Neuro Summary 5-10 Exam 4 PDF

9.1 sci fxnal prognosis prognosis ais classification & neurological level: significant predictors of outcome asia motor scores and ais classifications 72 hrs after injury pts w greater potential for fxnal recovery: present w early neurological return & have incomplete injuries conflicting evidence a...

9.1 sci fxnal prognosis prognosis ais classification & neurological level: significant predictors of outcome asia motor scores and ais classifications 72 hrs after injury pts w greater potential for fxnal recovery: present w early neurological return & have incomplete injuries conflicting evidence a. age b. surgical timing c. pattern of injury d. associated trauma surgeries 12-24 or days later linked to more positive outcomes no impact in sex, use of methylpresnisolone, MOC on recovery ais level conversion pt either improves, or declines pt can go from ASI A to B or from AIS D to C conversion shows poor correlation and predictive validity w fxnal ambulation marino 2020 increase rate of conversion from complete to incomplete (motor) increased rates for pts w tetraplegia or cervical level injuries odds increase w ppl who had nonviolent etiology and old age ais level conversion: 1 yr 1999 study 1 yr follow up: 15% of pts a AIS A able to convert to higher level 71% w AIS b improved motor strength>> changed to AIS C,D or E 67 % AIS C >> AIS D pts w AIS B, C, D or E able to fully recover recovery 3 months post injury continued recovery even at 5 yr follow up present w no sensory or motor differences motor recovery pts recover at least antigravity straight to full ROM in key muscle group, 1 level below their designated ASIA level of injury 65% complete tetra able to recovery greater than 3/5 strength ^^ stat significant bc fxnal use of one motor level can drastically increase fxn if MMT 0… 25% will have greater than 3/5 by a year if MMT is 2.5/5…100% will gain if mmt 1-2.5/5…75% if pts will recover greater than or equal to 3/5 strength prognosis for ambulation van middendorp 2011 indicators for fxnal ambulation: age strength sensation to 2 levels of sc prediction rule for ambulation using age less than 65, strength and sensation to light touch in L3 or the quadriceps, strength and sensation to light touch an S1 the gastrocsoleus muscle. used a total score of 40 where age greater than 65 merits a deduction of 10 points and the best motor and light touch scores in L3 and S1 are multiplied by 2 and then summed. 85% accurate rate w 79% SN and 90% SP some researchers say prediction rule did not apply for pts w traumatic etiology in their sci fxnal outcomes by neuro level C1-4 designed for pts who have limited to no fxn below stated level zone of partial preservation: drastically alter fxnal prog keep in mind for goal setting and pt education C1-4 limited to no use in UE (depending on zone of partial preservation) possible assistance w ventilation and no hand fxn require total assist w bed mobility, transfers, self care and ADLs no fxnal ambulation potential power wc using chin, head, mouth or breath control assistance w positional changes when in power fxnal outcomes by neuro level C6 wc use tilt and recline fxns fxnal outcomes by neuro level C5 ↓ biceps volitional mvmntmore distal muscles - have wrist extensors and biceps fxnal outcomes by neuro level C7-8 use of elbow extension ↳ manipulate objects gained c7-8 key for rehab fxnal outcomes by neuro level T1-9 more core strength and sensation gained at each level - may gain further trunk control some degree of hip flexors - summary there is significant potential for motor and functional recovery post-spinal cord injury ambulation potential appears to rely heavily on strength in quadriceps and gastrocsoleus muscles, along with age 9.2 SCI rehab management mobility mobility tasks initial strategies increase upright tolerance maintain ROM minimize secondary impairments progression (PT) a. assess pts ability to roll, sit up, transfer, mobilize in a WC, stand and potentially walk base of fxnal tasks transfers: clinical practice guidelines gagnon suggests level sitting pivot transfers avoid positions of impingement of shldr trailing hand- as close to ER as possible leading hand: provide enough room for transfer and minimal IR of shldr wrist stability: fisted hand and wrist in neutral painful shldr= use as leading arm bc less impact during transfer both feet on ground strengthen shldr flexors, ADD and scapular stabilizers transfers: car 1. most demanding transfer due to seat height, lifting we in n out of car and gap bw we and seat bc of door 2. some transfer w single leg, both or none 3. pts who placed leafing limb on steering wheel during transfer tend to have higher rates of shldr pain standing rehabilitation benefits ROM increase in bone mineral density limited evidence normalize tone spasticity improve BB jnt integrity via capsule or muscle length pressure relief from sitting recommended 5x/week for 30 mins challenging to induce benefits on bone strength or other impairment more active interventions become the focus of clinical practice and investigation activity based therapy locomotor training using: a. specific tasks b. sensory cues c. stimulation ^drives neuroplasticity training needs to be repetitive and task specific w an intense frequency of 60 sessions last 1.5 hrs technologies -platform walkers -body wt support treadmill training -ceiling tracts used across multiple dx ambulation in sci important to remember activity requires high energy consumption requires extent of trunk control and ability to initiate flex of hip pts w T10-L2 require assistance of trunk musculature for independent home ambulation L3 or lower: potential for independent ambulation w/in community probably use of orthosis & depend on LE strength and coordination summary general rehabilitation for individuals with SCI will focus on basic mobility tasks and should progress to high-intensity individualized activity-based therapy 9.3 sci wheelchair mobility why? wc mobility primary mode of mobility for individuals w sci & for others who are unable to ambulate safely adequate distances. important to remember that wc use is associated w high percentages of shoulder pain. shldr pain linked to poor propulsion biomechanics, and a higher impact of forces applied to the shoulder (more pain) those w higher level SCI will have less ability to efficiently and safely perform manual wc skills and propel greater distances. pts w hemiplegia: developing shldr pain in the non-paretic arm can further limit their ability to perform activities of daily living, transfers, and participation levels. stages of wc propulsion 2 phases 1. contact phase: hand touching wheel 2. recovery phase contract phase (2 points) a. initial contact b. propulsion then release recovery phase: time period where arm is preparing for next initial contact wheelchair propulsion technique: position raquelo 2015 increasing push arch results in increases in velocity and decreased frequency of pushed (more post initial contact on hand rim) higher post force-> increases demand on shldr flexors more ant hand release angle is associated w increased peak shldr forces in all direction (more demand on ADD and IR) want to decrease forces applied to shldr increase speed and decrease reps of strokes wheelchair propulsion techniques arcing when the hand makes contact and recovers from the stroke either above or at the level of the push rim Y - associated w higher shldr forces and joint compression. single loop double loop I semi circular allow for the hand to drop below the level of the top of the wheel during the recovery period, providing some degree of shldr joint relief double loop requires less muscle activity, lower cadence and braking mvmnts wheelchair mobility: rotator cuff injuries Madasingh at al. in 2020 observed scapula-thoracic ant tilt and GH joint IR at the end of contact phase (shldr pain) highest compression forces supraspinatus tendon was most commonly compressed regardless of the propulsion technique clincal practice guidelines for wc propulsion paralyzed vets of america 2005 recs: minimize frequency and force require in repetitive mvmnts avoid extreme shldr IR appropriate sized wc w good propulsion technique appropriate seated position and stabilization power or power assisted wc for high risk pts manual mf customized and composed of high strength but light wt materials rear axle adjusted as far forward as possible w/o compromising one’s stability allow elbow to be 100-120 degrees of flex when resting on wheel clinical practice guidelines for wc propulsion update In 2015, Sawatsky upgraded recommendations to include the propulsion technique. recommended users taught proper technique for propulsion bc pts use arc or single loop technique wc training should aim for velocity similar to gait for community fxn at a speed of 1.06 meters per second, -ontact angle of 85 to 100 degrees - frequency of one stroke per second summary wheelchair propulsion and setup education and training essential for long-term users to enhance function and minimize secondary impairments 9.4 SCI rehab management shldr health shldr pain 30-70% prevalance of shldr pain and sci pain due to chronic shldr impingement/ RC tears significant impact: fxn, independence, QoL factors leading to pain not clear weakly linked to -poor strength in shldr ADD -UE for higher impact activities -poor shldr ROM at discharge risk factors for shldr pain after sci risk factors: a. older age b. higher body mass index c. use of manual wc d. poor seating posture e. improper wc setup f. decreased muscle flexibility g. imbalance and strength bw rc and scapular stabilization m’s shldr pain: significant muscles pec major supraspinous deltoids lats target strength and endurance training of these muscles research sawatsky 2015 -education for pts and caregivers on risk of UE pain and injury, prevention, tx options and maintaining fitness clinicians regularly assess transfer, wc propulsion techniques, adaptive equipment and pts health status recommendations -mods to minimizes frequency, force required, extreme jnt positions in various tasks exercise programs incorporate flexibility and strengthening exercise to UE wc considerations stand w those w and w/o sci’s differences -resting shldr or hand is less likely/impossible for sci pts resting night splints for carpal tunnel home modifications/adaptive equipment temporary admission to facility/caregiver (maybe) pts should consider using power wc for fxnal mobility to decrease lifelong repetitive stress stomps study mulroy 2011 (randomized study) stomps: strengthening and optimal mvmnts for painful shldrs pts in study: paraplegia and shldr pain 12 wk home program for shldr strengthening and stretching exercises optimize transfers, pressure release and wc propulsion other group -hypertrophy training of shldr flex in scapular plane groups had significant improved levels of pain improvements: strength and QoL stomps study: education pts provided recommendations for transfers and wc propulsion endurance training: shldr flexors in scaption plane & retractors resistance training: shldr adductors & ER summary shldr pain is a common secondary condition in sci that pt must address to optimize fxn and participation