spinal cord - part 4 (medical management, PT exam, strategies, motor levels)

stabilize spine, prevent complications

specialized medical management is a must; what are two goals for this?

accident

medical management:

- pre-hospital care

- starts at ___ site (stabilize spin and precent additional damage; emergency management)

neurological, immobilize, care

medical management - emergency management at accident site:

- enhance survival and ___ integrity

- ventilation

- circulation

- ___ spine (head to below buttocks)

- transport to acute ___

neurological, spine, ventilation, hemorrhaging, hypotension, ventilation

medical management - acute care:

- treatment to life threatening conditions

- preserve ___ function

- avoid motion to ___

- ___, oxygenation and circulation

- control ___

- cardiac: treat arrhythmias or ___

- respiration: ABG, intubation, ___

survival, neurological

medical management -

- goal is to enhance ___ and prevent any additional ___ damage

cognitive, sensation, voluntary, radiologic

medical management - neuro exam/assessment:

- ___ exam (level of consciousness, CN function, rule out head injury)

- ___

- ___ motion

- reflexes

- ___ tests (assess SC damage, standard xrays - lateral, AP, flex-ext and open mouth odontoid view, CT scans, MRI)

consciousness, cranial, head

cognitive exam:

- level of ___

- ___ nerve function

- rule out ___ injury

history, urinary, 8, 48

medical management - neurological exam:

- medical ___

- GI

- ___

- evaluate and treat associated injuries

- methylprednisolone (standard practice of care, given ___-___hours post injury)

methylprednisolone

what is the standard practice of care to be given 8-48 hours post injury?

reduction, immobilization

fracture management - ___ and ___ of SCI can be achieved via conservative or operative methods

neurological, alignment, spine, impingement, positioning

fracture management goals:

- minimize ___ damage

- restore vertebral ___

- stabilize ___

- eliminate ___ on neuronal tissue

- minimize deformity

fracture management:

- traction

- ___

- orthoses

- surgery

subluxation

non surgical management - radiologic exam:

- vertebral angulation or ___

lateral, traction, decompress

immobilization cervical - tongs:

- ___ side of skull

- ___ rope with pulley

- ___ spine

- reduction confirmed with x-ray ... if not surgery

fracture, respiratory, stable

immobilization cervical - halo:

- for cervical ___

- halo ring with 4 steel screws attached to outer skull

- body jacket with 4 vertical posts

- contraindicated with severe ___ involvement

- most ___

posterior, pelvis, planes

immobilization cervical - minerva body jacket:

- thermoplastic encases chin and ___ aspect of skull

- extends down to ___

- headband around skull

- restricts cervical motion in all ___

cervical motion in all planes

what does the minerva body jacket restrict?

mandibular, flexion

immobilization cervical - somi:

- sterno occipital ___ immobilizer

- padded sternal plate attached to 3 uprights

- most effective restricting ___ at C1 to C5

flexion at C1 to C5

what is the somi most effecting at restricting?

soft, rigid

immobilization cervical - cervical collars:

- ___

- ___: miami J, philadelphia, aspen

alignment, traction, respiratory, obese, coma

immobilization positioning - turning beds/frames:

- stryker

- allow positional changes while maintaining ___

- turn without disruption of ___

- supine or prone

- need to be careful with cardiac or ___ involvement

- unsuitable for ___ or ___ pts

allow positional changes while maintaining alignment

what is the purpose of turning beds/frames?

stability

immobilization - thoracic/lumbar - thoracolumbosacral orthoses (TLSO):

- molded plastic body jacket

- clam shell

- maximum ___ (knight-taylor, jewett - prefabricated metal frame)

fracture, malalignment, compression, neurological, instability, mobility, facet

surgical management - indications:

- unstable ___ that will not reduce with closed reduction

- gross spinal ___

- evidence of continued cord ___

- deteriorating ___ status

- continued ___ following conservative management

- remove boney fragments in the canal

- remove foreign bodies impinging cord

- assist with earlier ___

- bilateral ___ dislocation

reduction, stabilization, anterior

surgical management-

optimal timing of surgery:

- hours vs days vs weeks

surgery:

- decompression

- ___

- ___ with rod and plates

approaches:

- ___

- posterior

- combination

level, instability, impingement, neurological

surgical approach - factors that affect surgery approach and internal stabilization:

- ___ and type of SCI

- extent of spinal ___

- number of vertebral levels

- location of bone and soft tissue

- ___ of SC

- extent of ___ impairment

- length of time since injury

subjective, goals

PT exam:

- ___ information

- history (document from acute care)

- relevant information

- pts ___ (be specific, know their definition of walking)

information, goals, evaluation

PT examination:

- foundation of PT program

- need thorough and accurate ___

- basis for development of realistic ___ and POC for pt

- ongoing ___ process

level, contraindications, injuries, social

PT exam - history - damage to SCI:

- date of injury

- ___ of injury

- extent of injury

- etiology

- specific ___

- additional ___ sustained

- summary of medical and surgical management

- pre-existing conditions

- ___ issues (need to know about their situation)

potential, functional independence

PT exam - voluntary motor function:

- important factor that affects ultimate ___

- results of MMT predict level of ___ ___

ASIA, control

PPT - MMT:

- ___

- conventional

- motor ___ vs MMT

- maybe limited secondary to mobility and/or surgical precautions

all, function

MMT - standardized MMT:

- test ___ muscles

- do not assume there is no ___ even if they say they have none

function

MMT - ASIA:

- calculate upper and lower limb motor scores

- useful for documenting changes in motor ___

use functioning muscles to perform actions of muscles that are weak or absent

describe substitution

extend, wrist extension, toe extension, abdominals

MMT substitution - use functioning muscle to perform actions of muscles that are weak or absent:

- ___ elbow in absence of tricep

- gross grasp with ___ ___ (tenodesis)

- ankle DF with ___ ___ (can mimic especially if pt has tone)

- hip flexors by ___ or adductors

- need to eliminate motions and carefully palpate muscles for MMT

biceps, ER

what muscles if the UE is fixated can mimic elbow extension if a pt lacks triceps?

absent, weaker

MMT - stabilization:

- muscles used to stabilize during MMT may be weak or ___

- need to accommodate for this or muscle tested may appear ___ than it is (ex- periscapular muscles, trunk/abdominals, quads)

trunk

MMT - ___ is difficult to assess:

- standard tests test entire length of muscle

- sit ups are often contraindicated

abs, T12

position of umbilicus stays central and uniform pull:

- ___ either totally function or are absent

- injury above T5 or below ___

beevors sign, T5, T12

position of umbilicus move cephalad ___ sign:

- muscle pull greater above umbilicus than below

- lesion between ___ and ___

beevors sign

what is it called when the umbilicus moves cephalad? - muscle pull greater above umbilicus than below

muscle pull greater above umbilicus than below

what does beevors sign mean?

injury above T5 or below T12

if the umbilicus stays central and uniform pull, what does this imply about injury?

lesion between T5-T12

if the umbilicus moves cephalad, what does this imply about injury?

voluntary, reflexive, synergistic, factors, ashworth

PT exam - tone:

- distinguish between ___ and not

- ___ movement

- associative motions

- quality

- muscle groups

- ___ patterns

- positions

- ___ that influence tone (ex- noxious stimuli inc)

- modified ___ to measue

0

modified ashworth - no increase in muscle tone

1

modified ashworth - slight increase in muscle tone, manifested by a catch and release or by minimal resistance at the end of the range of motion when the affected part(s) is moved in flexion or extension

1+

modified ashworth - slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the remainder (less than half of the ROM)

2

modified ashworth - more marked increase in muscle tone through most of the ROM, but affected part(s) easily moved

3

modified ashworth - considerable increase in muscle tone; passive movement difficult

4

modified ashworth - affected part(s) rigid in flexion or extension

functional, contractures, skin, severity, noxious

PT exam - muscle tone:

- positive or negative (how is ___ movement affected?, pain, ___, ___ breakdown)

- constant or fluctuating

- ___

- provides info re medical status (___ stimuli may inc tone)

proprioception, neurological

PT exam:

- ___

- sensation

- directly affected by a SCI

- reflection of ___ status

pinprick, light, deep, pain

PT exam - sensation - reflection of neurological status:

- improvement or deterioration evident by change in sensation

- ___ (important bc so close to motor)

- ___ touch

- ___ pressure

- temperature

- ___ (protects skin; if decreased more vulnerable to trauma)

voice, words, sensory

PT exam - sensory substitution - pt watches PT for possible hints:

- ___ intonation

- choice of ___

- eliminate any ___ clues (don't brush up against them by accident)

bicep, ECRL, tricep, quad, gastroc

PT exam - DTR:

- ___ (C5)

- ___ (C6)

- ___ (C7)

- ___ (L3)

- ___ (S1)

LE, vertebral, functional, measurements

PT exam - ROM:

- general ___ ROM

- avoid stress to areas of ___ instability

- mild restrictions can have huge ___ impact

- specific ___ needed

hip, elbow, SLR, flexion, DF

PT exam - ROM:

- avoid stress to areas of vertebral instability

- lumbar fx (limit ___ ROM to when resistance to motion occurs)

- mild restrictions can have huge functional impact

- ___ (needs to be hyperextended for mat mobility)

- shoulder

- ankle

- specific measurements needed

- ___ (test supine with pelvis stabilized at top)

- hip ___ (can go into lumbar lordosis and think they have more)

- ___ (may affect ability to walk if impaired)

positional, pressure, inspection

PT exam - skin:

- ___ changes in bed and wc

- ___ relief techniques

- ___ of at risk areas

rate, cough, posture, breath, expansion, strength

PT exam - respiratory:

- respiratory ___

- ___

- vital capacity

- ___ (abdomen protrusion, poor diaphragm rest position, lowers/sags)

- ___ pattern (accessory motions noted)

- chest ___ (measure at axilla and xiphoid process; difference between max expiration and max inspiration)

- ___/tone (diaphragm, abdominals, intercostals)

abdomen protrusion, diaphragm lowers/sags at rest

describe posture in terms of respiratory exam with SCI pt?

accurate, equipment, cues

PT exam - functional abilities:

- important to be ___ and specific (starting point, measure of success)

- during functional mobility evaluation - assistance need, ___ need, amount of ___ needed (verbal and manual)

incontinence, programs, equipment, digital

PT exam - bowel/bladder:

- ___

- type of ___ they're on and timing

- ___ needed

- meds may soften stool

- ___ stimulation (finger around anal area to stimulate bowel movement)

management, propulsion

PT exam - wc skills:

- ___ (can they remove armrests, put on breaks, get up if they fall, etc)

- ___ (indoor, community, advanced)

bed, transfers, balance, ambulation

PT exam - functional status:

- ___/mat

- ___ (even, uneven, functional)

- ___ (static and dynamic) - sit, stand

- ___

- wc skills

- instruction of others

true

t/f: the seating evaluation for wc is comprehensive, specialized, and expensive

FIM, wc, max, preferred, berg, modified CTSIB

PT exam - standardized tests:

- ___ (measures functional ability, both reliable and valid)

- ___ skills test (57 specific skills)

- WISCI/WISCI II (ranks ability of a person to walk 10 m; 0-20 most to least severe impairment)

- 10 m walk test (___ and ___ gait speeds)

- ___ for balance

- ___ for balance

effectiveness, meaningful, functional, measurable

PT exam - goal setting:

- gives direction

- used to measure ___

- involves the patient

- should be ___ goals

- ___ outcomes

- specific and ___

- set target date

what does walking mean to you? what activities do you want to be stronger for?

what are two examples of questions to ask the patient to make their goals more specific (about ambulation and strength)?

compensation, restoration

strategies for functional rehab - ___ vs ___:

- dependent on voluntary motor function

- neuroplasticity

- need to know neurologic levels for proper treatment

muscle substitution, substitution with gravity, substitution using tension in passive structures, substitution using fixation

what are 4 methods of substitution as strategies for functional rehab?

TFL for hip ABD

provide an example of muscle substitution in the LE as a strategy for function rehab

specific position of extremity used

describe how substitution with gravity is used as a strategy for functional rehab

tenodesis

provide an example of substitution using tension in passive structures for functional rehab

tighten finger flexors

if a pt intends on using tenodesis as substitution method, what should be done length wise to what muscle group?

short sit elbow extension

provide an example of substitution using fixation for functional rehab

place head in opposite direction of where you want the hips to go (hips should go in opposite direction as head)

describe head to hips ratio (use ratio to assist with movement for transfers and weight shifting)

momentum, velocity

strategies - ___/___

- throw extremity

- rolling

- keeping head forward when doing a supine to EOB transfer

functional, movement

mobility progression:

- ___ outcomes

- CPG outcomes

- ___ strategies

complications, obesity, trunk, arm, cognitive, fear

factors affect outcome:

- medical ___

- ___

- body type

- ___/___ ratio

- age

- ___ status

- proprioception

- ___ (want them to be comfortable)

- culture

athletic, adjustment, pain, spasticity, expertise

factors affect outcome:

- ___ ability

- motivation

- ___ to disability (suicide/depression screen)

- ___

- ___/tone

- fractures

- ___ of clinical team!

cervical flexors/extensors, diaphragm rhomboids, supraspinatus, SCM, levator scap, anterior/middle scalenes

what are the key muscles innervated by C4?

C4

the following functions are available with which motor level? -

- head control, neck movement, mouth movement, ability to breathe

rotator cuff, deltoids, biceps, brachialis, brachioradialis, serratus anterior, teres major

what are the key muscles innervated by C5?

C5

the following functions are available with which motor level? -

- movement of the deltoid, shoulder ABD/flx/rotation and some extension/depression, bicep

pec major, ECRB, ECRL, supinator, lats

what are the key muscles innervated by C6?

C6

the following functions are available with which motor level? -

- strong bicep, wrist extension, tenodesis, shoulder rotation/adduction/abduction and extension/depression

triceps, pronators, supinators, pec major/minor

what are the key muscles innervated by C7?

C7

the following functions are available with which motor level? -

- full shoulder movement, strong scapular stability, elbow extension, strong wrist, moderate grasp

FDP

what are the key muscles innervated by C8?

interossei

what are the key muscles innervated by T1?

intercostals, abs

what are the key muscles innervated by T2-L1?

C8-L1

the following functions are available with which motor level? -

- improved/normal grasp, trunk musculature/trunk stabilizers

iliopsoas

what are the key muscles innervated by L2?

quads

what are the key muscles innervated by L3?

tib ant, glute med

what are the key muscles innervated by L4?

EHL

what are the key muscles innervated by L5?

gastroc/soleus

what are the key muscles innervated by S1?

sphincter

what are the key muscles innervated by S2-5?

L2-S5

the following functions are available with which motor level? -

- pelvic stabilization, LE motion, bowel/bladder

C1-4

these are the functional outcomes and equipment for injury to what level?