Lecture 7: Rehabilitation of People with Spinal Cord Injury PDF

VII. REHABILTATION OF PEOPLE WITH SPINAL CORD INJURY 1. CLASSIFICATION OF SCI Tetraplegia Paraplegia It is highly important to have the knowledge of neuroanatomical organization and Structure. Ascending and descending tracts of the spinal cord...

VII. REHABILTATION OF PEOPLE WITH SPINAL CORD INJURY 1. CLASSIFICATION OF SCI Tetraplegia Paraplegia It is highly important to have the knowledge of neuroanatomical organization and Structure. Ascending and descending tracts of the spinal cord Relationship between spinal cord and nerve roots to vertebral bodies. DESIGNATION OF LESION LEVEL  In an effort to standardize the way in which severity of injury is determined and documented, the American Spinal Injury Association (ASIA) created the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI). It promotes better communication between and among professionals, provides guidance for establishing the prognosis, and is an important tool for clinical research trials.  COMPLETE INJURIES, INCOMPLETE INJURIES, AND ZONE OF PARTIAL PRESERVATION  The ISNCSCI defines a complete injury as having no sensory or motor function in the lowest sacral segments (S4 and S5), with no sacral sparing. Sacral sparing is determined by sensory function at S4–5 dermatome, ability to feel deep anal pressure, or voluntary anal sphincter contraction. An incomplete injury is classified as having motor and/or sensory function below the neurological level that includes sensory and/or motor function at S4 and S5, with presence of sacral sparing.  If an individual has motor and/or sensory function below the neurological level but does not have sacral sparing, then the areas of intact motor and/or sensory function below the neurological level are termed zones of partial preservation.  Individuals with incomplete injuries may have variable clinical presentations in terms of motor and/or sensory function below the neurological level. The ASIA Impairment Scale was created to distinguish among different types of SCI—complete, sensory incomplete, and motor incomplete. ASIA Impairment Scale https://www.physio- pedia.com/American_Spinal_Injury_Association_(AS IA)_Impairment_Scale CLINICAL SYNDROMES  Clinical Syndromes Brown- Anterior Central Cauda Sequard Cord Cord Equina Syndrome Syndrome Syndrome Injuries 2. IMPACT OF SPINAL CORD INJURY ACROSS THE ICF  Impact of SCI across the ICF Body structure/function impairments Secondary and other Activity limitations, participation impairments restrictions, and quality of life Spinal shock Contractures Motor and sensory impairment Heterotopic ossifications Autonomic dysreflexia Osteoporosis and Skeletal Spastic hypertonia Fracture Cardiovascular Impairment Impaired Temperature Control Pulmonary Impairment Bladder and Bowel Impairment Sexual Dysfunction Pain Spinal shock Immediately following SCI, there is a period of areflexia that is part of spinal shock. It is characterized initially by an absence of all reflex activity and impairment of autonomic regulation, resulting in hypotension and loss of control of sweating and piloerection (goose bumps). The initial period of total areflexia lasts approximately 24 hours. This is followed by a gradual return of reflexes 1 to 3 days after injury and a period of increasing hyperreflexia lasting 1 to 4 weeks. Motor and Sensory Impairments Following SCI, there will be either complete (paralysis) or partial (paresis) loss of muscle function below the level of the lesion. Disruption of the ascending sensory fibers following SCI results in impaired or absent sensation below the level of the lesion. The clinical presentation of motor and sensory impairments depends on the specific features of the lesion. These include the neurological level and the completeness of the lesion. Autonomic Dysreflexia (AD) Autonomic dysreflexia (AD), also referred to as autonomic hyperreflexia, is a pathological autonomic reflex that can be life- threatening. Typically, AD occurs in lesions above T6 (above the sympathetic splanchnic outflow). However, it has been reported in patients with lower injuries. Although AD is more common in the chronic stage of recovery (more than 3 to 6 months after injury), it may also occur in the early stages after SCI.  It is more common with complete injury, but it may also occur with an incomplete SCI. This clinical syndrome produces an acute onset of autonomic activity from noxious stimuli below the level of the lesion. Afferent input from these stimuli reach the lower spinal cord (lower thoracic and sacral areas) and initiate a mass reflex response resulting in elevation of blood pressure. This is a critical, emergency situation. Owing to the lack of inhibition from higher centers, hypertension will persist if not treated promptly. Hypertension triggered by AD can result in seizures, cardiac arrest, subarachnoid hemorrhage, stroke, or even death. Spastic Hypertonia Spastic hypertonia typically emerges below the level of the lesion after spinal shock evolves. There is a gradual increase in spastic hypertonia during the first 6 months, and a plateau is usually reached 1 year after injury. Various stimuli, including positional changes, cutaneous stimuli, environmental temperatures, tight clothing, bladder or kidney stones, fecal impactions, catheter blockage, urinary tract infections, decubitus ulcers, and emotional stress, may trigger or increase spasticity and muscle spasms. Spasticity is generally managed through a variety of methods, including stretch, modalities, and medications. Cardiovascular Impairment In healthy individuals with an intact spinal cord, cardiovascular function is regulated by the brain stem and hypothalamus via the sympathetic and parasympathetic nervous systems of the autonomic nervous system. Sympathetic outflow to the heart and blood vessels of the upper body comes from the cervical and upper thoracic region (above T6), while sympathetic outflow to blood vessels of the lower body come from below T5 (T6–L2). The resulting imbalance between sympathetic and parasympathetic control of the cardiovascular system after SCI can result in a variety of cardiovascular impairments including AD , neurogenic shock, bradyarrhythmias, hypotension, orthostatic hypotension, and impaired cardiovascular reflexes. Impaired Temperature Control After damage to the spinal cord, the hypothalamus can no longer control cutaneous blood flow or level of sweating. This autonomic (sympathetic) dysfunction results in loss of internal thermoregulatory responses. The ability to shiver below the level of the injury is also lost. The degree of impaired thermoregulation will vary depending on the level of the injury and whether the injury is complete or incomplete. Individuals with cervical-level injuries and complete injuries demonstrate more impairment. Pulmonary Impairment Bladder and bowel dysfunction Lesion above the conus medullaris and sacral segments Spastic or hyperreflexic bladder (UMN bladder). Lesion of the conus medullaris and sacral segments a flaccid or areflexic bladder (LMN bladder). Management: Spinal shock the bladder is flaccid and an indwelling catheter is inserted. After the patient is stable during rehabilitation intermittent catheterization: - Fluid intake pattern, approximately 2,000 mL/day. - Intake is stopped late in the day to reduce the need for catheterization during the night.  - Initially, the patient is catheterized every 4 hours. - Intake is stopped late in the day to reduce the need for catheterization during the night. - A record is maintained of voided and residual urine. Other managements include: - Suprapubic tapping: tapping directly over the bladder with fingertips, causing a reflexive emptying of the bladder (works only for UMN bladder without dyssynergia between the detrusor and sphincter). - Valsalva maneuver: Done by straining and used for individuals with an areflexive bladder.  The exact method used for bladder management will depend on a variety factors: type of bladder dysfunction, level of injury, functional ability, and personal preference. Whichever method(s) is used, the goal is for the patient to be catheter free, have low postvoid residual volume of urine in the bladder, and be without high bladder pressure during voiding. Because of impaired bladder function, over 60% of people with SCI will develop UTIs in the first year postinjury. Pain Pain is a common occurrence following SCI both in the acute and chronic stages of recovery. Pain can limit the performance of activities of daily living (ADL), affect sleep, and contribute to a lower quality of life. Pain can be grossly divided into twq broad categories. Nociceptive pain Musculoskeletal or visceral in origin. Can be below, at, or above the level of injury. Neurogenic pain Can take the form of allodynia or hyperalgesia. Contractures Contractures develop secondary to prolonged shortening of structures across and around a joint, resulting in limitation in motion. Spasticity, positioning in wheelchair or bed for prolonged periods of time, and abnormal muscle tone are all factors that place people with SCI at a high risk for developing contractures. Contractures of the ankle, knee, hip, elbow, and shoulder joints may have significant negative impact on a person’s ability to perform important activities and participate in valued social roles. Management: - The most important management is prevention, but once contractures develop, a consistent and concurrent program of ROM exercises, Contractures Contractures develop secondary to prolonged shortening of structures across and around a joint, resulting in limitation in motion. Spasticity, positioning in wheelchair or bed for prolonged periods of time, and abnormal muscle tone are all factors that place people with SCI at a high risk for developing contractures. Contractures of the ankle, knee, hip, elbow, and shoulder joints may have significant negative impact on a person’s ability to perform important activities and participate in valued social roles. Management: The most important management is prevention. a consistent and concurrent program of ROM exercises, positioning, and splinting is important to maintain joint motion and prevent contracture. Heterotopic (Ectopic) Ossification Heterotopic ossification (HO) is osteogenesis in soft tissues, usually near joints, below the level of the lesion. Factors associated with HO include complete injury, trauma, severe spasticity, UTI, and pressure injuries. Care should be taken while performing PROM. If it is too vigorous, it may cause trauma, which may be a causative factor for HO. It most often occurs in the hip and knee joints. Early symptoms of HO include swelling, joint and muscle pain, decreased ROM, erythema, and local warmth near a joint. HO can lead to contractures, pressure injuries, impaired mobility, and compromised ability to perform ADLs.  Management: - pharmacological management, physical therapy (maintaining ROM), and, with severe activity limitations, surgery. - Pulsed low-intensity electromagnetic field may also be an effective method to prevent HO formation. Osteoporosis and Skeletal Fracture Individuals with SCI may experience significant loss of bone both early after injury and long-term. There is a rapid bone mineral loss in the first 4 to 6 months after injury. The reduction in bone mineral density is thought to be due primarily to a combination of no (or limited) muscle action and limited (or no) weight-bearing. It is most common in the LEs, although osteoporosis may also occur in the UEs in people with cervical SCIs. The reduction in BMD places people with SCI at a significant risk for fracture. Falls or a forced maneuver during a transfer, ADL such as dressing, and stretching are common activities that precipitate a fracture.  Management: - Medical treatment (Bisphosphonate) is used in the early and later stages to prevent and reduce BMD loss. - Rehabilitation strategies used to prevent or reduce BMD loss are functional electrical stimulation and weight-bearing activities with either a standing frame or orthotics and assistive devices.  Activity Limitations, Participation Restrictions, and Quality of Life The neurological level of injury and whether the injury is complete or incomplete plays a major role in determining an individual’s independence with functional mobility tasks and ADL. Reported barriers to employment are transportation; health and physical limitations; lack of experience, education, or training; environmental barriers, discrimination, and loss of benefits. People with SCI generally report a lower quality of life (QOL) compared to nondisabled individuals. However, QOL is not consistently related to severity of injury and activity limitations. 3. PROGNOSIS FOR RECOVERY OF WALKING AND MOTOR FUNCTION  The potential for recovery from SCI is directly related to the neurological level of the lesion and completeness of the injury. An incomplete lesion (AIS B, C, or D) is a good prognostic indicator of recovery of motor function. Patients with an AIS impairment A are unlikely to regain the ability to walk. Preservation of pinprick sensation after injury in the LEs or sacral region is associated with a good prognosis for motor recovery and walking ability at 1 year after injury. Lower-extremity ASIA motor score, quadriceps and gastrocnemius strength in particular, can be a useful predictor of functional walking ability in people with motor incomplete injuries.  As with any clinical prediction guide, it is important to keep in mind that these factors should only be used as a guide to assist in the development of goals and the POC. Psychosocial support, insurance coverage, and patient psychological status and motivation can also affect the outcomes. Additionally, new therapies may be developed that improve neurological recovery. 4. EARLY MEDICAL MANAGEMENT  EARLY MEDICAL MANAGEMENT Emergency Fracture Immobilization care stabilization