meticulous skin care for SCI patients
A
- Reposition to provide pressure relief or turn at least every 2 hours while maintaining spinal precautions.
- Keep the area under the patient clean and dry and avoid temperature elevation.
- Assess nutritional status on admission and regularly thereafter.
- Inspect the skin under pressure garments and splints
10
Q
Describe importance of patient handling
A
- Place the patient on a pressure-reduction mattress or a mattress overlay, depending on the patient’s condition.
- Use a pressure-reducing cushion when the patient is mobilized out of bed to a sitting position
- Some degree of pressure ulcer formation occurs in 30%–50% of patients with new SCI during the first month post-injury, and the sacrum is the most common location for these ulcers
- Educate the patient and family on the importance of vigilance and early intervention in maintaining skin integrity.
11
Q
Describe the rehab management for SCI
A
- PTs should be involved during the acute hospitalization phase
- Consider directing SCI pts expeditiously to a specialized spinal cord injury center that is equipped to provide comprehensive, state of the art care
- Educate patients and families about the rehabilitation process and encourage their participation in discharge planning discussions
12
Q
Describe how to manage OH in SCI patients
A
- Use nonpharmacologic and pharmacologic interventions for orthostatic hypotension as needed.
- Provide non pharmacological interventions:
- Mobilize the patient out of bed to a seated position once there is medical and spinal stability.
- Develop an appropriate program for out-of-bed sitting.
- Limit in-bed and out-of bed semireclined sitting, as it often produces excessive skin shear and predisposes to pressure ulcer formation.
13
Q
Describe the Costophrenic assist technique for manually assisted coughing
A
- Can be performed in any position (supine, sidelying, and sitting most common)
- Therapist places their hands on the Costophrenic angles of the rib cage
- At the end of the patients exhalation, the therapist provides a quick manual stretch down and in toward the patients navel to facilitate a stronger diaphragmatic and intercostal muscle contraction during the succeeding inhalation
- You then have the patient hold it and just a moment before asking the patient to actively cough, the therapist applies a strong pressure again
- Most commonly used for patients with weak or paralyzed intercostal or abdominal muscles
14
Q
Describe an abdominal thrust (Heimlich type) technique for manually assisted coughing
A
- Therapist places heel of hand at the patients navel
- Patient takes in a deep breath and holds it
- As the patient is instructed to cough, the therapist quickly pushes up and in under the diaphragm
- Can be uncomfortable because: Abrupt nature, Concentrated area of contact & Force may cause GER
- Should only be used when the patient does not respond to other techniques
- Can emphasize one side for someone with unilateral or thorax disease, hemiplegic, or s/p trauma
15
Q
Describe the anterior chest compression assisted cough technique
A
- Therapist puts one arm across the pectoralis region to compress the upper chest
- Other arm placed parallel on the lower chest or abdomen
- Inspiration is facilitated first
- Followed by a hold
- Force is applied: Down and back on the upper chest & Up and back on the lower chest
- Effective for patients with very weak chest wall muscles
16
Q
Symptoms of autonomic dysreflexia
A
- Pounding headache
- Slow pulse
- Skin redness or flushing
- Chills without fever
- Restlessness
- Sweating above the level of injury
- Goose bumps
- Nasal congestion
- Blurred vision
- Cold & clammy skin below the level of injury
17
Q
What can trigger autonomic dysreflexia
A
- Full bladder that needs to be emptied
- Constipation/bowel needs to be emptied
- Skin irritation: pressure ulcer, pinched skin, ingrown toenail, something too hot or cold touching skin
- Broken bone
- Sexual activity
- Mensturation
18
Q
What are the key muscles for each spinal level
A
- C1-4: Sensory level
- C5: Elbow Flexors (Biceps, brachialis)
- C6: Wrist Extensors (Extensor carpi radialis and brevis)
- C7: Elbow Extensors (Triceps)
- C8: Finger Flexors (Flexor digitorum profundus, middle finger)
- T1: Finger Abductors (Abductor digiti minimi)
- T2-L1: Sensory level
- L2: Hip Flexors (Iliopsoas)
- L3: Knee Extensors (Quadriceps)
- L4: Ankle Dorsiflexors (Tibialis anterior)
- L5: Long Toe Extensors (Extensor hallucis longus)
- S1: Ankle Plantar Flexors (Gastrocnemius)
- S2-5: Sensory level
19
Q
Grading for muscle function in SCI
A
- 0: total paralysis
- 1: palpable or visible contraction
- 2: active movement, full range of motion (ROM) with gravity eliminated
- 3: active movement, full ROM against gravity
- 4: active movement, full ROM against moderate resistance in a muscle specific position
- 5: (normal) active movement, full ROM against full resistance in a muscle specific position expected from an otherwise unimpaired person
- 5*: (normal) active movement, full ROM against gravity and sufficient resistance to be considered normal if identified inhibiting factors (i.e., pain, disuse) were not present
- NT= not testable (i.e., due to immobilization, severe pain such that the patient cannot be graded, amputation of limb, or contracture of over 50% of the normal range of motion)
20
Q
How do you perform the sensory exam portion of the ASIA Scale for SCI
A
- Test each of the 28 dermatomes C2 to S4-5: right and left sides separately
- Performed with the patient in supine position
- Rectal exam may be performed in side-lying position
- Eyes closed for exam
- “Normal sensation”: face is used as the baseline
21
Q
How do you score sensation on the ASIA Scale for SCI
A
- 0 = Absent
- 1 = Altered or Impaired, including hyperaesthesia
- 2 = Normal or intact
- NT= Not testable
22
Q
What sensations do you test on the ASIA Scale for SCI
A
- Light touch: Tapered wisp of cotton; Stroke across about one centimeter area of skin
- Pin prick: Determine sharp/dull discrimination; Safety pin: pointed end = sharp; rounded end = dull
23
Q
What are the key sensory points on the ASIA Scale for SCI (C-spine)
A
- C2: At least 1cm lateral to the occipital protuberance at the base of the skull, alternatively can be located at least 3cm behind the ear
- C3: in the supraclavicular fossa at the midclavicular line
- C4: over the acromioclavicular joint
- C5: On the lateral (radial) side of the antecubital fossa just proximal to the elbow
- C6: On the dorsal surface of the proximal phalanx of the thumb
- C7: On the dorsal surface of the proximal phalanx of the middle finger
- C8: On the dorsal surface of the proximal phalanx of the little finger
24
Q
What are the key sensory points on the ASIA Scale for SCI (T-spine)
A
- T1: On the medial (ulnar) side of the antecubital fossa just proximal to the medial epicondyle of the humerus
- T2: At the apex of the axilla
- T3: At the midclavicular line & the 3rd intercostal space found by palpating the ant. chest to locate the 3rd rib & the corresponding 3rd intercostal space below it
- T4: At the midclavicular line & the 4th intercostal space located at the level of the nipples
- T5: At the midclavicular line & the 5th intercostal space located midway b/w the level of the nipples & the level of the xiphisternum
- T6: At the midclavicular line located at the level of the xiphisternum
- T7: At the midclavicular line 1/4 the distance b/w level of xiphisternum & umbilicus
- T8: At midclavicular line 1/2 the distance b/w level of xiphisternum & umbilicus
- T9: At the midclavicular line 3/4 the distance b/w level of xiphisternum & umbilicus
- T10: At midclavicular line located at the level of umbilicus
- T11: At the midclavicular line midway b/w level of umbilicus & inguinal ligament
- T12: At the midclavicular line over the midpoint of the inguinal ligament
25
What are the key sensory points on the ASIA Scale for SCI (L-spine)
- L1: Midway b/w key sensory points for T12 & L2
- L2: On the anterior-medial thigh at the midpoint drawn on an imaginary line connecting the midpoint of the inguinal ligament & the medial femoral condyle
- L3: At the medial femoral condyle above the knee
- L4: Over the medial malleolus
- L5: On the dorm of the foot at the 3rd metatarsal phalangeal joint
26
What are the key sensory points on the ASIA Scale for SCI (S-spine)
- S1: On the lateral aspect of the calcaneus
- S2: At the midpoint of the popliteal fossa
- S3: Over the ischial tuberosity or infragluteal fold
- S4/5: In the perianal area, less than 1cm lateral to the mucocutaneoux junction
27
What is involved in an Anorectal exam in SCI patients
- Very important when discriminating AIS classifications
- Sensation at S3 and S4/5: light touch and pin prick
- Deep anal pressure (DAP)
- Voluntary Anal Contraction (VAC): scored yes = present; scored no = absent
28
How do you interpret the ASIA Scale sensory level
- Most caudal “intact” dermatome for both light touch and pin prick
- Both scores of two at that level and above
- Separate for right and left
29
How do you interpret the ASIA Scale motor level
- Lowest key muscle function that has a grade of at least three, providing the key muscle functions of segments above that level are intact (grade of five on MT)
- Separate for right and left
30
How do you interpret the ASIA Scale neurological level of injury (NLI)
- The NLI refers to the most caudal segment of the spinal cord with normal sensory and antigravity motor function on both sides of the body, provided that there is normal (intact) sensory and motor function rostrally
31
How do you interpret the ASIA Scale Zone of partial preservation
- (ONLY FOR COMPLETE INJURY) partial preservation of motor or sensory function for one to three segments caudal to the neurological level of lesion
32
What are the grades for the ASIA Impairment Scale (AIS)
- AIS A complete: no sensory or motor function is preserved in S4-5
- AIS B sensory incomplete (aka motor complete): sensory function is preserved below the neurological level and includes S4 to 5
- AIS C motor incomplete: motor function is preserved below the neurological level; More than half of the key muscles are less than 3/5 strength
- AIS D motor incomplete: motor function is preserved below the neurological level; At least half of the key muscles below the neurological level are greater or equal to 3/5 strength
- AIS E incomplete: sensory & motor function is normal
33
What AIS Score is associated with a N-O-O-O-O-N sign?
- ASI A: complete injury
34
Types of spinal cord injury syndromes
- Slide 53
