Concorde Career College Physical Therapist Assistant

1. Concorde Career CollegePhysical Therapist Assistant PTA 150: Fundamentals of Treatment II Day 13 & 14 Spinal Cord Injury Concorde Career College

2. Lesson Objectives • Describe the pathophysiology of spinal cord injury • Describe physical and neurological disorders associated with spinal cord injury • Identify functional outcomes for patients with spinal cord injury at various spinal cord lesion levels • Describe physical therapy treatment interventions for patients with spinal cord injury Concorde Career College

3. Spinal Cord Injury • 11,000 new SCI cases in the US yearly • Etiology: traumatic vs. nontraumatic • Traumatic is most common – MVA, fall, GSW • Nontraumatic – usually result from disease or pathological influence • Vascular malfunctions (AVM, thrombosis, embolis…) • Vertebral subluxations (secondary to RA or DJD) • Infections such as syphilis or transverse myelitis • Spinal neoplasms • Multiple sclerosis, amyotrophic lateral sclerosis Concorde Career College

4. Mechanism of Injury • Indirect force produced by head or trunk movement • Flexion force (head-on collision; blow to back of head) • Lateral flexion force • Compression force (diving, falling objects…) • Hyperextension force (strong rear-end collision, fall hitting chin …) • Flexion and rotational force (rear-end collision with passenger rotated towards driver) • Direct force trauma Concorde Career College

5. Types of Injury • Complete (ISNCSCI) • No motor or sensory functions is preserved in the sacral segments S4 to S5 (anal sensation and voluntary external and sphincter contraction) • Partial/Incomplete • Partial motor or sensory functions below the level of lesion Concorde Career College

6. Spinal Cord Injury (SCI) • Partial or complete spinal cord lesion may result in: • Paralysis • Paresis • Sensory loss • Altered autonomic nervous system function • Altered reflex activity Concorde Career College

7. Spinal Cord Injury (SCI) • Injury often accompanied by: • Fracture of the vertebra, body, laminae, spinous process • Stretched or torn ligaments • Disc herniation • Disk compression • Malalignment of spinal vertebrae Concorde Career College

8. Designation of Lesion Level • American Spinal Injury Association (ASIA) • International Standards of Neurological Classification of Spinal Cord Injury (ISNCSCI) – standardizes the way in which severity of injury is determined • Neurological Level – most caudal level of spinal cord w/ normal motor & sensory function bilaterally • Motor Level – most caudal level of spinal cord w/ normal motor function bilaterally • Sensory Level – most caudal level of spinal cord w/ normal sensory function bilaterally Concorde Career College

9. ISNCSCI Scoring • Motor • Most caudal segment with normal motor function (B) • Uses the same scale as MMT • Cannot test one muscle and assume this represents an entire myotome • Sensation • Defined in the same way in terms of sensory function • Usually tested with light touch and pin prick • 0 = absent,1 = impaired, 2 = normal Concorde Career College

10. ASIA Impairment Scale Concorde Career College

11. SCI Classification • Tetraplegia/Quadriplegia • Complete paralysis of all 4 extremities & trunk • Upper Motor Lesion • C1 – C8 (Trunk, Limbs) • Paraplegia • Complete paralysis of all or part of trunk & both LEs • Upper Motor Lesion • T 1 – T12, L1 • Lower Motor Lesion • Below L1 Concorde Career College

12. Clinical Syndromes • Brown-Sequard Syndrome (incomplete) • Hemisection of spinal cord • Usually secondary to penetration wound – GSW, stab • Ipsilateral sensory loss of sensation, reflexes, vibration and position sense (lateral and dorsal columns) • Contralateral sensory loss of pain and temperature sense (spinothalamic tract) • Cauda Equina Injury • Lesion is below L1 vertebra • Peripheral injury (lower motor neuron injury) • Flaccidity, absent reflexes Concorde Career College

13. Clinical Syndromes • Anterior cord syndrome • Injury site: anterior spinal cord or ant. spinal artery • Usually related to flexion injuries, compression from fracture, dislocation or cervical disc protrusion) • Characterized by loss of motor function (corticospinal tract) & pain and temp (spinothalamic tract) • Central cord syndrome • Injury site: center of the spinal cord • Most commonly occurs because of hyperextension; congenital or degenerative narrowing of spinal canal • Most common with hyperextension of cx region • Posterior cord syndrome • Injury site: posterior spinal cord or posterior spinal artery Concorde Career College

14. Clinical Syndromes • Posterior cord syndrome • Injury site: posterior spinal cord or posterior spinal artery • Characterized by preserved motor function, sense of pain and temperature and light touch; loss of proprioception and epicritic sensations (ie: 2 point discrimination) below the level of the lesion Sacral Sparing refers to incomplete lesion; clinical signs include perianal sensation and external anal sphincter contraction Concorde Career College

15. Clinical Manifestations • Spinal Shock • Motor and Sensory Impairments • Autonomic Dysreflexia • Postural hypotension • Impaired temperature control • Respiratory Impairment • Spasticity • Bowel and Bladder dysfunction (Micturition; Crede maneuver) • Sexual Dysfunction Concorde Career College

16. Acute Medical Care • Stabilize respiratory status • C1 to C4 lesions effect the phrenic nerve & diaphragm • Patient placed on respiratory ventilator • Minimize spinal shock and edema that results from the injury • Steroids • Control of hydration and nutrition to avoid over hydration and further cord necrosis Concorde Career College

17. Acute Medical Care • Catheterization bladder • Spinal stabilization • Surgery to realign vertebra & spinal cord • Insertion of halo to head & spine • Rigid to semi-rigid cervical collar • Thoracolumbarsacral Orthoses (TLSO) • Immobilize patient in bed • Stryker Frame, air support beds Concorde Career College

18. TLSO Concorde Career College

19. Spinal Cord Injury Disorders • Respiratory Impairment • Impairment is directly related to: • Lesion level • Residual respiratory muscle function • Additional trauma at time of injury • Premorbid respiratory status • Will be dependent on artificial ventilation or phrenic nerve stimulation with C1 – C3 injury • Low respiratory endurance (C4 to T12) • Higher level lesions may result in difficulty with coughing Concorde Career College

20. Spinal Cord Injury Disorders • Complete to partial motor and sensory dysfunction below the level of the lesion • Autonomic Dysreflexia (Hyperreflexia) • Deep Vein Thrombosis • Inactivity & diminished muscle contraction effect circulation • Sympathetic Pain, Phantom Pain • Dyesthesia • Heterotrophic bone formation in soft tissue • Orthostatic Hypotension (aka Postural Hypotension) • ↓ in BP when assuming an erect or vertical position • Caused by loss of sympathetic vasoconstriction and lack of muscle tone • Example: supine to sitting, sit to stand Concorde Career College

21. Spinal Cord Injury Disorders • Pressure Sores/Decubitis Ulcer • 2 ˚↓ sensation, difficulty w/ positional changes • Motor Impairment • Spasticity • Varies in range, mild to severe • Influence by internal and external stimuli • Can be managed via drug therapy, injections, surgery • Flaccidity • Muscle weakness • Muscle atrophy Concorde Career College

22. Spinal Cord Injury Disorders • Bladder and Bowel Dysfunction • UTIs are a common early complication • Lesions above conus medullaris typically develop a reflexive/spastic bladder & bowel (automatic bladder & bowel) • Conus Medullaris and Cauda Equina lesions typically develop a nonreflex/flaccid bladder & bowel (autonomic bladder & bowel) • Calcium Absorption (renal calculi) • Osteoporosis Concorde Career College

23. Spinal Cord Injury Disorders • Contractures • Autonomic Nervous System Disturbances • Loss of thermal regulation • Vasodilation does not occur in response to heat • Vasoconstriction does not occur in response to cold • Absence of sweating • Often associated with compensatory excessive sweating above the level of the lesion- diaphoresis • Flushing, headaches • Sexual Dysfunction Concorde Career College

24. Spinal Cord Lesion Level & Functional Outcomes Refer to O’Sullivan, Table 23.6, page 961 Concorde Career College

25. C1 to C3 • Muscles preserved: Face and Neck Muscles • Respiration: Ventilator dependent • Bed Mobility: Dependent • Transfers: Dependent • Self Care: Dependent (Groom, Dress, Bath, Feed) - Full time attendant • Wheelchair: Power, microswitch or sip-and-puff controls Concorde Career College

26. C4 • Muscles preserved: All of above • Diaphragm, Trapezius • Endurance: Low • Bed Mobility: Dependent • Transfers: Dependent • Self Care: Dependent • Wheelchair: Powered; head/chin/mouth control or sip-and-puff control • Attendant Care Concorde Career College

27. C5 • Movement preserved: All of the above • Scapula elevation, adduction • Shoulder abduction, ER, flexion (limited) • Elbow flexion & supination • Endurance: Low • Bed Mobility: Dependent • Transfers: Dependent → Assistance • Self Care: Dependent • Wheelchair: Powered with joystick or adapted UE controls or manual with hand rim projections Concorde Career College

28. Hand Rim Projections Joystick Concorde Career College

29. C6 • Muscles preserved: All of the above • Scapular abduction & upward rotation • Shoulder flexion, extension, IR and adduction • Forearm pronation • Wrist extension (Tenodesis grasp) • Endurance: Low • Bed Mobility: Assistance (Rolling, Sit, Mobility) • Transfers: Assistance→Independent (Slide board) • Self Care: Assistance • Wheelchair: Powered or manual with projections or friction surface hand rims Concorde Career College

30. C7 • Movement preserved: All of the above • Elbow extension • Wrist flexion • Fingers extension • Endurance: Low • Bed Mobility: Independent • Transfers: Assistance → Independent (Slide board) • Self Care: Assistance → Independent • Wheelchair: Manual with friction surface hand rims Concorde Career College

31. C7 Continued • Ambulation: Spinal Orthoses, Long leg braces, Pelvic Band • Drag to gait Concorde Career College

32. C8 to T1 • Movement preserved: All of the above • Full UE innervations including fine coordination & strong grasp • Endurance: Low • Bed Mobility: Independent • Transfers: Independent • Self Care: Assistance/Independent • Wheelchair: Independent with manual chair • Ambulation: Spinal Orthoses, Long leg braces, Pelvic Band, Drag to gait Concorde Career College

33. T4 toT6 • Movement preserved: All of the above • Improved trunk control • Pectoral girdle stabilization • Endurance: Increased • Bed Mobility: Independent • Transfers: Independent • Self Care: Independent • Wheelchair: Independent, improved skills • Ambulation: Minimal distances with assist; bilateral knee-ankle-foot orthoses with spinal attachment Concorde Career College

34. T9 to T12 • Movement preserved: All of the above • Thoracic Extensors, Lower Abdominal Muscles (Flexion); Improved trunk control • Endurance: Increased • Bed Mobility: Independent • Transfers: Independent • Self Care: Independent • Wheelchair: Independent, used to conserve energy • Ambulation: Functional with bilateral long leg braces; walker or crutches; swing thru, 4 point, 2 point gait Concorde Career College

35. Concorde Career College

36. L2 to L4 • Muscles preserved: All of the above • Hip flexion and adduction • Knee extension (quadriceps) • Endurance: Increased • Bed Mobility: Independent • Transfers: Independent • Self Care: Independent • Wheelchair: Independent, used to conserve energy • Ambulation: Functional with bilateral KAFO and crutches; 4 point, 2 point gait Concorde Career College

37. L4 to L5 • Muscles preserved: All of the above • Stronger hip flexion • Stronger knee extension, weak knee flexion • Improved trunk control • Endurance: Increased • Bed Mobility: Independent • Transfers: Independent • Self Care: Independent • Wheelchair: Independent; used to conserve energy • Ambulation: (B) AFO w/ crutch or cane, 2 pt. gait Concorde Career College

38. PT Examination • Respiratory Examination • Integumentary examination • Sensation • Tone and DTR • MMT • ROM • Functional Status Concorde Career College

39. SCI – Outcome Measures • Functional Independence Measure (FIM) • Wheelchair Skills Test (O’Sullivan, pg 966) • Examining walking ability: • SCI Functional Ambulation Inventory SCI-FAI (O’Sullivan, pg 967) • Walking Index for Spinal Cord Injury (WISCI) Concorde Career College

40. Physical Therapy Intervention • Respiratory Management • Diaphragmatic breathing • Glossopharyngeal breathing • Assisted coughing • Abdominal support • Stretching pectorals and chest wall muscles • Postural draining Concorde Career College

41. Physical Therapy Intervention • ROM • Spinal motion is normal in the acute phase depending on the level of injury • ROM in supine & prone (if cleared by MD) • Less than full ROM of joints is often beneficial Concorde Career College

42. Physical Therapy Interventions • Positioning • Splints for wrist, hands & fingers • Ankle boots or splints • Once cleared, tolerance to prone position is important • Therapeutic Exercise • Passive, Active Assistive, Active, Strengthening & Functional exercises • Must be aware of contraindications in acute phase Concorde Career College

43. Physical Therapy Interventions • Orientation to vertical position • Mat/Bed Exercises Achievement of stability within a posture ⇓ Controlled mobility ⇓ Skill in functional use Concorde Career College

44. Physical Therapy Interventions • Mat/Bed exercises • Often individual components of a functional skill • Sequenced from easiest to most difficult • Complete mastery of one skill is not always required to move on to the next skill • Degree of independence and rate of progression depends on level of spinal lesion and the individual Concorde Career College

45. Physical Therapy Interventions • Mat Programs Progression • Rolling (Prone, Supine, Sidelying) • Prone on elbows • Prone on hands (paraplegia) • Supine on elbows • Pull ups (tetraplegia) • Sitting (long sitting & sitting at edge of bed) • Quadruped • Kneeling • Transfers Concorde Career College

46. Physical Therapy Interventions • Rolling • Easiest to begin supine to prone • If applicable, easier to roll towards weaker side • Should always encourage independence, however adaptive devices may be used if unable to perform activity independently • Bed rails, ropes, canvas “ladders”, trapeze Concorde Career College

47. Physical Therapy Interventions • Rolling assists with bed mobility, pressure relief and dressing • Rolling techniques • Flexion of head & neck w/ rotation for supine→prone • Extension of head & neck w/rotation for prone→supine • Pendular motion with outstretched UEs • Crossing the ankles • Place pillows under the patient’s pelvis • PNF patterns – UE D1 Flexion, D2 Extension Concorde Career College

48. Physical Therapy Interventions • Prone on elbows • Assists with improved bed mobility & preps for quadruped and sitting later • Facilitates head, neck and shoulder girdle strength • May need assistance from therapist initially • Caution with thoracic and lumbar injuries! Concorde Career College

49. Physical Therapy Interventions • Prone on elbows activities • Weightbearing improves shoulder stability • Weightshifting – lateral 1st, progressing to anterior and posterior movements • Rhythmic stabilization • Manually applied approximation • Unilateral weightbearing on one elbow • Strengthening the serratus anterior & other scapular muscles Concorde Career College

50. Physical Therapy Interventions • Prone-on-Hands • Promotes extension of the hips and low back • Assists with standing and ambulation • Can use bolster, wedge, pillows to assist with tolerance and independence with position • Activities may include weight shifting, approximation, scapular depression and prone push ups Concorde Career College