C7 Tetraplegia: Rehab and Prognosis

• Romberg is used to determine the cause of motor coordination loss (ataxia).

Rhomberg Test

• To test if ataxia is due to sensory or cerebellar issues
• The patient stands with feet together, arms at their side, and eyes open.
• After, the patient closes their eyes and the therapist stays close by, for safety.
• The test is positive if the patient loses balance once eyes are closed.
• A positive test suggests that the ataxia is sensory in nature, due to loss of proprioception.
• If a patient is ataxic and the test is not positive, it suggests cerebellar ataxia.
• Individuals need at least 2 of 3 systems (Vestibular, Proprioception, Vision) intact to maintain balance in standing.
• If vision is removed in standing, the vestibular and proprioception systems are the only systems left.
• If the patient loses balance with eyes closed, the sensory system is not working adequately.
• It can be used with individuals without ataxia and uses the same principles.
• Patients who lose their balance when their eyes are closed are said to have a positive test.
• It can direct the therapist to look into the function of the vestibular and proprioceptive systems.

Spinal Cord Injuries

• SCI stands for spinal cord injury.

Causes of SCI

• Traumatic: 40% are cervical incomplete; tetraplegic and paraplegic common.
• Traumatic events include hyperflexion, hyperextension, axial load, rotation, penetrating injury, falls.
• Non-traumatic: most are paraplegic
• Non-traumatic events include cancer, infection, inflammation, motor neuron disorders, vascular diseases.

Immediate Treatment

• Application of ice can prevent edema from occurring to prevent secondary injury.
• Prevention of edema can prevent: some secondary injury (ischemia, hypoxia, necrosis).
• The spine needs to be immobilized immediately to prevent secondary injury.
• There needs to be management of airway, breathing, circulation, and other injuries.
• Benefits of surgery include realignment, stabilization, early mobilization, early rehab, less medical complications, and decreased length of stay in the hospital.
• The goal of surgery is spinal stability while maximizing future mobility.
• Reasons for surgery include unstable fracture and worsening neurological symptoms.
• A lumbar laminectomy decompresses the cauda equina/nerve roots.

Spinal Cord Tracts

• Ascending tracts are sensory.
• Descending tracts are motor.

Ascending Tracts

• Lateral spinothalamic: pain, temperature, tested by sharp/dull, hot/cold discrimination, and crosses within spinal cord 1-2 segments above point of entry.
• Anterior spinothalamic: crude touch, pressure, tested by light touch, crosses within spinal cord 1-2 segments above point of entry.
• Dorsal Columns (medial lemniscus): proprioception, deep touch, 2-point discrimination, vibration, stereognosis, tested by tuning fork, 2-point discrimination, stereognosis, kinesthesia, proprioception, and crosses at the pyramid motor in the brainstem (medulla).

Descending Tracts

• Lateral corticospinal: 90% of the corticospinal tract, the main motor path, motor function of limbs/digit musculature, crosses at the pyramid motor (medulla) in the brainstem.
• A clinic test cannot determine specific corticospinal tract function, though transcranial cortical stimulation can be used.
• Injury results in spastic paralysis (UMNL) of the limb(s) below the level of the lesion
• Anterior corticospinal: 10% of the corticospinal tract, motor function of postural and axial musculature, within the spinal cord at the level of innervation, and there's no specific test.

ASIA Scale

• AISA score is comprised of the grade and level of lesion.

Level of Lesion

• Defined as the most caudal (lowest) segment of the spinal cord with normal sensory and motor function on both sides of the body.
• Motor level is the most caudal segment with a grade >/= 3 provided all segments above are grade 5.
• The motor exam looks at 10 bilateral myotomes, always performed in supine.
• C5 = test elbow flexion (different than standard myotomes)
• The motor level is determined by the intact sensory level if an injury is above C5 or T2-L1, due to absence of myotome testing for these levels.
• Sensory level is the most caudal segment with a bilateral score of 2 for both light touch and pin prick.
• Key contact points are assigned to each dermatome
• Sensation is graded as: 0 = absent, 1 = impaired, 2 = normal

ASIA Grade

• ASIA A Complete: No motor or sensory function is preserved in the sacral segments (S4-5).
• ASIA B Sensory incomplete, motor complete: Sensation but not motor is preserved below the neurological level and includes the sacral segments (S4-5).
• ASIA C Motor incomplete: More than half the key muscles below the neurological level have a muscle grade less than 3.
• ASIA D Motor incomplete: More than half of the key muscles below the neurological level have a muscle grade greater or equal to 3.
• ASIA E Normal: Normal motor and sensory function, used with a patient having history of prior SCI deficits.
• Deep anal pressure (DAP), if present, indicates sensory incomplete injury (ASIA B).
• Voluntary anal contraction (VAC), if present, indicates motor incomplete (ASIA C).
• There may be dermatomes below the sensory level and myotomes below the motor level that remain partially innervated, is the Zone of Partial Preservation (ZPP).
• The most caudal segment with some sensory or motor innervation defines the extent of ZPP.
• ZPP is only ever referenced when describing a complete (ASIA A) injury.
• Prognosis for spinal cord injuries: pinprick preservation (LE and sacral) within 72 hours is a good prognostic indicator of motor function and ability to walk to return.

Central Cord Syndrome

• Is the most common syndrome, and it can be very disabling.
• Often associated with spinal canal stenosis
• Damage is to the central portion of the cord, and an incomplete lesion.
• It is typically caused by hyperextension injury of the neck, usually in an elderly person.
• There is greater loss of UE function compared to LE (will lose most ADL function, have no mechanism to save self when falling) Why is the upper extremity more affected than the lower extremity: the cervical spine is the most central tract in the corticospinal tract, followed by the thoracic, lumbar and sacral tracts. Since only the central portion of the corticospinal tract is affected with this injury, the upper extremities are more affected.

Brown Sequard Syndrome

• Traumatic neurological disorder resulting from compression of one side of the spinal cord or hemisection.
• It is typically seen in penetrating/knife-type injury and asymmetrical damage to cord.
• Ipsilateral loss of proprioception/vibration sense and motor control at/below level of lesion
• Contralateral loss of pain and temperature sensation a few levels below the lesion

Anterior Cord Syndrome

• Relatively rare, but can happen from occlusion of blood supply to the anterior cord.
• Bilateral loss of motor function, pain and temperature (anterior tracts) below injury level.
• Preservation of discriminative touch, vibration, proprioception (dorsal columns)

Conus Medullaris Syndrome

• The Spinal cord terminates at ~L1-L2.
• the Conus lies in close proximity to nerve roots, and injury to this region results in combined UMN and LMN features.
• Sacral reflexes may be spared.

Cauda Equina Syndrome

• There is damage to lumbar and sacral nerve roots (L2 and below) which is a lower motor neuron type injury.
• There is a variable loss of areflexic (flaccid) bowel and bladder affecting more than one nerve root, necessitating a surgical emergency .
• It typically presents with: bilateral leg pain/numbness/weakness, sacral root problems, urinary retention, stool incontinence, absent reflexes

Neurogenic Bladder

• Spastic bladder = injuries ABOVE the conus medullaris
• Messages go to travel from bladder and spinal cord since reflex arc is still intact.
• Depending on the extent of spasticity, patients can learn to manage it, or they require intermittent catheters.
• Flaccid bladder: injuries in conus and/or cauda equina: Messages don't travel between spinal cord and bladder since the reflex center is damaged.
• The bladder loses the ability to empty reflexively and will continue to fill.
• The bladder must then be catheterized.

Autonomic System

• The peripheral nervous system has 2 major subdivisions: somatic and autonomic nervous systems.
• Somatic nervous system is associated with activities that are conscious or voluntary.
• Autonomic nervous system controls internal organs and glands, is associated with activities beyond our conscious and voluntary control.
• The autonomic nervous system is divided into the sympathetic and parasympathetic nervous systems.
• Sympathetic "fight or flight" prepares the body for an emergency, the fibers arise from thoracic and lumbar portions of spinal cord: T1-L1.
• Actions: Arteries to skin/intestines are constricted/ HR and BP increases/ bronchial muscles relaxes.
• Parasympathetic "rest and digest" conserves/restores energy.

Autonomic Nervous System Dysfunction in SCI

• The amount of sympathetic influence relies on the level of injury.
• In higher-level lesions, T6 and above, a portion of the sympathetic nervous system is disconnected with effects: Decreased heart rate with sympathetic innervation to the heart being T1-4.
• Injuries above T4 impact the heart rate
• Parasympathetic influence is intact and unopposed via vagus nerve. Causes decreased HR w a blunted heart rate response during exercise.
• HR is due to vague which isn’t a good indicator of exercise intensity. Decreased blood pressure occurs with limited cardiac output.
• Combination of altered autonomic HR control and decreased muscle tone in the lower body (venous pooling) contributes to decreased BP in this population.

Autonomic Dysreflexia In Lesions Above Equal To T6

• Noxious stimulus goes below lesion level = sympathetic response causing vasoconstriction, sharp rise in BP (increase of >20-30mmHg)
• Baroreceptors detect hypertension stimulates parasympathetic nervous decrease HR.
• Due to spinal cord lesion descending inhibitory response travels the level of injury won’t cause the parasympathetic fibers to control.
• Above the injury there sympathetic is dominance with flushing and Bradycardia.

Spinal shock

• spinal shock means temporary suppression of reflexes, decreased reflexes, loos of sensation, flaccid paralysis, can last days.
• It doesn't mean circulatory collapse so don’t confuse it.

Neuro-genic shock

• Neuro shock is caused by vascular tone which means it is also a para-ympathetic tone, loss of sympathetic system. The clinical signs are bradycardia, hypo-tension, hypo-thermia. Lasts 6 weeks.
• SCI (sores)- prevent with movement, clear secretes, check skin DVT(VENOUS) venous
• Signs sudden lower ext pain, promote PROM exercise.

Secondary Risks Osteo

• Rapid calcium, decrease bone load, cause fracture
• Post truama-block fluid flow lead compress- treat decrease tension.

Heteroptopic Occification

• Main cant dos: forced PROM or seriel
• Symptoms pain sensory spas, local swell, decreased RoM, low grade fvewr.

ScI Exercise Guidelines

• Benefits: heart, breath, immune
• Caution low BP blood pool. Above T6 regulation -exercise. Hrt limit and check with pt

C1-C4 Functional Expectation

• Muscle paralyzed.
• Have the option of speaking can.

C7 Pattern

• No release exten can lock it so it stable
• Tenodes sis to help grip things

L3 -L5 Level

• quad-afos allow 3 pattered cane as walking post
• Lower week-foot week use as gait
• Umnl-spasatic

Spacticity

• Depend increase streth, Velocity, resistance in upper motor.
• Pros maintain muscle, circ return, acts sign warning
• Cons contractions, painful, positiong, fatigue, treats meds.

Signs And Findigs

• Normal findings of pt movement
• Hypertone increase resistance.
• Treat for lower tension.

Exploration of finger flexor education, muscle innervation (C7 level), and potential functional abilities in C6-C7 tetraplegia. Examination of motor function return prognosis after spinal cord injury and outcomes for individuals with C7 tetraplegia; Includes central cord syndrome, Romberg test interpretation, and balance maintenance systems.