Spinal Cord Injury (Eighth Edition) PDF

Spinal Cord Injury P H Y S I C A L R E H A B I L I T AT I O N, EIGHTH EDITION O ’ S U L L I VA N, S C H M I T Z A N D F U L K CHAPTER 20  Spinal Cord Injury (O’Sullivan and Schmitz, p.760) Spinal Cord Injury  18,000 new...

Spinal Cord Injury P H Y S I C A L R E H A B I L I T AT I O N, EIGHTH EDITION O ’ S U L L I VA N, S C H M I T Z A N D F U L K CHAPTER 20  Spinal Cord Injury (O’Sullivan and Schmitz, p.760) Spinal Cord Injury  18,000 new cases per year in U.S.  Approx. 300,000-2 million individuals with a SCI living in the U.S.  Average age of injury – 43  Most commonly occurs between:  16-30 years of age  65 or older  80% Male, 20% Female  Spinal Cord Injury (O’Sullivan and Schmitz, p. 760) Etiology  Two categories  Traumatic injury – 62%  Nontraumatic damage – 38%  Spinal Cord Injury (O’Sullivan and Schmitz, p. 760) Etiology  Traumatic injury  Motor vehicle accident (MVA) – 38%  Falls – 32%  Violence – 14%  Sport-related  Spinal Cord Injury (O’Sullivan and Schmitz, p. 760) Etiology  Nontraumatic damage  Disease or pathological influence  i.e. MS, ALS  Vascular dysfunction  Thrombosis  Embolus  Hemorrhage  Spinal stenosis and other degenerative processes  Spinal neoplasms  Infection  Spinal Cord Injury Statistics (O’Sullivan and Schmitz, p. 760) Spinal level  56% cervical  44% thoracic, lumbar or sacral lesion Impact of injury  18% incomplete paraplegia  33% incomplete tetraplegia  24% complete paraplegia  18% complete tetraplegia  Spinal Cord Injury Statistics (O’Sullivan and Schmitz, p. 760) Hospital stay average  Much shorter than it used to be  Acute care – 11 days  Rehab unit – 32 days Life expectancy  Has significantly improved since 1980s but is lower than individuals without SCI  Factors that influence this:  Age of onset  Level and extent of neurological injury  Spinal Cord Injury Statistics (O’Sullivan and Schmitz, p. 760) Financial impact  Extremely high  Long hospital stays  Medical complications  Extensive follow-up care  Recurrent hospitalizations  Medical costs first year postinjury  $1,000,000 (C1-C4)  $500,000 (Paraplegia)  Average lifetime costs (injured at 25)  $3.5 million (C1-C4)  $2.5 million (C5-C8)  $1.6 million (Paraplegia)  Classification of Spinal Cord Injuries (O’Sullivan and Schmitz, p. 760) Classification (two categories)  Tetraplegia (quadriplegia)  Motor and/or sensory impairments of 4 extremities and trunk  Includes respiratory muscles  Lesion at the cervical cord  Paraplegia  Motor and/or sensory impairments of all or part of trunk and both lower extremities  Lesion at the thoracic, lumbar spinal cord or cauda equina  Spinal Cord Review (O’Sullivan p. 761) Spinal Cord  Extends from the medulla at the foramen magnum at the base of skull 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, nonneural filament running from the conus medullaris  Central Nervous System (O’Sullivan p. 761) Cross section view of the Spinal Cord  Central grey matter  Neuronal cell bodies  “H” or butterfly shape  Posterior horn transmits sensory impulses  Anterior horn transmits motor impulses  Peripheral white matter  Myelinated axons and fiber tracts  Contains ascending (sensory) and descending (motor) fiber pathways  Spinal Nerves (O’Sullivan pp. 761) 31 pairs of spinal nerves (Fig. 20.2)  8 cervical  12 thoracic  5 lumbar  5 sacral  1 coccygeal  C1 – C7 exit above the corresponding vertebrae  C8 exits below the C7 vertebrae Cross Section of Spinal Cord Showing Tracts The Spinal Cord  Classification of Spinal Cord Injuries (O’Sullivan and Schmitz, pp. 762-765) Designation of lesion level  Extremely important to identify lesion accurately  Determine extent of neurological impairment  Motor and sensory loss  Used in setting functional goals  American Spinal Injury Association (ASIA)  International Standards of Neurological Classification of SCI  See Figure 20.3, p. 762  Standardized tool to determine and document the severity of motor and sensory function loss  Classification of Spinal Cord Injuries (O’Sullivan and Schmitz, pp. 762-763) Neurological level  Most caudal level of the spinal cord with normal motor and sensory function bilaterally Motor level  Most caudal segment of the spinal cord with normal motor function bilaterally  MMT Sensory level  Most caudal segment of the spinal cord with normal sensory function bilaterally  Pin prick and light touch Sensory and motor levels can be different  Classification of Spinal Cord Injuries (O’Sullivan and Schmitz, Box 20.1, p. 763) Complete Spinal Cord Injury  No sensory or motor function in the lowest sacral segments (S4 and s5)  No sacral sparing (p. 763) Incomplete Spinal Cord Injury  Motor and/or sensory function is present below the neurological level  This includes S4 and S5 – Sacral sparing  Classification of Spinal Cord Injuries (O’Sullivan and Schmitz, p. 763) ASIA Impairment Scale  Individuals with incomplete SCIs present very differently  ASIA Impairment Scale (Box 20.1, p. 763)  Allow clinicians and researchers a standardized way to communicate the degree of impairment  Classification of Spinal Cord Injuries (O’Sullivan and Schmitz, p. 764) Clinical Syndromes  Brown-Sequard  Anterior Cord  Central Cord  Cauda Equina  Brown-Sequard Syndrome (O’Sullivan and Schmitz, p. 764)  A lesion involving damage to 1 side of the spinal cord (hemisection) (Figure 20.4)  Etiology  Penetration wounds  Gunshot or stab  True hemisections are rare  Clinical Presentation  Ipsilateral weakness and proprioceptive, light touch and vibratory sense  Contralateral loss of pain and temperature  Prognosis  Favorable - Most patients able to ambulate with therapy  Anterior Cord Syndrome (O’Sullivan and Schmitz, p. 764) A lesion involving the anterior two thirds of the spinal cord preserving the posterior columns (Figure 20.4) Etiology  Flexion injuries  Compression of the anterior cord from fracture, dislocation or cervical disk protrusion  Anterior Cord Syndrome (O’Sullivan and Schmitz, p. 764) Clinical Presentation  Loss of motor function and loss of sense of pain and temperature  Preservation of proprioception, kinesthesia and vibratory Prognosis  Longer length of stay for inpatient rehab  Central Cord Syndrome (O’Sullivan and Schmitz, p. 764) Lesion involving the center of the spinal cord (Figure 20.4)  Most common SCI syndrome Etiology  Hyperextension injuries  Congenital or degenerative narrowing of the spinal canal  Compressive forces cause hemorrhage and/or edema  Central Cord Syndrome (O’Sullivan and Schmitz, p. 764) Clinical Presentation  More severe neurological involvement in UEs than LEs  Greater motor deficits than sensory impairment Prognosis  Most individuals are able to ambulate long term  Typically distal UE weakness remains  Cauda Equina Injuries (O’Sullivan and Schmitz, p. 764-765) Cauda equina lesions are peripheral nerve injuries  Lower motor neuron injury  Potential to regenerate as peripheral nerves elsewhere in the body Clinical Presentation  Variable  Motor and sensory  Body Structure/Functional Impairments (O’Sullivan and Schmitz, p. 765) Spinal Shock  Initial period after injury  Period of areflexia  Absence of all reflex activity  Flaccidity  Loss of sensation and motor function below the level of lesion  Duration (p. 765)  Several days to several weeks  Body Structure/Functional Impairments (O’Sullivan and Schmitz, p. 765-767) Autonomic dysreflexia (hyperreflexia)  Pathological autonomic reflex that can be life threatening  Typically occurring in lesions above T6  Incidence - 48-70%  Acute onset of autonomic activity from noxious stimuli below the level of the lesion  Sudden elevation in blood pressure  Critical emergent situation  Hypertension triggered AD can result in:  Seizures, cardiac arrest, subarachnoid hemorrhage, stroke, death  Occurs less over time  Body Structure/Functional Impairments (O’Sullivan and Schmitz, p. 766) Autonomic dysreflexia (hyperreflexia)  Initiating stimuli – Table 20.1  Bladder and bowel distention/irritation  Blocked catheter  UTI  Kidney stones  Irritation of bladder or urethra during catheterization or other procedures  Pressure injuries  Noxious cutaneous stimuli below the level of the lesion  Body Structure/Functional Impairments (O’Sullivan and Schmitz, p. 766) Autonomic dysreflexia (hyperreflexia)  Symptoms  *Hypertension*  Bradycardia  Headache – severe and pounding  Profuse sweating  Increased spasticity  Restlessness  Vasoconstriction below the level of the lesian  Vasodilation (flushing) above the level of the lesion  Constricted pupils  Nasal congestion  Piloerection  Blurred vision  Body Structure/Functional Impairments (O’Sullivan and Schmitz, p. 766) Autonomic dysreflexia (hyperreflexia)  Intervention  Treat as medical emergency  If lying flat, patient should be brought to an upright position  Loosen any tight clothing or restrictive devices  Blood pressure and pulse monitored  Question patient for possible triggers  Check bladder drainage system  Notify medical staff  Educate patient and family on AD Autonomic Dysreflexia Following Spinal Cord Damage  Body Structure/Functional Impairments (O’Sullivan and Schmitz, p. 767)  Spastic Hypertonia  Occurs in 65% of people with spasticity  Emerges below the level of lesion after spinal shock evolves  Gradual increase in spasticity during the first year after SCI  Can be increased by:  Positional changes  Cutaneous stimuli  Environmental temperatures  Tight clothing  Bladder or kidney stones  Fecal impactions  Catheter blockage  UTI  Decubitis ulcers  Emotional stress  Body Structure/Functional Impairments (O’Sullivan and Schmitz, p. 767) Spastic Hypertonia  Varies in degree of severity  Interventions  Medicine  Nerve blocks  Surgery  Body Structure/Functional Impairments (O’Sullivan and Schmitz, p. 767-768) Cardiovascular impairment  Postural Hypotension (orthostatic hypotension)  A decrease in blood pressure when assuming a more upright or vertical position  Caused by a loss of sympathetic vasoconstriction control  Common after long periods of immobilization  More common with SCI above T6  Symptoms  Blurred vision  Ringing in the ears  Light-headedness  Fainting  Body Structure/Functional Impairments (O’Sullivan and Schmitz, p. 768) Orthostatic Hypotension  Interventions  Slowly begin adaptation to vertical  Elevate head of bed  Reclining wheelchair  Tilt table  Monitor vital signs  Compressive stockings  Abdominal binders  Medicine  Body Structure/Functional Impairments (O’Sullivan and Schmitz, p. 768) Impaired Thermoregulation  Hypothalamus can no longer control cutaneous blood flow or level of sweating  Loss of internal thermoregulatory responses  Inability to shiver  Vasodilation does not occur with heat  Vasoconstriction does not occur with cold  More of a concern with cervical lesions Must rely upon input of sensory input of the head and neck region  Clinical manifestations  May see increased sweating above the level of the lesion  Body Structure/Functional Impairments (O’Sullivan and Schmitz, p. 768-769) Pulmonary Impairment  Effects depends on the level of the injury  A progressive loss of respiratory function occurs with increasingly higher lesion levels  Increased use of accessory muscles  Pulmonary complications are a leading cause of death both in early and late stages of recovery  Body Structure/Functional Impairments (O’Sullivan and Schmitz, p. 769) Pulmonary Impairment  See Table 20.2, p. 769  C1 and C2 - phrenic nerve innervation and spontaneous respiration are significantly impaired or lost  Muscles which control breathing paralyzed  Intercostals, diaphragm and abdominal muscles  An artificial ventilator or phrenic nerve stimulator is required to sustain life  C3 and C4 – have partial diaphragm innervation, scalenes, levator scapulae, and trapezius  May be able to breathe on own after rehab, but more likely will use mechanical ventilation  Body Structure/Functional Impairments (O’Sullivan and Schmitz, p. 769) Pulmonary Impairment  C5 through C8  Fully innervated diaphragm and many accessory muscles  Able to breathe independently  Intercostal muscles impaired  Coughing impaired  T1 through T10  Able to breathe independently  Coughing impaired  Below T10  Preservation of normal breathing and cough reflexes  Body Structure/Functional Impairments (O’Sullivan and Schmitz, p. 770-771) Bowel and Bladder Impairment  Requires long term management  Catheters  UTIs – major cause of mortality and morbidity  Two types of bladder dysfunction  Failure to store urine  Failure to empty urine  Bladder and Bowel Management Sexual Dysfunction  Body Structure/Functional Impairments (O’Sullivan and Schmitz, p. 772) Pain  Nociceptive Pain  Neuropathic Secondary and Other Impairments (p. 772)  Pressure injuries  UTI  Pulmonary infections  DVT  Musculoskeltal injuries  Contractures  Osteoporosis  Fracture  Heterotopic ossification  Osteogenesis in soft tissues near joints below the level of the lesion  Early Medical Management Emergency Care (p. 773-774)  Treatment and rehabilitation begin at the time of injury  Maintain breathing and prevent shock  Fracture Stabilization  Hospital traction or surgery  Relieve pressure and repair tissues  Immobilization  Ongoing care to prevent complications related to immobility  Immobilization Halo vest (O’Sullivan, p. 774): - Provides traction and virtually eliminates movement of cervical spine - Allows for early out- of-bed activities - Don’t make adjustments at patient request!  Immobilization Thoracolumbosacral Orthosis (TLSO) (O’Sullivan, p. 774)  Should be custom-made for maximum stability and comfort  Hard plastic, fully encasing trunk from sternum to caudal to iliac crests  Minimizes thoracolumbar movement  Immobilization  Harrington rods  Pair of rods that centrally contact each lamina and are hooked proximally and distally  Used for distraction or compression  Needs intact anterior longitudinal  Spinal Cord Injury Physical Therapy Outcomes and Goals  Functional expectations for patients with SCI  Table 20.5 (pp. 784-787)  Handouts, discussion and texts from lab  If any inconsistencies, go with lecture text  Physical Therapy Management Early After Injury Physical Therapy Interventions  Respiratory Management (pp. 789-791)  Respiratory Muscle Training  Glossopharyngeal Breathing  Mid to high level cervical lesions  Abdominal Binder  Compresses abdominal contents Increases intra-abdominal pressure Elevates diaphragm to a more optimal position for breathing  Helps maintain intrathoracic pressure and decrease postural hypotension  Manual stretching  Facilitates mobility and compliance of thoracic wall  Physical Therapy Interventions Skin care (p. 791-792)  Prevention is the most effective intervention  Education by team  Turning and sitting schedules  Pressure relief techniques/weight shifts  Should be performed every 15 minutes in wheelchair  Figure 20.14 STRYKER FRAME BED ROTOREST BED  Physical Therapy Interventions Mobility Skills (pp. 793-809) Strength and Range of Motion  Maintain tenodesis grasp if hand intrinsics are absent  With tetraplegia, maintain low back tightness  Maximal strengthening of all innervated muscles Cardiovascular/Endurance Training Sitting Balance Transfers Locomotor Rehabilitation Activity-Based Upper Extremity Training Physical Therapy Interventions (pp. 799-800) Head-hips relationship Momentum Muscle substitution Task modification Working in and out of the task Motor learning concepts should be implemented Physical Therapy Interventions (pp. 801-811) Wheelchair Skills Gait/Walking Skills Neurotechnologies Wheelchair and Seating System Health and Wellness Patient-Related Education  Secondary Complications of SCI  Psychological Considerations  Independence to dependence  Isolation  Body image  Cognitive impairments  Depression and anxiety most common  Pain and increases in pain increase depression  Medication side effects