EHR525 Week 10 Spinal Cord Injury, Part A (DG) PDF

WARNING This material has been reproduced and communicated to you by or on behalf of Charles Sturt University in accordance with section 113P of the Copyright Act 1968 (Act). The material in this communication may be subject to copyright under the Act. Any further reproduction or communication of th...

WARNING This material has been reproduced and communicated to you by or on behalf of Charles Sturt University in accordance with section 113P of the Copyright Act 1968 (Act). The material in this communication may be subject to copyright under the Act. Any further reproduction or communication of this material by you may be the subject of copyright protection under the Act. Do not remove this notice School of Allied Health, Exercise and Sports Sciences 1 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 1 EHR525 EXERCISE FOR NEUROLOGICAL & MENTAL HEALTH CONDITIONS Spinal Cord Injury- Part A Presenter: Darren Gray School of Allied Health, Exercise and Sports Sciences 2 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 2 What We Will Cover ■ Review spinal cord injury and it’s primary features. ■ Prevalence statistics for spinal cord injury in Australia. ■ Structural organisation of the spinal cord. ■ Pathophysiology of spinal cord injury. ■ Classifications of spinal cord injury. ■ General complications associated with spinal cord injury. School of Allied Health, Exercise and Sports Sciences 3 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 3 Introduction ■ Spinal cord injury (SCI): Refers to damage to the neural elements of the spinal canal often resulting in permanent impairments in motor, sensory, and/or autonomic nervous system (ANS) function. ■ Injury severity is dependent on segmental level and completeness of injury. ■ Spinal cord does not have to be completely severed for there to be sensory, motor, or ANS dysfunction and the spinal cord remains intact in many cases. ■ SCI has profound consequences for functioning and disability affecting body systems, physical activities, and participation. ■ Also associated with reduced health-related outcomes that increase morbidity and mortality. School of Allied Health, Exercise and Sports Sciences 4 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 4 Spinal Cord Injury Statistics ■ >15,000 Australians currently living with a SCI (0.07% of total population). ■ ~80% of newly reported CSI cases are due to traumatic injury (20% non-traumatic). ■ More than 1 traumatic SCI occurs every day. ■ Traumatic SCI occurrence is highest in 1524 year olds (accounting for 30%) (av. 19 years). ■ Traumatic SCI:and84% male and 16% female. School of Allied Health, Exercise Sports Sciences MVA 8% 9% 9% Falls 46% 28% Strike/hit/ impact Water-related Other Australian Spinal Injury Registry, (2017). 5 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 5 Economic Impact ■ Total cost of CSI in Australia is estimated to be $2 billion/ year. ■ Lifetime cost of SCI per incidence of paraplegia is $5 million. ■ Lifetime cost of SCI per incidence of tetraplegia is $9.5 million. ■ If 10% of carers were able to return to the workforce there would be a $3 billion boost into the economy per year. School of Allied Health, Exercise and Sports Sciences 6 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 6 Anatomy And Physiology Of The Spinal Cord ■ Primary functions of the spinal cord are to: □ Conduct sensory information from PNS to brain. □ Conduct motor information from brain to PNS. □ Serve as a centre for sensory-motor integration and reflex production. ■ Extends from the medulla to L1-L2 vertebrae (~45cm). ■ Protected by 33 vertebrae: □ □ □ □ □ 7 Cervical 12 Thoracic 5 Lumbar 5 Sacral 4 Coccygeal School of Allied Health, Exercise and Sports Sciences 7 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 7 Gross Anatomy Of The Spinal Cord ■ Cervical enlargement (C3-T1): Upper limbs. ■ Lumbosacral enlargement (T9-T12): Lower limbs. ■ Conus medullaris (L1-L2): Tapered, lower end of the spinal cord. ■ Cauda equina (L1/L2-coccyx): Long roots that extend from spinal cord that exit from the lumbosacral region. School of Allied Health, Exercise and Sports Sciences 8 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 8 Gross Anatomy Of The Spinal Cord ■ Grey Matter: Sensory and motor cell bodies, dendrites, unmyelinated axons, interneurons, and synapses. ■ White Matter: Mainly myelinated axons. ■ Dorsal Root: All the sensory axons enter the spinal cord. ■ Ventral Root: All the motor axons exit the spinal cord. ■ Spinal Nerve (PNS): Merger of School of Allied Health, and Sports Sciences dorsal andExercise ventral roots. Proportion of grey and white matter changes at spinal different levels 9 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 9 Ascending White Matter Tracts Of Spinal Cord Dorsal Columns ■ Fasciculus gracilis tract (≤T7). ■ Fasciculus cuneatus tract (≥T6). □ Discriminative touch and proprioception. ■ Posterior spinocerebellar tract. ■ Anterior spinocerebellar tract. □ Unconscious proprioception. Anterolateral system ■ Lateral spinothalamic tract. ■ Anterior spinothalamic tract. ■ Lateral spinoreticular tract. □ Pain, temp, crude touch. School of Allied Health, Exercise and Sports Sciences 10 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 10 Descending White Matter Tracts Of Spinal Cord Pyramidal pathways ■ Lateral corticospinal tract. □ Fine motor control. ■ Medial corticospinal tract. □ Central axis and girdle ■ Rubrospinal tract. ExtraPyramidal pathways □ Flexor muscle activation. ■ Medial and lateral reticulospinal tract. □ Regulate sensitivity of the flexors. ■ Lateral and medial vestibulospinal tract. □ Postural adjustments and head movements. ■ Tectopsinal tract. School of Allied Health, Exercise and Sports Sciences □ Integration of vision and movement 11 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 11 Grey Matter Rexed’s Laminae ■ Laminae I-II: Sensory fibres. ■ Laminae III-IV: Sensory relay/ processing. ■ Laminae V: Visceral sensation and descending movement. ■ Laminae VI: Proprioception. ■ Laminae VII: Visceral sensation and descending movement. ■ Laminae VIII: Reticulospinal and vestibulospinal tracts (muscle tone). ■ Laminae IX: Motor neurons. ■ Laminae X: Central canal. School of Allied Health, Exercise and Sports Sciences 12 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 12 Segmental Organisation Of The Spinal Cord ■ Mixed spinal nerve: Marks the division between the CNS and PNS. ■ Dorsal (posterior) ramus: □ Contains sensory/motor nerves connected to the paravertebral and posterior regions. ■ Ventral (anterior) ramus: □ Contains sensory/motor nerves connected to the limbs and anterior trunk. School of Allied Health, Exercise and Sports Sciences 13 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 13 Segmental Organisation Of The Spinal Cord ■ Segmental organisation: Each segment of the spinal cord is connected to a specific region of the periphery by axons travelling through a pair of spinal nerves. ■ In the cervical region, spinal nerves are found above the corresponding vertebrae (except the C8 spinal nerve). ■ Remaining spinal nerves lie below the corresponding vertebrae. School of Allied Health, Exercise and Sports Sciences Quick review of segmental structure 14 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 14 Myotomes, Dermotomes And Peripheral Nerves ■ Myotome: Refers to the muscles innervated by axons from a single spinal segment. ■ Dermatome: Refers to the area of skin innervated by axons from a single spinal segment. ■ Peripheral nerve field: Muscle or areas of skin innervated by axon from an individual peripheral nerve. ■ Understanding myotomes, dermatomes, and peripheral nerve School of Allied Health, Exercise to and Sports Sciences 15 fields helps diagnosis the cause of neural impairments. SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 15 Peripheral Nerve Fields ■ Multiple peripheral nerves enter/exist the same spinal segment. ■ Number of muscles and area of skin innervated from each spinal segment is large. ■ Peripheral nerve fields are different. ■ Pattern of impairment helps to determine location of neural lesion (spinal/peripheral). School of Allied Health, Exercise and Sports Sciences 16 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 16 Myotomes ■ Upper limbs: □ □ □ □ □ C5 - Deltoid. C6 - Wrist extensors. C7 - Elbow extensors. C8 - Long finger flexors. T1 - Small hand muscles ■ Lower Limbs: □ □ □ □ □ L2 - Hip flexors. L3,4 - Knee extensors. L4,5 - S1 - Knee flexion. L5 - Ankle dorsiflexion. S1 - Ankle plantar flexion School of Allied Health, Exercise and Sports Sciences 17 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 17 Dermotomes School of Allied Health, Exercise and Sports Sciences 18 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 18 Aetiology Of Spinal Cord Injury ■ Traumatic SCI: Related to direct mechanical damage to neural tissues. □ Penetration or direct damage: Bone or metal fragments. □ Abnormal movements: Head, neck, or back movements can pull, compress, twist, or tear tissues. □ Swelling: Accumulation of blood or other fluids can cause swelling within causing compression of nerve tissue. ■ Non-Traumatic CSI: Related to vascular disorders, infections, degenerative spinal conditions, genetic disorders, and cancerous lesions. School of Allied Health, Exercise and Sports Sciences 19 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 19 Classification Of Spinal Cord Injury ■ Classification of SCI is based on there (3) factors: 1. Level of the lesion: Determined as the most distal uninvolved spinal segment with normal function 2. Complete or incomplete lesion: Determined based on the preservation or absence of sensory or motor function below the level of the lesion. □ Complete: No sensory or motor function below the level of the lesion. □ Incomplete: Preservation of some sensory or motor function below the level of injury. 3. Tetraplegia or paraplegia: Determined based on the number of limbs involved. □ Tetraplegia: Involvement of all 4 extremities, trunk, and respiratory muscles. □ Paraplegia: Involvement of all or part of the trunk and both lower extremities. School of Allied Health, Exercise and Sports Sciences 20 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 20 Note the level of COMPLETE INJURY and impact on function School of Allied Health, Exercise and Sports Sciences 21 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 21 Determination Of Neurologic Levels ■ American Spinal Injury Association (ASIA) developed standardised assessment for evaluating lesion level in SCI. ■ Muscle strength testing using MMT. ■ Key sensory points tested with safety pin to determine the ability to distinguish sharp from dull; light touches with cotton to determine ability to localize light touch. School of Allied Health, Exercise and Sports Sciences 22 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 22 American Spinal Injury Association Impairment Scale Note ASIA Scale School of Allied Health, Exercise and Sports Sciences 23 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 23 Effects Of Complete Spinal Cord Injury On Function ■ Level C1-C3: □ □ □ □ □ Limited head/neck movement. Requires ventilator. Total paralysis of trunk, UE and LE. 24 hr care needed. Able to direct care needs. ■ Level C4: □ Usually has head and neck control. □ May shrug their shoulders. □ Can operate an electric wheelchair by using a head control, mouth stick, or chin control. School of Allied Health, Exercise and Sports Sciences 24 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 24 Effects Of Complete Spinal Cord Injury On Function ■ Level C5-C6: □ Has movement in head, neck, shoulders, arms and wrists. □ Can shrug shoulders, bend elbows, turn palms up and down and extend wrists. □ Can use a manual wheelchair for daily activities, may use power wheelchair for greater independence. ■ Level C7-T1: □ Has similar movement to C6, with added ability to straighten his/her elbows and greater precision of fingers that result in limited or natural hand function. □ Uses manual wheelchair, can transfer School of Allied Health, Exercise and Sports Sciences independently. 25 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 25 Effects Of Complete Spinal Cord Injury On Function ■ Level T2-T6: □ Has normal motor function in head, neck, shoulders, arms, hands and fingers. □ Has increased use of rib and chest muscles, or trunk control. □ Should be totally independent with all activities. ■ Level T7-T12: □ Has added motor function from increased abdominal control. □ Able to perform unsupported seated activities. □ Possibility capable of limited walking with extensive bracing (requires extremely high energy and can School of Allied Health, Exercise and Sports Sciences lead to damage of upper joints). 26 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 26 Effects Of Complete Spinal Cord Injury On Function ■ Level L1-L5: □ Has additional return of motor movement in the hips and knees. □ Walking can be a viable function, with the help of specialised leg and ankle braces. ■ Level S1-S5: □ Depending on level of injury, there are various degrees of return of voluntary bladder, bowel and sexual functions. □ Increased ability to walk with fewer or no supportive devices. School of Allied Health, Exercise and Sports Sciences 27 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 27 Incomplete Lesion Syndromes ■ Because of structure and organisation of the various ascending (sensory) and descending (motor) tracts in the spinal cord incomplete injuries may be associated with specific patterns of functional deficit. ■ There are four (4) specific incomplete lesion syndromes: □ □ □ □ Anterior cord syndrome. Brown-Sequard’s syndrome/ Hemicord lesion. Central cord syndrome. Posterior cord syndrome. School of Allied Health, Exercise and Sports Sciences 28 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 28 Anterior Cord Syndrome ■ Usually caused by cervical flexion. □ Compresses and damages the anterior part of the spinal cord and/or anterior spinal artery. ■ Complete motor function lost bilaterally. ■ Complete loss of crude touch, pain and temperature sensation bilaterally. ■ Fine touch and proprioception sense are preserved. School of Allied Health, Exercise and Sports Sciences 29 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 29 Brown-Sequard’s Syndrome/ Hemicord Lesion ■ Result of hemisection of spinal cord (gunshot or stab wound). ■ Ipsilateral paralysis and loss of fine touch and proprioception. ■ Contralateral loss of crude touch, pain and temperature sense. School of Allied Health, Exercise and Sports Sciences 30 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 30 Central Cord Syndrome ■ Result from hyperextension and compressive injuries that cause central cord swelling. ■ Impairment of motor function in the UE greater than LE. ■ Varying degrees of sensory loss but less severe than motor deficits. ■ High % of patients will attain ambulatory function, B & B control and hand function. School of Allied Health, Exercise and Sports Sciences 31 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 31 Posterior Cord Syndrome ■ Generally very rare. ■ Results from compression by tumour or infarction of the posterior spinal artery. ■ Touch and proprioception are lost below the lesion. ■ Complete motor function is preserved. ■ Complete crude touch, pain, and temperature are preserved. School of Allied Health, Exercise and Sports Sciences 32 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 32 Complications Associated With Spinal Cord Injury ■ Loss of bladder and bowel function: □ Incontinence. □ Lesions above S2 result in reflexive autonomic emptying of bladder. □ Catheter and bag. ■ Spasticity: □ Increased muscle tone and hyperactive stretch reflexes. □ Muscle spasm result from exposure to cold, light touch, contact with clothing during transfer from chair to bed. □ Antispasmatic medications used. ■ Contractures: □ Occur when a muscle has not been moved loses flexibility (3-7days). School of Allied Health, Exercise and Sports Sciences 33 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 33 Complications Associated With Spinal Cord Injury ■ Impaired thermoregulation: □ □ □ □ ANS system responsible for vasodilation. Absence of vasodilation/vasoconstriction below level of lesion. Impaired sweating response. Greatly influenced by external temperature. ■ Postural hypotension: □ Occurs when moving from a supine to upright position. □ Poor venous return (vasodilation/vasoconstriction and limited muscle pump). □ Common in older SCI clients. ■ Pressure sores: □ Damage to skin from unrelieved pressure and poor circulation. □ Bed sores are very common. School of Allied Health, Exercise and Sports Sciences Note these complications 34 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 34 Complications Associated With Spinal Cord Injury ■ Osteoporosis: □ Lack of weight bearing results in a loss of BMD. □ Increased fracture risk. Note these complications ■ Diminished pulmonary function: □ Lesion above C4 usually require artificial ventilator. □ Abdominal muscles important for expiration and forceful expiratory effort, controlled by T6-T12. □ Higher the lesion the greater the loss in respiratory function. ■ Bunted CVD responses and diminished exercise capacity: □ Diminished ANS sympathetic outflow limits aerobic exercise due to low maximal cardiac output (HR and BP). School of Allied Health, Exercise and Sports Sciences 35 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 35 Autonomic Dysreflexia ■ Autonomic dysreflexia: A potentially dangerous and possibly lethal clinical syndrome resulting in acute, uncontrolled hypertension due to vasoconstriction in the splanchnic bed. ■ Primarily occurs in SCI ≥T6 in persons <3 years of injury. ■ Involves a sudden rise in peripheral blood pressure due to an overreactive parasympathetic nervous system: □ □ □ □ □ Profuse sweating &sudden rise in blood pressure. Shivering. Headache and nausea. Slowed HR. Constricted pupils and blurred vision. School of Allied Health, Exercise and Sports Sciences 36 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 36 Autonomic Dysreflexia ■ Autonomic dysreflexia can be triggered by any painful, irritating, or even strong stimulus below the level of the lesion. ■ Bladder distension or irritation is responsible for 75-85% of cases. □ Caused by a blocked or kinked catheter or missed intermittent catheterisation program. ■ Bowel distention due to faecal impaction accounts for 13-19% of cases. ■ Other potential causes may include: □ □ □ □ □ □ □ Urinary tract inflection. Appendicitis. Pulmony emboli. Pressure sores. Ingrown toenail. Insect bites. Deep vein thrombosis. School of Allied Health, Exercise and Sports Sciences 37 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 37 Autonomic Dysreflexia ■ Considered a medical emergency and must be recognised immediately. ■ If left untreated autonomic dysreflexia can cause: □ □ □ □ □ □ □ Seizures. Retinal haemorrhage. Pulmonary edema. Renal insufficiency. Myocardial infarction. Stroke. Death. Monitor BP regularly and seek medical attention. ■ Management of autonomic dysreflexia: □ Sit the client upright (promote blood pooling in lower limbs). □ Loosen tight clothing. □ Find source of instigating cause. School of Allied Health, Exercise and Sports Sciences 38 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 38 Deep Vein Thrombosis ■ Deep vein thrombosis: A blood clot in the legs primarily related to physical inactivity and immobility. ■ May lead to pulmonary embolism that can be fatal. ■ Symptoms: □ Local swelling. □ Redness. □ Heat. School of Allied Health, Exercise and Sports Sciences 39 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 39 Summary ■ Spinal cord injury occurs as a result of traumatic or non-traumatic damage to nerve tracts within the spinal canal. ■ Spinal cord injury typically results in permanent impairment of motor, sensory, and/or autonomic nervous system (ANS) function. ■ Injury severity is dependent on segmental level and completeness of injury. ■ Spinal cord injury is associated with a range of acute and chronic complications that impact a number of systemic functions, including the cardiopulmonary, musculoskeletal, and integumentary systems. School of Allied Health, Exercise and Sports Sciences 40 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 40