Spinal Cord
Part of the CNS and, like the brain, the cells of the spinal cord DO NOT REGENERATE.
What is a Tetraplegic?
Any degree of paralysis of the four limbs and trunk muscles
What is a Paraplegic
A paralysis of the (LE) with some involvement of the trunk and hips depending on the level of the lesion
What is a Complete Injury?
Total paralysis and loss of sensation result from a complete interruption of the ascending and descending nerve tracts below the level of the lesion (damage)
What is an Incomplete Injury?
Some of the sensory or motor nerve pathways below the levels of the lesion (damage) are preserved and intact
Spinal Cord Injury Loss of Motor Control
- Includes the loss of bowel and bladder control and can include the loss of postural control and paralysis of the muscles required for breathing.
- The amount of paralysis will depend on the level of injury to the spinal cord.
American Spinal Injury Association
Uses the findings from the neurological examination to categorize injury types into specific categories.
ASIA Classification A
Indicates a complete lesion; there is no motor or sensory function preserved in the sacral segments S4-S5
ASIA Classification B
Indicates an incomplete lesion; sensory but no motor function is preserved below the neurological level and includes the sacral segments S4-S5
What is a Central Cord Syndrome?
Central Cord Syndrome occurs when there is more cellular destruction in the center of the spinal cord than in the periphery.
ASIA Classification C
Indicates an incomplete lesion; motor function is preserved below the neurological level, and more than half of the key muscles below the neurological level have muscle grade less than 3
Side Question- Why are Paralysis and sensory loss are greater in the UEs?
Because the UE nerve tracts are more centrally located in the spinal cord, than nerve tracts for the LEs
ASIA Classification D
Indicates an incomplete lesion; motor function is preserved below the neurological level, and at least half of the key muscles below the neurological level have a muscle grade of 3 or more.
What is Brown- Sequard Syndrome (Lateral Damage)?
Brown- Sequard Syndrome results when only one side of the spinal cord is damaged, as in a stabbing or gunshot injury.
ASIA Classification E
Indicates that motor and sensory functions are normal
Side Question- What occurs on the ipsilateral side for Brown-Sequard Syndrome (Lateral Damage)?
Motor paralysis and loss proprioception occur below the level of the injury, on the ipsilateral side
Side Question- What symptoms occur on the contralateral side for Brown Sequard Syndrome (Lateral Damage)?
Loss of pain, temperature, and touch sensation occurs on the contralateral side
What is Anterior Spinal Cord Syndrome?
Anterior Spinal Cord Syndrome results from injury that damages the anterior spinal artery or the anterior aspect of the cord
Side Question- What symptoms occur in Anterior Spinal Cord Syndrome?
This syndrome involves paralysis and loss of pain, temperature, and touch sensation.
What is Cauda Equina (Peripheral)?
Cauda Equina injuries involve peripheral nerves rather than directly involving the spinal cord. Patterns of sensory and motor deficits are highly variable and asymmetrical.
Side question- Why is prognosis for recovery better with Cauda Equina (Peripheral) injury?
Because peripheral nerves possess a regenerating capacity that the cord does not
Side question- What type of paralysis occurs in Cauda Equina (Peripheral) injury?
Flaccid type of paralysis
Side question- Where does Cauda Equina (Peripheral) injury occur in the spinal cord?
Below the L2 level
What is Conus Medullaris Syndrome?
Injury of the sacral cord (conus) and lumbar nerve roots within the neural canal usually result in an areflexic (absent flexes of ) bladder, bowel, and lower extremities
What happens with a SCI in the post traumatic period?
The victim enters a stage of spinal shock that may last 24 hours to 6 weeks
During the post traumatic period of SCI, does Areflexia occur below the level of the injury?
Yes, during the post traumatic period of SCI, reflect activity ceases below the level of the injury
During the post traumatic period of SCI are the bladder and bowel are atonic or flaccid?
Yes during the post traumatic period of SCI the bladder and bowel are atonic (without/lacking tone or flaccid
Prognosis for Recovery
1. 24-48 hr window of function return will foretell recovery; most happens in first few weeks
2. Incomplete Lesion has a better chance of recovery; no amount of hard work will make the nerve function return (complete lesions).
3. Mechanism and severity of
Medical & Surgical Mgmt.
1. Thorough on-site or ER questioning
2. Immobilize suspected or known injuries
3. Prevent further injury
4. Reverse neuro damage w/ decompression
5. Medication for inflammation
6. Medical imaging (CT & MRI)
7. Rotating Kinetic bed (skeletal traction)
8.
Spinal Nerves & areas they supply
C1-C3: Head and neck
C4: Diaphragm
C5: Deltoids & Biceps
C6: Wrist Extensors
C7: Triceps
C8-T1: Hand
T2-T7: Chest muscles
T8-T12: Abdominal muscles
L1-L5: Leg muscles
S2-S5: Bowel, Bladder, sex
What are complications of SCI?
(Name9)
p. 538-539
1. Skin Breakdown
2. Pressure Sores
3. Decubitus Ulcers
4. Decreased Vital Capacity
5. Osteoporosis
6. Orthostatic Hypotension
7. Autonomic Dysreflexia
8. Spasticity
9. Heterotopic Ossification
Spasticity Triggers
- Stretching your muscles.
- Moving your arm or leg.
- Any irritation to the skin, such as rubbing, chafing, a rash, in-grown toenails, or anything that would normally be very hot or cold or cause pain.
- Pressure sores.
- A urinary tract infection or ful
Problems Caused by Spasticity
- Spasticity can be painful.
- Spasticity can result in loss of range of motion in your joints (contractures).
- Severe spasms can make it difficult for you to drive or transfer safely, or to stay properly seated in your wheelchair.
- Spasticity in your c
Areflexia
Period in which reflex activity ceases below the level of injury.
Vital Capacity
A problem in people who have sustained cervical and high throacic lesions. Such individuals have markedly limited chest expansion and decreased ability to cough because of weakness or paralysis of the diaphragm and the intercostal and latissimus dorsi mus
What is the role of the OTA in prevention of pressure sores?
The OTA will share in the responsibility for inspecting the patient's skin and the patient must be taught to inspect their own skin using a mirror.
How long in minutes can skin damage or pressure sores develop?
30 minutes
Can the patient be taught to examine their own skin on a consistent daily basis using a mirror or caregiver assistance to watch for signs of developing problems? True or False
True
Osteoporosis
Increased risk due to NWB with LE
* May result in pathological fractures (femur)
Tx = standing schedule w/ tilt table or assist
Orthostatic Hypotension (OH)
Quick drop in BP due to position change or lack of muscle tone in (B)LE and abdominal muscles.
OT = Quickly recline pt
OT = Provide education & compression garments
OT = Increase sitting & standing tolerance
Autonomic Dysreflexia - symptoms
* Immediate headache
* Sudden HTN
* Anxiety
* Sweating or Chills
* Nasal congestion
* Bradycardia (slow heart rate)
Autonomic Dysreflexia - Treatment
* Stay with pt or take them with you to get help
* Bring pt to upright
* check catheter tubing for obstruction
* remove compressive garments
* Notify medical staff immediately
Heterotopic Ossification (HO)
Abnormal bone development in abnormal areas
* Primarily at hip, knee areas
* May occur at shoulder and elbow
* Onset is 1-4 months after injury
Heterotopic Ossification - symptoms
Warmth, Redness and decreased ROM
Heterotopic Ossification - Treatments
* Gentle ROM (no hard end feel)
* Bed & wc positioning
* maintenance of pelvis/trunk symmetry
* Maintenance of mobility
* Pain management
Heterotopic Ossification - OT Intervention
1. Evaluation
2. Treatment Planning
3. Treatment
OT Intervention Evaluation - Physical
* PROM, AROM, MMT,
* Impairments to scapulothoracic rhythm (imbalances/n root compression) cause pain
* Spasticity (presence & degree)
* UE, hand, wrist function ( for AE)
* Endurance
* Head & Neck control
* Total body functional strength & function
* Sen
OT - Treatment Planning/Objectives
1. To maintain or increase jt ROM and prevent deformities via AROM and PROM, splinting and positioning.
2. To increase the strength of all innervated and partially innervated muscles through the use of enabling and purposeful activities.
3. To increase ph
OT - Treatment - Acute Phase
Begin treatment ASAP
* All areas of involvement are immobilized
* All medical precautions must be followed!
* Target hand splinting for Tenodesis Grasp
* Optimizing total body positioning
* AROM, AAROM depending on strength & tolerance
* PROM to avoid con
Dermatome
An area of skin that is innervated by the sensory axons within each segmental nerve root.
Splints
May be based on the dorsally surface to increase sensory input to palmar (volar) surface
Tenodesis Grasp
(cervical injury)
wrist is extended with fingers passively flexed; wrist is flexed when fingers are passively extended .. use fingers and palm to grasp item.
Acute Phase - Shoulder/UE Positioning
Intermittently positioned in:
1. 80* of shoulder ABduction, ER w/ scapular depression, and full elbow extension.
2. Forearm in pronation (to decrease contractures)
OT - Treatment - Active Phase
* Address graded tolerance for upright position (tilt table or wc positioning)
* Address methods for pressure relief/skin protection
* Continue AROM/PROM
* Implement progressive resistive exercises
* Assess & train w/ adaptive equip
* Evaluate w/ team for
Spinal Cord Injury
Expected Functional Outcomes (Table 27-1)
Level C1-C3: Total Assist
Level C4
Level C5
Level C6
Level C7-C8
Level T1-T9
Level T10-L1
Level L2-S5
Respiratory, Bowel/Bladder, Bed mobility, transfers, pressure relief/positioning, Self-care, wc propulsion, standing/ambulation, communication, transport
Level C1-C3
Functionally relevant muscles innervated:
SCM, cervical paraspinal, neck accessories
Movement possible:
neck flexion, extension, rotation
Patterns of weakness:
TOTAL paralysis of trunk, UE, LE, dependent on ventilator
TOTAL ASSIST in all functions
Level C4
Functionally relevant muscles innervated:
Upper traps, diaphragm, cervical paraspinal
Movement possible:
neck flexion, extension, rotation, scapular elevation; inspiration
Patterns of weakness:
TOTAL paralysis of trunk, UE, LE; inability to cough, paralys
Level C5
Functionally relevant muscles innervated:
deltoid, biceps, brachialis, Brachioradialis, rhomboids, SA (partial)
Movement possible:
shoulder flexion, ABduction, & extension; elbow flexion & supination; scapular ADDuction/ABduction
Patterns of weakness:
abs
Level C6
Functionally relevant muscles innervated:
Clavicular, Pectoralis, Supinator; extensor carpi radialis longus/brevis, SA, latissimus dorsi
Movement possible:
scapular protraction; some horizontal ADDuction, forearm supination, radial wrist extension
Pattern
Level C7-C8
Functionally relevant muscles innervated:
Latissimus dorsi, sternal pectoralis, triceps, pronator quadratus, extensor carpi ulnaris, flexor carpi radialis, flexor Digitorum Profundus and Superficialis, extensor communis, pronator/flexor/extensor/abductor
Level T1-T9
Functionally relevant muscles innervated:
Intrinsics of the hand/thumb, internal and external intercostals, erector spinae, Lumbricals, flexor/extensor/abductor Pollicis
Movement possible:
UE fully intact; limited upper trunk stability; increased enduranc
Level T10-L1
Functionally relevant muscles innervated:
Fully intact intercostals, external oblique, rectus abdominis
Movement possible:
fair to good trunk stability
Patterns of weakness:
paralysis of LE
Mostly Independent w/ some assist
Level L2-S5
Functionally relevant muscles innervated:
fully intact abdominals and trunk muscles, possible hip flexors/extensors/abductors; knee flexors/extensors; ankle dorsiflexors, plantar flexors
Movement possible:
good trunk stability; partial to full control of
Treatment objective for the OTA for the treatment of the person with SCI. Fill in Blank.
To maintain or increase joint ROM and prevent deformity via _____and____, splinting and positioning
AROM; PROM
Treatment objective for the OTA for the treatment of the person with SCI. Fill in Blank.
To increase the _______of all innervated and partially innervated muscles through the use of enabling an purposeful activites
Strength
Treatment objective for the OTA for the treatment of the person with SCI. Fill in Blank.
To increase physical _______via enabling and purposeful activites
Endurance
Treatment objective for the OTA for the treatment of the person with SCI. Fill in Blank.
To maximize _______in all aspects of self care mobility and homemaking and parenting skills
Independence
Treatment objective for the OTA for the treatment of the person with SCI. True or False
To explore leisure interests and vocational potential
True
Treatment objective for the OTA for the treatment of the person with SCI. True or False
To aid in the psychosocial adjustment to disability
True
Treatment objective for the OTA for the treatment of the person with SCI. Fill in Blank.
To ___,____,and _____ the patient in the use of care of necessary durable medical and AE
Evaluate, Recommend, and Train
Treatment objective for the OTA for the treatment of the person with SCI. Fill in Blank.
To ensure safe and independent home and environment accessibility through_________.
Safety and Accessibility Recommendations
Treatment objective for the OTA for the treatment of the person with SCI. True or False
To assist the patient in developing the communication skills necessary to train and instruct caregivers to provide safe assistance
True
Treatment objective for the OTA for the treatment of the person with SCI. Fill in Blank
To _________patients and their families as to the benefits and consequences in relation to long term function and the aging process of maintaining healthy an responsib
Educate
Name 3 Respiratory Equipment required for a Level C1-3 SCI
Two ventilators (bedside or portable)
Suction management device
Generator/battery back up
Name 2 Bowel movement Equipment required for a Level C1-3 SCI
Padded reclining shower/commode chair (if roll in shower available)
Name 1 Bed Mobility Equipment required for a Level C1-3
Full electronic hospital bed with side rails and Trendelenburg feature (patient head down and elevating the feet)
Name 1 Bed/W/C Transfers Equipment required for a Level C1-3 SCI
Transfer Board
Name 5 Pressure Relief/Positioning Equipment required for a Level C1-3 SCI
Power Recline and/ or Tilt W/C
W/C pressure-relief cushion
Postural support and head control devices as indicated
Hand splints may be indicated
Speciality bed or pressure relief mattress may be indicated
Name 3 Bathing Equipment required for a Level C1-3 SCI
Handheld shower
Shampoo tray
Padded reclining shower/commode chair if roll in shower available
Name 2 W/C Propulsion Equipment required for a Level C1-3 SCI
Power recline and/or tilt w/c with head, chin, or breath control and manual recliner
Vent tray
Name 3 Communication Equipment required for a Level C1-3 SCI
Mouth Stick
High tech computer access
Environmental control unit
Name 1 Transportation Equipment required for a Level C1-3 SCI
Attendant operated van (eg lift, tie downs, or accessible public transportation
Name the 16 Expected Functional Outcome for a Level L2-S5 SCI
Respiratory
Bowel
Bladder
Bed mobility
Bed/wheelchair transfers
Pressure relief/ positioning
Eating
Dressing
Grooming
Bathing
Wheelchair Propulsion
Standing/Ambulation
Communication
Transportation
Homemaking
Treatment methods used in the Acute (immobilized) Phase of SCI for OTA? Fill in Blank
During the Acute, immobilized phase the OTA should optimize totaland _______and necessary hand splinting should be intitated at the same time
Body positioning
Treatment methods used in the Active (mobilized) Phase of SCI for OTA? Fill in Blank
The patient can sit in a wheelchair and should begin developing upright _______
Tolerance
Treatment methods used in the Active (mobilized) Phase of SCI for OTA? Fill in Blank
A high priority at this time is determining a method of relieving sitting pressure for the purpose of preventing _________ on the ischial, trochanteric, and sacral bony p
Decubitus Ulcers-Injury to skin and underlying tissue resulting from prolonged pressure on the skin also known as bed sores or pressure sores
Treatment methods used in the Active (mobilized) Phase of SCI for OTA? Fill in Blank
Weight shifts should be performed every ________ until skin tolerance is determined
30 to 60 minutes
Treatment methods used in the Active (mobilized) Phase of SCI for OTA? Fill in Blank
AROM and PROM exercises should be continued regularly to _________________
Prevent contractures
Treatment methods used in the Active (mobilized) Phase of SCI for OTA? Fill in Blank
Splinting or casting of the elbows may be indicated to correct _________that are developing
Contractures
Treatment methods used in the Active (mobilized) Phase of SCI for OTA? Fill in Blank
________should never be allowed to develop
Elbow contractures