neuromuscular quiz 2

Paraplegia

the impairment or loss of motor and/or sensory function in the thoracic, lumbar, or sacral segments of the spinal cord secondary to damage of neural elements within the spinal canal. With paraplegia, arm function is spared, but depending on the level of the injury, the trunk,legs, and pelvic organs may be involved.

paraplegia includes

cauda equina and conus medullaris

tetraplegia/quadriplegia

the impairment or loss of motor and/or sensory function in the cervical segments of the spinal cord due to damage in the cervical segments of the spinal cord due to damage of neural elements within the spinal canal. Tetraplegia results in impairments of function in the arms as well as the trunk, legs, and pelvic organs. It does not include brachial plexus lesions or injury to peripheral nerves outside the neural canal.

areas most prone to SCIs

cervical and lumbar (C4-C6 and T11-L2)

Complete

absence of sensory and motor function in the lowest sacral segment

Incomplete

partial preservation of sensory and/or motor function is found below neurological level and includes the lowest sacral segment

anterior cord syndrome

loss of pain and temp sensations below the level of the lesion

how does anterior cord syndrome usually occur

hyperflexion injuries or anterior vascular supply damage

central cord syndrome

UE motor function more affected than LE. Varying degree of sensory impairments- depending in mechanism of injury (hyperflexion vs space occupying lesion)

central cord syndrome is caused by

hyperextension injuries and degenerative narrowing of the spinal canal

Brown-Sequard Syndrome

Ipsilateral loss of motor, proprioception, light touch, and vibration sense (damage to lateral corticospinal tract and dorsal column)

indications for a spine CT

acute trauma, post op evaluation of bone graft or fusion, when MRI is contraindicated, modality of choice for assessing the degree of vertebral collapse and for measuring the diameter of the spinal cord

indication for a spine MRI

direct visualization of the spinal cord, nerve root, and discs, when a spinal cord lesion or an occult injury is suspected

ABCDs of imaging

Alignment, bone density, canal space, disc integrity, soft tissues

goal of ASIA scoring

define standard method of assessing neurological level and standard approach to classify severity

what determines neurological level

The most caudal level of intact motor and sensory function on both sides of the body

A= COMPLETE

no sensory or motor function is preserved in sacral segments S4-5

B= SENSORY INCOMPLETE

sensory but not motor function is preserved below the neurological level and includes sacral segments S4-5 (light touch or pin prick at S4-5 or deep anal pressure) AND no motor function is preserved more than three levels below the motor level on either side of the body

C= MOTOR INCOMPLETE

motor function is preserved at the most caudal sacral segments for voluntary anal contraction OR the patient meets the criteria for sensory incomplete status (sensory function preserved at the most caudual sacral segments S4-5 by LT, PP, or DAP), and has some sparing of motor function more than three levels below the ipsilateral motor level on either side of the body.

D= MOTOR INCOMPLETE

motor incomplete status as defined above, with at least half (half or more) of key muscle functions below the single NLI having a muscle grade of 3 or above

sensory examination has how many points

28

what is the determinant of complete vs incomplete

deep anal pressure

optional testing

joint movement and deep pressure appreciation

scoring for sensory examination

0= absent

1= impaired

2= normal

how many muscles are examined in the motor exam

10

motor level is determined by

level at which motor function is at least 3/5 with next rostral level of 5/5

C5

elbow flexion

C6

wrist extension

C7

elbow extension

C8

finger flexion

T1

finger abduction

L2

hip flexion

L3

knee extension

L4

ankle dorsiflexion

L5

big toe extension

S1

ankle plantarflexion

Zone of partial preservation

Refers to the dermatomes and/or myotomes below the neuro level that remain partially innervated, in individuals without sacral sparring

substitutions for triceps

External rotators and gravity

rebound/recoil of biceps

substitutions for wrist extensors

ER shoulder and gravity

Supinating forearm and gravity

Long finger extensors

substitutions for finger flexors

Using wrist extension tenodesis

substitutions for hip flexors

Lower abdominals with posterior pelvic tilt

Hip adductors

what can you do with lesion of C5

Elbow flexion and supination, shoulder external rotation, shoulder abduction and flexion to 90 degrees

what can you do with lesion of C6

Shoulder flexion, extension, internal rotation, and adduction, scapular adduction, protraction, and upward rotation, forearm pronation, wrist extension (tenodesis grasp)

what can you do with lesion of C7

Elbow extension, wrist flexion, finger extension

what can you do with lesion of T1 to T2

Improved trunk control with more caudal SCI, increased respiratory reserve, pectoral girdle stabilization for lifting objects

what can you do with L1, L2, L3

Hip flexion, hip adduction, knee extension

what can you do with L4, L5, S1

Hip flexion, knee extension, knee flexion, ankle dorsiflexion, ankle plantarflexion, ankle eversion, toe extension

what scale tests tone/spasticity

Modified ashworth scale

1 for modified ashworth scale

slight increase in tone, catch/release at end ROM

1+ for modified ashworth scale

slight increase in tone, catch/release and resistance through rest ROM (½ ROM)

2 for modified ashworth scale

more marked increase in tone through ROM, but affected part moved easily

3 for modified ashworth scale

considerable increase in tone, passive movement difficult

4 for modified ashworth scale

affected part in rigid flexion and extension

3 classifications for cough

functional, weak functional, nonfunctional

functional cough

strong enough to clear secretions

weak functional cough

adequate force to clear upper respiratory tract secretions in small quantities, assistance is required to clear mucous secondary to infection

nonfunctional cough

unable to produce any cough force

Diaphragm pacing

via intramuscular electrode in each hemidiaphragm - delivers individualized rate/pace of stimulation

C1-C5 injuries

Neurological impairment of the phrenic nerve

Weakened diaphragm activation

integumentary for patients with SCI

skin integrity, consider sensation, pressure considerations, teach inspection and unweighting, seating and positioning considerations

What impacts neuroplastic changes

Age, injury severity, chronicity, specificity of therapeutic interventions employed

How can PTs create opportunity for neuroplasticity

Personalized rehab programs, innovative therapeutic techniques, maximize the benefits of neuroplasticity, enhance clinical outcomes in SCI management

Spinal cord independence measure

Used to measure the efficiency of rehabilitation treatment in patients with SCI, includes: Self care, respiration and sphincter management, mobility (room and toilet), mobility (indoor and outdoors), transfers, stairs

Wheel chair uses shoulder pain index (WUPSI)

15 item self report that measures intensity of shoulder pain during functional activities

special considerations for C6

ER to lock out elbows, 90-100 degrees shoulder extension

C6 supine to long sit

supine, hook hands palm up under hips, weight shift with head/shoulder side to side while driving elbows into mat to get to long sit, hamstring ROM 100-110 SLR

strengthening ideas for C6

prone on elbows and supine on elbows

prone on elbows

strengthens shoulder girdle and posterior musculature

when positioning someone with a C6 SCI you need to consider

elbow pads for shear/friction, work on shoulder extension/ER, chest expansion, breathing exercises

when doing short sit to long sit

one leg at a time, lean towards BOS

consideration for tuck and roll

maintain balance while getting arms under legs, down to arm and back up as initial training, commit to the movement, throwing back with roll - do not let go of legs/may use leg loops or strap legs together

considerations for mobility: thoracic

long sit transfer, sit pivot, focus on sitting/trunk balance, quadruped with assistance, high level WC training

recovery of function

restoration of the neuromuscular system so that the motor task is performed in a similar manner as it was before the SCI

compensation

use of an alternative or new movement strategy OR technology to compensate for neuromuscular deficits to accomplish a daily task

spinal shock is characterized by

absence of all reflexes and impairment of autonomic regulation, resulting in hypotension, and loss of control of sweating and piloerection

spinal shock

immediately following SCI, resulting in areflexia

how does spinal shock evolve

initial areflexia- 24 hrs, gradual return of reflexes over 1-3 days, with initial hyperreflexia than lasting 1-4 weeks, stabilizing over the next 6 months

impact of spinal shock on PT

monitor reflexes, monitor vitals d/t risk of hyporeflexia and impairments in autonomic regulation

autonomic dysreflexia

typically occurs in complete lesions above T6, acute onset of autonomic activity from noxious stimuli below the level of the lesion

initiating stimuli for autonomic dysreflexia

bowel and bladder irritation, pressure sores, noxious cutaneous stimuli below the level of the lesion, kidney malfunction, E stim below the level of the lesion, sexual activity, skeletal fx below the level of the lesions

signs and symptoms of autonomic dysreflexia

HTN, bradycardia, headache, profuse sweating and flushing above level of the injury, seizures, blurred vision, increased spasticity, restlessness, vasoconstriction, constricted pupils, nasal congestion, piloerection

impact of autonomic dysreflexia on PT

management of AD is a medical emergency, sit pt up (their BP drops), check for kinked catheter, ask about recent BM

during PT what can be done to prevent AD

monitor thermal regulation and vitals at rest and during exercise, understand impact of medications on HR and BP response, perform active cool down after exercise to support venous return, consider emptying catheter bag before/after treatment

UMN syndrome

spasticity, muscle spasms, increased muscle tone, hyperactive stretch reflexes, and clonus

causes of spastic hypertonia

position changes, cutaneous stimulation, environmental temperature, tight clothing, infections, stress

spastic hypertonia can be a warning sign for

pressure sores, UTI, ingrown toenail, tight clothing, autonomic dysreflexia, broken bone or cyst, appendicitis, kidney stones

orthostatic hypotension could happen for those with SCIs because

vasodilation below level of injury with resultant venous pooling secondary to poor muscular tone

pulmonary impairment C1-2

vent dependent, as well as need for airway clearance

pulmonary impairment C3-4

partially innervated diaphragm, likely need airway clearance assistance (suction)

pulmonary impairment C5-8

full diaphragm, weak cough

pulmonary impairment T1-12

impaired intercostals, abdominal, and spinal musculature will impact airway clearance

how do pulmonary impairments affect PT POC

monitor vitals for breathing, patient education for breathing techniques, cough function, as well as health/wellness related to pulmonary function

damage to temp control for pt's with SCI bc

inability of the hypothalamus to regulate body temp

poikilothermia

the inability to regulate core body temperature, so the persons body temp tends to follow the surrounding envirnoment

major cause of morbidity and mortality in people with SCI

UTI

empties in response to pressure

spastic/hyperreflexive bowel and bladder

does not reflexively empty in response to pressure

flaccid/areflexic bowel and bladder

spastic/hyperreflexive bowel and bladder can lead to

decreased coordination for emptying

flaccid/areflexic bowel and bladder can lead to

retention and incontinence

bowel management

timed/routine, medications, dietary intake, fluid intake, function/mobiliy, digital stimulation