Podcast
Questions and Answers
What is the primary purpose of a Thoracolumbosacral Orthosis (TLSO)?
What is the primary purpose of a Thoracolumbosacral Orthosis (TLSO)?
What is a key function of the abdominal binder in early physical therapy management after spinal cord injury?
What is a key function of the abdominal binder in early physical therapy management after spinal cord injury?
Which intervention technique is crucial for preventing skin complications in patients with spinal cord injury?
Which intervention technique is crucial for preventing skin complications in patients with spinal cord injury?
What type of breathing strategy is particularly utilized in patients with mid to high-level cervical lesions?
What type of breathing strategy is particularly utilized in patients with mid to high-level cervical lesions?
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What is the purpose of maintaining tenodesis grasp in patients with spinal cord injury?
What is the purpose of maintaining tenodesis grasp in patients with spinal cord injury?
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Which aspect of physical therapy management addresses mobility skills after a spinal cord injury?
Which aspect of physical therapy management addresses mobility skills after a spinal cord injury?
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What common psychological issue is often seen in individuals with spinal cord injuries?
What common psychological issue is often seen in individuals with spinal cord injuries?
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What primary focus does cardiovascular endurance training serve in the rehabilitation of spinal cord injury patients?
What primary focus does cardiovascular endurance training serve in the rehabilitation of spinal cord injury patients?
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What is the most common etiology for spinal cord injuries?
What is the most common etiology for spinal cord injuries?
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Which demographic has the highest incidence of spinal cord injury?
Which demographic has the highest incidence of spinal cord injury?
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Which condition is associated with autonomic dysreflexia?
Which condition is associated with autonomic dysreflexia?
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What is the primary source of revenue in the first year post spinal cord injury?
What is the primary source of revenue in the first year post spinal cord injury?
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Which spinal cord injury classification involves complete loss of function in the lowest sacral segments?
Which spinal cord injury classification involves complete loss of function in the lowest sacral segments?
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What is the average length of acute care hospital stay for spinal cord injury patients?
What is the average length of acute care hospital stay for spinal cord injury patients?
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What syndrome involves more severe neurological involvement in upper extremities compared to lower extremities?
What syndrome involves more severe neurological involvement in upper extremities compared to lower extremities?
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Which clinical feature is associated with postural hypotension?
Which clinical feature is associated with postural hypotension?
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What is the role of the American Spinal Injury Association (ASIA) classification?
What is the role of the American Spinal Injury Association (ASIA) classification?
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What is a potential result of autonomic dysreflexia?
What is a potential result of autonomic dysreflexia?
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What percentage of spinal cord injuries are due to nontraumatic damage?
What percentage of spinal cord injuries are due to nontraumatic damage?
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Which type of spinal cord injury typically occurs due to hyperextension?
Which type of spinal cord injury typically occurs due to hyperextension?
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What is a common symptom of spastic hypertonia?
What is a common symptom of spastic hypertonia?
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Study Notes
Spinal Cord Injury Overview
- 18,000 new cases per year in the U.S.
- Approximately 300,000-2 million individuals with SCI in the U.S.
- Average age of injury: 43
- Most common between 16-30 years old and 65+.
- 80% Male, 20% Female
Etiology
- Two categories:
- Traumatic injury (62%):
- Motor vehicle accident (MVA) - 38%
- Falls - 32%
- Violence - 14%
- Sport-related
- Nontraumatic damage (38%):
- Disease or pathological influence (e.g., MS, ALS)
- Vascular dysfunction (thrombosis, embolism, hemorrhage)
- Spinal stenosis and other degenerative processes
- Spinal neoplasms
- Infection
- Traumatic injury (62%):
Spinal Level and Impact of Injury
- 56% cervical
- 44% thoracic, lumbar, or sacral lesion
- 18% incomplete paraplegia
- 33% incomplete tetraplegia
- 24% complete paraplegia
- 18% complete tetraplegia
Other Statistics
- Hospital stay average is much shorter than in the past.
- Acute care - ~11 days
- Rehab unit - ~32 days
- Life expectancy has improved since the 1980s but remains lower than for individuals without SCI.
- Age of onset
- Level and extent of neurological injury significantly affect life expectancy.
- Financial impact is extremely high.
- ~$1,000,000 (C1-C4)
- ~$500,000 (Paraplegia)
- Average lifetime costs (injured at 25): ~$3.5 million (C1-C4), ~$2.5 million (C5-C8), and ~$1.6 million (Paraplegia)
Classification of Spinal Cord Injuries
- Two categories:
- Tetraplegia (quadriplegia): Motor and/or sensory impairments of all four extremities and trunk. Includes respiratory muscles. Lesion at the cervical cord.
- Paraplegia: Motor and/or sensory impairments of all or part of the trunk and both lower extremities. Lesion at the thoracic, lumbar spinal cord, or cauda equina.
Spinal Cord Review
- Extends from the medulla at the foramen magnum to the L1 vertebral level.
- Cauda equina: Nerve roots running down from the spinal cord beyond L2 (L2 through S5 nerve roots).
- Filum terminale: Threadlike, non-neural filament running from the conus medullaris.
Central Nervous System Cross-section View of the Spinal Cord
- Central grey matter: Neuronal cell bodies in an "H" or butterfly shape.
- Posterior horn: Transmits sensory impulses.
- Anterior horn: Transmits motor impulses.
- Peripheral white matter: Myelinated axons and fiber tracts (ascending - sensory and descending - motor)
Spinal Nerves
- 31 pairs of spinal nerves
- C1-C7 exit above corresponding vertebrae
- C8 exits below C7 vertebrae
- Nerves named based on vertebral level.
Cross Section of Spinal Cord Showing Tracts
- Key tracts and their functions are diagrammed.
The Spinal Cord
- Detailed diagram showing innervation levels for muscles, sympathetic/parasympathetic systems and nerves associated with the different regions of the body.
Designation of Lesion Level
- Essential to accurately identify the lesion.
- Determine extent of neurological impairment.
- Used to set functional goals (e.g., American Spinal Injury Association (ASIA) International Standards of Neurological Classification of SCI)
- Find figure 20.3, p. 762 for detailed standardized assessment tool.
Neurological/Motor/Sensory Levels
- Neurological level: Most caudal level of spinal cord with normal bilateral motor and sensory function.
- Motor level: Most caudal segment of spinal cord with normal bilateral motor function.
- Sensory level: Most caudal segment of spinal cord with normal bilateral sensory function (pin prick and light touch).
Complete vs. Incomplete Spinal Cord Injury
- Complete spinal cord injury: No sensory or motor function in lowest sacral segments (S4 and S5).
- Incomplete spinal cord injury: Motor or sensory function present below neurologic level.
ASIA Impairment Scale
- Standardized way to communicate degree of impairment.
- Find Figure 20.1, p. 763.
Clinical Syndromes
- Brown-Sequard syndrome: Lesion involving one side of the spinal cord (hemisection). Key characteristics noted.
- Anterior cord syndrome: Lesion involving the anterior two-thirds of the spinal cord. Key characteristics noted.
- Central cord syndrome: Lesion involving the center of the spinal cord. Key characteristics noted.
- Cauda equina: Lesion in lower spinal cord affecting various nerves responsible.
Body Structure/Functional Impairments
- Spinal shock: Initial period after injury characterized by areflexia, flaccidity, and loss of sensation/motor function below lesion level. Duration typically several days to weeks.
- Autonomic dysreflexia (hyperreflexia): Pathological reflex potentially life-threatening. Typically occurs in lesions above T6. Several initiating stimuli causing rapid onset blood pressure increases.
- Spastic Hypertonia: Spasticity occurs in about 65% of people with spasticity. Spasticity occurs below lesion after spinal shock.
- Cardiovascular impairment (Postural Hypotension): Decrease in blood pressure when assuming upright/vertical posture. Caused by loss of sympathetic vasoconstriction control. More common with SCI above T6.
- Impaired Thermoregulation: Hypothalamus can't control blood flow. Inability to shiver/vasodilate with heat and/or vasoconstrict with cold.
- Pulmonary Impairment: Affected by level of the injury. Progressive loss of respiratory function as level of injury increases/uses of accessory muscles.
- Bowel and Bladder Impairment: Requires long term management/UTIs - major cause of morbidity and mortality.
- Pain: Nociceptive and neuropathic.
- Secondary and other impairments: Pressure injuries, UTI, pulmonary infections, DVT, musculoskeletal injuries (contractures, osteoporosis, fractures), heterotopic ossification (osteogenesis in soft tissues).
Early Medical Management
- Emergency Care: Begin treatment and rehab at time of injury, maintain breathing and prevent shock, fracture stabilization, immobilization.
Immobilization
- Halo vest: Provides traction and virtually eliminates movement.
- Thoracolumbosacral orthosis (TLSO): Custom-made, hard plastic device to contain trunk, minimize movement.
- Harrington rods: Pair of rods to provide support in spinal traction or compression.
Physical Therapy Outcomes and Goals
- Functional expectations for patients with SCI.
- Table 20.5, pp. 784-787; Handouts; lecture.
Physical Therapy Interventions
- Respiratory management (Respiratory Muscle Training, Glossopharyngeal Breathing, Abdominal Binder).
- Skin care (prevention).
- Mobility skills and Strength.
- Cardiovascular and Endurance Training.
- Sitting Balance.
- Transfers.
- Locomotor Rehabilitation.
- Activity-Based Upper Extremity Training
- Wheelchair skills.
- Gait/Walking Skills.
- Neurotechnologies.
- Health and Wellness.
- Patient-related education.
Secondary Complications of SCI
- Psychological Considerations: independence, isolation, body image, cognitive impairments, depression, pain, medication side effects.
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