spinal cord injury part 1

etiology

traumatic: MVA, falls, violence, sports
non-traumatic: MS, ALS, tumor, spinal column degeneration, vascular dysfunction, infection

tetraplegia

aka quadriplegia
motor/sensory impairment of all four extremities and trunk including resp muscles
lesion in cervical cord

paraplegia

motor/sensory impairment of all or part of trunk and both LEs from lesions of thoracic or lumbar SC or cauda equina

spinal nerves

cervical exit horizontal, C8 below C7 vertebrae
remaining exit in a downward direction, do not emerge at corresponding level

conus medullaris

L1 level where spinal cord ends, below this get LMN signs only

cervical injury

low C7, C8: retain gross UE function, still have triceps and some hand
upper C5, C6: may require PWC, no wrist/hand/tricep
high: ventilator

complete SCI

absent sensory and motor function in S4-5
NOOOON sign
need all 3: absent voluntary anal contraction, all S4-5 sensory scores, absent deep anal pressure

incomplete SCI

sparing of sensory or motor function in lowest sacral segments, criteria for complete not met

designation of lesion level

ASIA created ISNCSCI, standardized examination to determine extent of motor and sensory function loss, gives neurological level of injury

neurological level of injury

most caudal level of spinal cord with normal motor and sensory function on both left and right sides

life expectancy

lower than people without SCI
influencing factors: age, incomplete > complete, lower injury better, ventilator dependency

medical management of SCI

stabilize spine, maintain open airway, imaging to confirm injury, high steroid dose may be given which increases fall risk d/t blood sugar, hypothermia, orthoses for fx, surgery often for spinal decompression or fusion

cervical orthoses

halo: most stable, raises COM and risk of infection
other stable ones: minerva and SOMI
less stable: miami J, aspen, philadelphia

thoracolumbosacral orthosis

clamshell/turtleshell, CASH or jewett brace
provide external support so transfers may worsen after removal

lumbosacral orthosis

corset or chairback orthosis

spinal shock

acute phase
areflexia below LOI, impairment of autonomic regulation resulting in hypotension and loss of control of sweating and piloerection (temp regulation problems)
areflexia lasts 24 hours followed by gradual return 1-3 days after and then increasing hyperreflexia lasting 1-4 weeks

spastic hypertonia

spasticity common, gradually increases in first 6 months, can worsen with various triggers
stretching has no long term benefit for spasticity but may be used short term before mobility

DVT

common following SCI, always check for

neurogenic shock

acute, above T6, SBP < 90 and HR < 50
severe bradyarrhythmias, AV conduction block, hypotension
may resolve in weeks post injury, be aware of and report, may need med intervention
can do compression, bring to sitting, monitor

PT focus in acute stage

medical and hemodynamic stability, prevent secondary complications, prep for rehab (tolerance to upright position), education

acute interventions

ROM/stretching, strengthening, pulm interventions, bed mobility, transfers, locomotion, education

subacute and chronic

UMN signs emerge, most rapid neuro and functional recovery up to 6 months
possible complications: pressure injuries, HO, UTI, AD, OH, osteoporosis, DVT

pressure injuries supine

occiput, scapula, vertebrae, elbows, sacrum, coccyx, heels

pressure injuries prone

ears, shoulders ant aspect, iliac crest, male genital region, patella, dorsum of feet

pressure injuries side-lying

ears, shoulder lat aspect, greater trochanter, head of fibula, med aspect knees, lat malleolus, med malleolus

pressure injuries

always check skin integrity, prevention important because healing takes very long time
implications: reduced mobility, increased cost and dependence, possible amputation, infection, death
grade 3-4 has higher risk of hospitalization

pressure injury PT management

pressure relief every 15 min in w/c for at least 2 min, at least every 2 hrs supine including at night, always educate pt
push up (require trunk control), lean to side, or lean forward (need strength to get back)
forward lean needs to be more than 45 deg, if tilting w/c back need to be at least 65 deg

heterotopic ossification

subacute, calcium deposits in muscles, most common hips/knees/elbows, restricts ROM - cause unknown
signs: decreased ROM, bony end feel, swelling, local heat/redness, fever
always report, no aggressive ROM

autonomic impairments

AD, cardiovascular and resp changes, pelvic organ function, temp regulation

autonomic dysreflexia

life threatening, rise in SBP 20 above baseline, continues to rise until you intervene, above T6
noxious stimulus below level of injury reaches cardiac baroreceptors before level of lesion and causes vasoconstriction increasing BP, brain recognizes increase in BP and tries to lower by decreasing HR
more common chronic stage

AD triggers

bowel and bladder issues, pressure injuries, HO, fx, trauma, sexual activity, noxious stimulus below LOI

AD intervention

sit up to decrease BP, DO NOT lay down
loosen tight clothing and restrictive devices, monitor BP and HR, identify triggers
call for assistance if s/s don’t subside, call 911 in outpatient

AD s/s

HTN, bradycardia, increased spasticity, piloerection/goosebumps above LOI, diaphoresis and flushing above LOI, pupillary constriction
HA, chills, anxiety, nausea, blurred vision
if even 1 sign check vitals, cycle BP throughout session during higher risk activities

AD education

may not manifest until after d/c, explain signs

cardiovascular changes

dizziness, lightheadedness, faintness, nausea
bradycardia and hypotension most common cervical injuries, orthostatic hypotension
signs: pallor, diaphoresis, LOC

orthostatic hypotension

SBP decrease > 20, DBP decrease > 10
can cause AD
from decrease muscle pump, lack SNS control T6 or higher, loss reflexive vasoconstriction, impaired hydration
blood pools in LEs so drop in BP

counteracting OH

abdominal binder, ace wrap LEs, ted hose/compression stockings
tilt table/standing frame, upright sitting, tilt in space w/c, progressive habituation to upright
medications

pulmonary considerations

leading cause of death
inspiration: diaphragm primary
expiration: abdominals and internal intercostals, normally passive but loss decreases efficiency, control T6-T12

respiratory management

respiratory muscle training
glossopharyngeal breathing for mid to high cervical injuries, gulping pattern 6-10x, allows ventilator dependent to breathe in emergency situations
abdominal binder improves function, cough, and speech by increased pressure
assisted coughing, diaphragmatic pacing stimulates diaphragm

nociceptive pain

visceral or MSK
common in UEs especially shoulder due to overuse, from improper training in w/c propulsion to decrease stress on UEs

neuropathic pain

central or peripheral, below/at/above level of lesion, spontaneous or provoked
spontaneous continuous: burning, cold, squeezing
spontaneous intermittent: shooting, stabbing, electric
evoked: hyperalgesia or allodynia

thermoregulation

loss of peripheral sensory input and impaired vasomotor control below level of lesion, worse above T6
impaired thermoregulatory responses
cervical may have poikilothermia (body temp correlated with room temp)
may have hyperhidrosis, anhidrosis, hypohidrosis
education on regulation, dressing appropriately

chronic stage

impairments fairly stable, improvement slower
complications: shoulder pain, abnormal posture, risk and severity increase with age

contractures

increased risk due to lack of muscle activation
contributing factors: spasticity, positioning, abnormal muscle tone
at ankle, knee, hip, elbow, shoulder may impact ability to perform ADLs

motor level

strength of 10 key muscles
lowest myotome with a key muscle that has grade of at least 3 provided that muscle functions in key muscles above are normal

sensory level

sensitivity to light touch and pinprick at key dermatomes
0: absent, 1: impaired, 2: normal
most caudal level with 2 for light touch and pinprick

ASIA exam principles

performed in supine, reference point is face
normal: 3/5 MMT, 2 for sensation
check PROM prior to motor if <50% must score as NT
motor and sensory levels may be different, unless at T2-L1 where they are assumed the same

asterisk with ASIA testing

non-SCI condition present that may be affecting score

neurologic levels

sensory: most caudal dermatome for both pinprick and light touch sensations
motor: lowest key muscle function that has grade of at least 3 as long as muscles above intact
in regions with no myotome, motor level presumed same as sensory T2-L1

ASIA-A

complete, no sensory or motor function preserved at S4-5, NOOOON

ASIA-B

sensory incomplete, sensory but not motor function preserved S4-5

ASIA-C

motor incomplete, some motor and sensory S4-5, more than 1/2 of muscles < 3/5

ASIA-D

motor incomplete, same as C but more than 1/2 > 3/5
best prognosis