PT Exam Prep PDF - Spinal Cord Injuries - 2024

Helping you prepare for and pass the Canadian Physiotherapy Competency Exams WRITTEN COURSE MANUAL 2024 Written Course Manual | Page 1 of 383 Rhomberg: used to determine the cause of loss of motor coordination (ataxia): Is a person’s ataxia due...

Helping you prepare for and pass the Canadian Physiotherapy Competency Exams WRITTEN COURSE MANUAL 2024 Written Course Manual | Page 1 of 383 Rhomberg: used to determine the cause of loss of motor coordination (ataxia): Is a person’s ataxia due to sensory issues or cerebellar issues? Testing procedure: Patient stands with feet together, arms at their side and eyes open. Patient is then asked to close their eyes (therapist stays close for safety): o Positive test if patient loses their balance once eyes are closed o A positive Romberg test suggests that the ataxia is sensory in nature (due to loss of proprioception). If a patient is ataxic and Romberg's test is not positive, it suggests that ataxia is cerebellar in nature. Individual need at least 2 of the 3 following systems intact to maintain balance in standing: Vestibular Proprioception Vision If vision is taken away in standing, there are only 2 systems left to use: vestibular and proprioception. If the patient loses balance once eyes are closed (positive test), we can determine that the sensory system is not working adequately and is contributing to the individual’s ataxia. Note: Romberg 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 Romberg. When vision is removed, only 2 of the three systems remain to aid in balance and if there is a vestibular issue or proprioceptive dysfunction, the patient will become unbalanced. A positive Romberg can direct the therapist to look further into the function of the vestibular and proprioceptive systems to see which one is not functioning correctly. Spinal Cord Injuries Spinal Cord Injury Causes of SCI: Traumatic: 40% are cervical incomplete; tetraplegic and paraplegic common o Types: hyperflexion, hyperextension, axial load, rotation, penetrating injury, falls Non-traumatic: most are paraplegic o Cancer, infection and inflammation, motor neuron disorders, vascular diseases (spinal cord infarcts) Immediate treatment: Prevention of edema can prevent some secondary injury (ischemia, hypoxia, necrosis) → direct application of ice. Spine needs to be immediately immobilized to prevent secondary injury. Management of airway, breathing, circulation, injuries. Benefits of surgery: realignment, stabilization, early mobilization, early rehab, less medical complications, decreased length of stay in hospital. o Goal: spinal stability while maximizing future mobility o Reasons for surgery: unstable fracture, worsening neurological symptoms o Lumbar laminectomy: helps to decompress the cauda equina/nerve roots 2024 Written Course Manual | Page 218 of 383 Spinal Cord Tracts Category Tract Role Where it crosses How to test it Ascending Lateral Pain Within spinal cord, 1-2 Sharp/dull tracts spinothalamic Temperature segments above the Hot/cold (Sensory) point of entry Anterior Crude touch Within spinal cord, 1-2 Light touch spinothalamic Pressure segments above the point of entry Dorsal columns Proprioception Crosses at the Tuning fork (medial Deep touch pyramid motor 2-point discrimination lemniscus) 2-point (medulla) in the Stereognosis discrimination brainstem Kinesthesia Vibration Proprioception Stereognosis Descending Lateral Main motor path Crosses at the No simple clinic test tracts corticospinal (90% of CS tract) pyramid motor can determine (Motor) (medulla) in the specific CS tract Motor function of brainstem function limbs and digit Transcranial cortical musculature stimulation can be used Injury will result in spastic paralysis (UMNL) presentation of the limb(s) below the level of lesion Anterior 10% of CS tract Within the spinal No specific test corticospinal cord at the level of Motor function of innervation postural and axial musculature 2024 Written Course Manual | Page 219 of 383 2024 Written Course Manual | Page 220 of 383 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. o Motor level: most caudal segment with a grade >/= 3 provided all segments above are grade 5 ▪ Motor exam looks at 10 bilateral myotomes (always performed in supine) ▪ Note: C5 = test elbow flexion (different than standard myotomes) ▪ If an injury is above C5 or T2-L1, then the motor level is determined by intact sensory level (because there is no myotome testing for these levels) ▪ Strength can differ between right and left sides Overall motor level is based on the uppermost intact level o Sensory level: most caudal segment with bilateral score of 2 for both light touch and pin prick Key contact points assigned to each dermatome Sensation is graded as follows: 0 = absent; 1 = impaired; 2 = normal ASIA Grade (A-E) Grade Findings ASIA A No motor or sensory function is preserved in the sacral segments (S4-5) Complete ASIA B Sensation but not motor is preserved below neurological level and includes Sensory incomplete, motor the sacral segments (S4-5) complete ASIA C More than half the key muscles below the neurological level have a muscle Motor incomplete grade less than 3 ASIA D More than half of the key muscles below the neurological level have a Motor incomplete muscle grade greater or equal to 3 ASIA E Normal motor and sensory function Normal Used with patient having a 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). Zone of partial preservation (ZPP): There may be dermatomes below the sensory level and myotomes below the motor level that remain partially innervated which is known as the Zone of Partial Preservation (ZPP). The most caudal segment with some sensory or motor innervation defines 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 good prognostic indicator of motor function and ability to walk to return. 2024 Written Course Manual | Page 221 of 383  Clinical Syndrome Characteristics Central cord syndrome Most common syndrome seen and can be very disabling Damage to the central portion of the cord and an incomplete lesion Caused by hyperextension injury of neck, usually an elderly person who falls Presents with greater loss of UE function compared to LE (will lose most ADL function, have no mechanism to save self when falling) Often associated with spinal canal stenosis Here is a tip to help you remember central cord syndrome: MUDE Motor > Sensory Upper extremity > Lower extremity Distal > Proximal Extension injury 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 Traumatic neurological disorder resulting from compression of one side of the spinal syndrome cord or hemisection, typically seen after a penetrating/knife-type injury; 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 Tip for remembering the spinothalamic tract: pain and temperature sPinoThalamic, P = Pain and T= Temperature Anterior cord Relatively rare, but can happen from occlusion of blood supply to anterior cord syndrome Bilateral loss of motor function, pain and temperature (anterior tracts) below injury level Preservation of discriminative touch, vibration, proprioception (dorsal columns) Conus medullaris Spinal cord terminates at ~L1-L2 syndrome Conus lies in close proximity to nerve roots and injury to this region can result in combined UMN and LMN features (e.g. spasticity) May be sparing of sacral reflexes Cauda equina Damage to lumbar and sacral nerve roots (L2 and below) syndrome Lower motor neuron type injury Variable loss, areflexic (flaccid) bowel and bladder Affects more than one nerve root, surgical emergency Usually presents with: bilateral leg pain/numbness/weakness, sacral root problems, urinary retention, stool incontinence, absent reflexes 2024 Written Course Manual | Page 222 of 383 Neurogenic Bladder Spastic bladder: injuries ABOVE the conus medullaris: Messages will continue to travel between bladder and spinal cord since reflex arc is still intact. Depending on the extent of spasticity present, patients can learn to either manage it on their own with medication, bladder routine, facilitation trigger emptying (like tapping) or they will require intermittent catheters or condom/foley drainage. Flaccid bladder: injuries in conus and/or cauda equina: Messages don’t travel between spinal cord and bladder since the reflex center is damaged. Bladder loses ability to empty reflexively and will continue to fill. Bladder must be catheterized. Autonomic System The peripheral nervous system has 2 major subdivisions: somatic nervous system and autonomic nervous system. Somatic nervous system is associated with activities that are conscious or voluntary. Autonomic nervous system controls internal organs and glands and is associated with activities that are beyond our conscious and voluntary control to help maintain homeostasis. o The autonomic nervous system is further divided into the sympathetic and parasympathetic nervous systems. Sympathetic nervous system: “fight or flight”: Prepares body for an emergency. Fibers arise from thoracic and lumbar portions of spinal cord: T1-L1. Short pre-ganglionic fibers and long post-ganglionic fibers. Actions: o Arteries to skin and intestines are constricted (to allow for redirection of blood to skeletal muscle) o Increases HR and BP o Relaxes bronchial muscles to allow for increased O2 supply 2024 Written Course Manual | Page 223 of 383 Parasympathetic nervous system: “rest and digest” Conserves and restores energy, maintains bodily functions. Fibers arise from cranial nerves III, VII, IX, X and sacral nerve roots 2-4. Long pre-ganglionic fibers and short post-ganglionic fibers. Actions: o Primary interest is the vagus nerve which decreases HR and contractility o Increases blood flow to smooth muscle to aid in reproduction, digestion o Contracts bronchial muscles Autonomic nervous system dysfunction in SCI The amount of sympathetic influence occurring is dependent on the level of injury. In higher level lesions, T6 and above, a significant portion of the sympathetic nervous system has been disconnected from normal communication along the spinal cord which can have the following effects: Decreased heart rate: Sympathetic innervation to heart is T1-4. o Injuries above T4 will directly impact heart rate Parasympathetic influence remains intact and unopposed via the vagus nerve. Causes decreased HR and limits cardiac output. HR response to exercise is blunted with a max of only 110-120bpm. Heart response is due to vagal withdrawal rather than sympathetic drive. HR is not a good indicator of exercise intensity with these individuals - use RPE, dyspnea, sing/talk/gasp scales instead. Decreased blood pressure: With decreased HR, cardiac output is limited. Decreased cardiac output = blood pressure response to exercise will also be limited (unless they are having an episode of AD). Do not let BP fall below 70/40. A combination of altered autonomic HR control and decreased muscle tone in the lower body (venous pooling) contribute to decreased BP in this population. Poor regulation of body temp (will go up and down with environment temperature): Body temperature regulation via autonomic nervous system: o Normal increase in body temperature: vasoconstriction of blood vessels in skin to maintain heat in the core of the body; shivering to create heat through muscle activation. o Normal decrease in body temperature: vasodilation of blood vessels in skin to bring heat to surface for heat loss/cooling; sweating for increased heat loss through evaporation. Messages sent to increase or decrease body temperature are blocked due to the spinal lesion. This can lead to increases in body temperature with exercise and risk of hypothermia when in a cold setting. Prevent overheating during exercise by: o Ensuring adequate hydration pre-exercise, appropriate light clothing, cooling with fans, close monitoring for signs of over-heating, avoid exercising in heat 2024 Written Course Manual | Page 224 of 383 Reasons for dizziness in SCI patient: autonomic dysreflexia, orthostatic hypotension, hypoglycemia Ensure you understand why your patient is feeling dizzy. Example: patient with a SCI is elevated on a tilt table to 60 degrees and begins to feel nauseous and dizzy - always monitor vitals: o If BP is elevated, could be an episode of autonomic dysreflexia – keep patient upright and look for source of noxious stimulus and monitor vital signs o If BP has dropped, it is an episode of orthostatic hypotension - most immediate response is to lower the tilt table to horizontal and monitor vital signs o Episodes of hypoglycemia causing dizziness are usually associated with excessive perspiration so look for this as well to indicate possible hypoglycemic episode Autonomic Dysreflexia In lesions above or equal to T6: A noxious stimulus below level of lesion causes a reflexive sympathetic response that causes blood vessels to constrict. Vasoconstriction causes a sharp rise in BP (increase of >20-30mmHg). The baroreceptors in the carotid sinus and aortic arch detect the hypertension and stimulate the parasympathetic nervous to decrease BP by decreasing HR (via vagus nerve). Because of the spinal cord lesion, the descending inhibitory response (via the parasympathetic system) only travel as far as the level of injury and do not cause the desired response in the sympathetic fibers below the injury allowing the hypertension to remain uncontrolled. Above the injury there is parasympathetic dominance resulting in: flushing and sweating above the level of injury, bradycardia, pupillary constriction, and nasal congestion (unopposed parasympathetic responses). Below the level of injury there is a sympathetic dominance resulting in: chills, pale, cool/clammy skin (vasoconstriction to blood vessels of skin). Patient will have a sudden significant increase in BP (>200/100), may feel dizzy, nauseated and have a headache. Why is this more common in lesions above T6? The splanchnic vascular bed is one of the body’s largest reserves of circulatory volume and is controlled primarily by the greater splanchnic nerve. This important nerve derives its innervation from T5-T9. Lesions to the spinal cord at or above T6 allow the strong and uninhibited sympathetic tone to constrict the splanchnic vascular bed, causing systemic hypertension. Lesions below T6 generally allow enough descending inhibitory parasympathetic control to modulate the splanchnic tone and prevent hypertension. Physiotherapist’s immediate response: If standing, sit patient down for safety. If patient is sitting, keep them in sitting. Keep head elevated – do not lie patient flat. Find the source of the noxious stimulus - check bladder/catheter and bowel for impairment. o Bladder distension or irritation is responsible for 75-85% of the cases. Monitor BP. 2024 Written Course Manual | Page 225 of 383  If BP remains >150 mmHg for adults, despite removal of noxious stimuli, then pharmacological management of hypertension should be initiated → send to emergency for assessment and management. If severe, complications include: uncontrolled hypertension that can result in intracranial hemorrhage, retinal detachment, seizure, or death. Spinal Shock and Neurogenic Shock Spinal shock Neurogenic shock Causes Due to an acute spinal cord Due to an acute spinal cord injury: level T6 and above only injury Signs and Temporary suppression of Hemodynamic phenomenon due to loss of sympathetic Symptoms all reflex activity below the vascular tone and unopposed parasympathetic response level of injury: Decreased reflexes Occurs only after a significant proportion of the sympathetic nervous system has been damaged – lesions at T6 level or Loss of sensation higher Flaccid paralysis 3 clinical signs: Bradycardia – due to unopposed parasympathetic stimulation Hypotension – due to massive vasodilation Hypothermia – unable to regulate temperature due to vasodilation of blood vessels in skin Time Frame Can last days to months Occurs within 30 minutes of cord injury levels T6 and above (transient) and can last up to 6 weeks Additional Spinal shock does not refer Can be life threatening if not treated Info to circulatory collapse and Treatment for hypotension: volume resuscitation (saline), should not be confused vasopressors (to counter loss of sympathetic tone) with neurogenic shock SCI Health Risks Pressure sores/wounds. o In supine, area most susceptible to pressure sore is the coccyx Poor secretion clearance. DVT and PE due to: o Venous stasis (lack of muscle pump action) ▪ DVT signs: sudden lower extremity pain, redness, swelling, increased temperature, positive Homan’s ▪ Prevention: anticoagulation meds, compression stockings, sequential compression devices, PROM/AROM, early mobilization ▪ Note: for PE → tachycardia may be masked by parasympathetic dominance 2024 Written Course Manual | Page 226 of 383  Heterotrophic ossification → 2 main contraindications for treatment are forced PROM and serial casting o Signs and symptoms: pain (if sensory sparing), increased spasticity, warmth, low grade fever, erythema, local swelling, sudden decreased ROM with an abnormal firm or hard end-feel o Treatment: PROM within tolerable range → mobilize as able, medications and surgery if long standing Osteoporosis: o Due to rapid increase calcium excretion within few days of SCI o Decreased bone loading post injury o Large incidence of fracture, especially in LE Post traumatic syringomyelia: o Formation of an abnormal tubular cavity in the spinal cord o Dura tethers/scars to the arachnoid blocking cerebrospinal fluid (CSF) flow o CSF is forced into the spinal cord progressively enlarging the cyst o Leads to compression of cord and vascular supply o Cyst develops below level of lesion ▪ Can occur years after the original injury o Signs and symptoms ▪ Looking for differences or increase in presentation of the injury (presenting like a higher level), pain at level and spreading upwards, sensory changes, motor weakness, increased spasticity, bladder and bowel dysfunction, increased episodes of autonomic dysreflexia, hyperhidrosis o Treatment and prevention → surgery → decompression or shunt Multisystem: o Individuals with SCI tend to have lower BP, have decreased lean muscle mass and increased adipose tissue which can lead to impaired glucose uptake, glucose homeostasis and abnormalities in lipid metabolism o Cardiovascular disease is a major cause of death in people surviving 30+ years post SCI o Left ventricular myocardial atrophy seen in individuals with SCI o 100x higher rate of bladder cancer in individuals with SCI o Infections due to pressure wounds can lead to sepsis SCI and Exercise Adapted from website: http://sci.washington.edu/info/forums/reports/exercise_2013.asp Benefits of exercise in SCI population: Reduce risk of heart disease Improve respiration Increase muscle strength Improve circulation Improve mental health Increase independence with functional mobility and ADL’s Prevent secondary complications (e.g. urinary tract infections, pressure ulcers, resp infections) Reduce the risk for diabetes Improve immune system function Reduce constipation 2024 Written Course Manual | Page 227 of 383 Every SCI is unique based on level and grade of the injury. Special exercise precautions for people with SCI: Blood pressure Individuals with SCI have low blood pressure due to blood pooling in legs resulting in light- headedness: o The higher and more complete the lesion, the more problematic o Ways to manage this include: ▪ Compression stockings ▪ Medications ▪ Start slow and progress gradually when exercising Temperature For injuries at T6 or above temperature regulation is affected: o Decreased temperature regulation = increased risk of overheating ▪ Exercise environment should be cool ▪ Dress in loose clothing ▪ Stay hydrated Heart rate For injuries at T4 or above, heart rate is affected: o Results in difficulty gauging exercise effort using HR o Use of alternative options for monitoring exercise intensity ▪ BORG Moderate intensity 11-13 on BORG; 3-5 on modified BORG ▪ Sing Talk Gasp Scale Should exercise hard enough to be breathing heavily but not so hard that they can’t carry on a conversation without gasping for air Skin breakdown Protect and monitor skin during exercise. Autonomic dysreflexia Know signs and symptoms of AD. Empty catheter bag before starting exercise activity. Overuse injuries Maintaining good exercise technique. Avoid repetitive motion injuries. Choose exercises that do not overuse muscles already used a lot during daily activities (e.g. muscles used to push a manual wheelchair). 2024 Written Course Manual | Page 228 of 383  Medications Make note if patient is on a pain medication or has sensory loss. Pain medication and/or sensory loss may increase pain threshold and make it difficult to know if an exercise is causing injury. Frequency: 5x/week Cardiovascular conditioning: 3-5x/week Strength training: 2-3x/week Stretching: daily Intensity Cardiovascular conditioning: moderate (see above) Strength training: start with low weight and gradually work to heavier loads, pain free Stretching: gentle, pain free Time Cardiovascular conditioning: 30-60 mins Strength training: 3-5 sets; 10-15 reps Stretching: ~1min hold; 3 sets Type Cardiovascular conditioning: o Wheelchair pushing o Seated aerobics o Arm ergometer o Swimming o Rowing o Cycling o Circuit training o Adapted sports o Walking (if applicable) Strength training: free weights, body weight, elastics, machines etc. o Focus on back muscles, scapular stabilizers, rotator cuff muscles, triceps 2024 Written Course Manual | Page 229 of 383 Levels of Injury and Functional Expectations Levels - cough Injury Level Cough C1-3 Absent C4-T4 Non-functional T5-T10 Weak functional: able to clear normal daily secretions; may have difficulty with abnormal secretions (e.g. pneumonia) T11-below Normal Levels - respiratory status Injury Level Respiratory Status C1-3 Ventilator dependent Vital capacity is 5-10% C4 Phrenic nerve (C3-5): diaphragm innervation (main muscle of inspiration) C4: enough innervation to diaphragm to breath independently Without full diaphragm innervation, patient may need to use ventilator at night C2-C7 Innervation of accessory muscles of inspiration: SCM, scalenes, pectoralis minor Vital capacity is 20% T1-T10 Intercostals (external intercostals = inspiration; internal intercostal = expiration) Abdominals (aid in active expiration via rectus abdominus, obliques, TA) Vital capacity 30-50% in higher t-spine lesions T11-below Normal vital capacity 2024 Written Course Manual | Page 230 of 383 Levels – functional expectations C1-C4 Patterns of weakness Paralysis of trunk, UE and probably diaphragm Muscles innervated SCM (CN XI), neck extensors, neck flexors, trapezius (CN XI) fully Muscles partially Levator scapulae (C3-C5), diaphragm (C3-C5), rhomboids (C4-C5) innervated Possible movements Neck movements, slight shoulder retraction, adduction and elevation Functional outcomes Independent use of power wheelchair with sip and puff or head controls (C4) PT role ROM, spasticity management (prevent contractures), neck strengthening, inspiratory muscle training, chest physiotherapy C5 Patterns of weakness Paralysis of trunk, significant imbalance around shoulder girdles, absence of elbow extension, forearm pronation, wrist extension/flexion and all hand movements Muscles innervated Levator scapulae (C3-C5), diaphragm (C3-C5), rhomboids (C4-C5) fully Muscles partially Deltoids (C5-6), biceps (C5-6), brachioradialis, teres minor (C5-6), teres major (C5- innervated 7), serratus anterior (C5-7), supraspinatus/infraspinatus (C5-6), pectoralis major/minor (C5-T1) Possible movements Shoulder abduction, flexion and extension (weak), scapular protraction and retraction, elbow flexion, forearm supination Functional outcomes Independent use of power wheelchair with modified hand controls Potential for independent use of manual wheelchair with projection rims (flat surfaces indoors, w/c setup is essential for success) Able to maintain propped sitting position (locked elbows) but stand by assist necessary at all times and assist needed to get into this position Independent hand to mouth for feeding with adapted gripping aids (universal cuff) Potential independent grooming with adapted gripping aids Able to assist with bed mobility, transfers PT role As above plus…. Shoulder strengthening/ shoulder health education Wheelchair skills 2024 Written Course Manual | Page 231 of 383  C6 Patterns of weakness No wrist flexion, elbow extension, hand movement Muscles innervated Deltoids (C5-6), biceps (C5-6), brachioradialis (C5-6), teres minor (C5-6), fully supraspinatus/infraspinatus (C5-6) Muscles partially Serratus anterior (C5-7), triceps (C6-8), teres major (C5-7) innervated Pectoralis major/minor (C5-T1), ECRL (C6-7), ECRB (C6-C8), Latissimus dorsi (C6- 8) Possible movements Horizontal adduction, wrist extension Functional outcomes Independent use of manual wheelchair with projection rims on indoors and outdoors on relatively flat surfaces (e.g. may be able to move over grass) Power wheelchair for distance Independent bed mobility is possible Independent with pressure relief Independent transfer with slide board is possible Maintain propped sitting using shoulder ER (teres minor) and locked elbows Independent upper body dressing Assist with LE dressing Assisted self-care Independent LE PROM program possible Tenodesis grip - able to grab light objects First level of SCI to have potential to function independent without a care assistant (but this is very rare) Driving with hand controls Limited participation in wheelchair sports PT role As above plus… Propped sitting practice Transfer practice with slide board Functional strengthening Teach independent PROM program for LE Wheelchair practice Teach “trick” movement strategies (e.g. tenodesis) Education on avoiding stretching long finger flexors in order to maintain functional tenodesis (only stretch finger flex when wrist is flexed) 2024 Written Course Manual | Page 232 of 383  C7 Patterns of weakness Limited grasp and release due to limited finger flexion/extension Muscles innervated Serratus anterior (C5-7), teres major (C5-7), pectoralis major (clavicular head), fully ECRL (C6-7) Muscles partially Triceps (C6-8), latissimus dorsi (C6-8), ECRB (C6-C8), ED (C7-C8), FDS (C7-T1), FDP innervated (C7-T1), FCR (C6-8), intrinsic hand muscles Possible movements Elbow extension, wrist flexion, finger flexion/extension (very weak) Functional outcomes First level of SCI to have potential to live independently in community without aid Seat lifts for independent pressure relief in manual w/c Independent transfers without slide board due to tricep function Independent with manual wheelchair outdoors with potential to maneuver over slightly uneven terrain (e.g. small curb) May still use power wheelchair for longer distances Independent with most/all ADL’s Stronger tenodesis grip Strong stable shoulder girdle enabling better control over maneuvering body PT role As above plus… Transfer training on uneven heights Manual wheelchair training outdoors on uneven terrain C8-T1 Patterns of weakness C8 level: still have diff with fine motor skills because intrinsics are not fully innervated Muscles innervated Triceps (C6-8), latissimus dorsi (C6-8), FDS (C7-T1), FDP (C7-T1), FCR (C6-8), ED fully (C7-C8), interossei (C8-T1), lumbricals (C8-T1) Possible movements Improved grasp and release due to intrinsic finger flexor activation (C8), selective PIP/DIP flexion/extension and MCP flexion/extension (C8), normal fine motor hand control: opposition, pincer grip (T1) Functional outcomes Potential to primarily/solely be a manual wheelchair user May still use power wheelchair for longer distances Independent with all ADL’s PT role As above plus…. W/c endurance training Hand and fine motor strengthening 2024 Written Course Manual | Page 233 of 383  T2-T6 Patterns of weakness Trunk weakness Muscles innervated Full innervation of upper limb fully Muscles partially Intercostals, erector spinae innervated Functional outcomes Independent sit balance with adequate righting and protective reactions Manual wheelchair propulsion outdoors on uneven terrain, negotiating 4-8” curbs, steep ramps, hills, gravel, sand, ascend/descend stairs becomes possible Uneven transfers e.g. floor to/from w/c transfers Brace walking with HKAFOs and parallel bars (non-functional) PT role As above plus…. Standing and gait in parallel bars T7-T12 Patterns of weakness Trunk weakness Muscles innervated Full innervation of upper limb and upper trunk musculature fully Muscles partially Intercostals, erector spinae, abdominals (rectus, obliques, TA) innervated Functional outcomes Potential to be an indoor ambulator with bilateral KAFO’s and appropriate assistive device (walker, forearm crutches) “Non-functional” because using trunk to throw legs forward which is very energy consuming Will use wheelchair for primary means of community mobility PT role As above plus… Core strengthening Indoor ambulation with KAFO’s and appropriate assistive device (walker, forearm crutches) 2024 Written Course Manual | Page 234 of 383  L1 - L2 Patterns of weakness Lower limb weakness Muscles innervated Intercostals, erector spinae, abdominals (rectus, obliques, TA) fully Muscles partially Iliopsoas, quadratus lumborum innervated Functional outcomes Hip flexion during the swing phase of gait allows for a swing through gait pattern or a 4-point gait pattern with bilateral KAFO’s and assistive device (walker or forearm crutches) = functional ambulation Indoor/outdoor ambulation with orthoses and devices Will still use wheelchair for primary means of community mobility PT role As above plus… Functional ambulation training and balance work L3 - L5 Patterns of weakness Ankle weakness - no gastrocs/soleus (S1-S2), no intrinsic foot activation Muscles innervated Intercostals, erector spinae, abdominals (rectus, obliques, TA), iliopsoas, fully quadratus lumborum Muscles partially Quadriceps (L2, L3, L4), adductors, abductors (L4-S1), hamstrings (L5-S2), external innervated rotators, tibialis ant/post (L4-L5), EHL, EDL/B (L5, S1), peroneals (L5-S1) Functional outcomes Transition to AFO’s at L3 level due to quadriceps strength L4/5 = walking is primary means of community ambulation with bilat AFOs and aid (cane, walking poles) Decreased standing balance due to PF weakness = AFO’s required for balance PT role As above plus… Functional ambulation training and balance work UMNL vs LMNL SIGNS LMNL UMNL Type of paralysis Reflex response Response in muscle Early, marked atrophy (total absence Limited and delayed atrophy of any muscle activity) (muscles still receive some Muscle fasciculations stimulation) Conduction velocity of Reduced (if compressed) or absent (if Unchanged nerve severed) 2024 Written Course Manual | Page 235 of 383 Spasticity A velocity-dependent increase in stretch reflexes with exaggerated tendon jerks, resulting from hyper- excitability of the stretch reflex, as one component of the upper motor neuron syndrome: Velocity dependent resistance to passive stretch. Clinical characteristics: increased muscle tone/firmness; increased stretch reflexes, uncontrolled movements. Spasticity Pros and Cons Pros Cons Maintain muscle bulk, venous return, useful for Leads to contractures transfers and moving limbs Possibly painful Reflex erection can be achieved Positioning difficulties Acts as warning sign Fatigue Treatment: Medications: o Baclofen: is not selective and makes other muscles weak as well o Botox: local injections for specific muscles Therapeutic exercise Outcome measures specifically used for spasticity: Modified Ashworth, Tardieu. Normal Minimal, if any resistance to passive movement is encountered Findings Abnormal Hypertonia: increased resting tone of a Increased resistance due to spasticity Findings muscle Rigidity: a continuous resistance to passive movement in either joint direction regardless of speed Hypotonia: decreased resting tone Lower than normal resting tone or flaccidity 2024 Written Course Manual | Page 236 of 383