WAFL 16: Neuromuscular Conditions

most common causes of spinal cord injury

vehicle accidents

diving/falls

violence

spinal cord ischemia accounts for....

6% of acute myelopathies and has a poor prognosis

what is spinal cord ischemia?

spinal stenosis that compresses the cord

in children what are causes of spinal cord ischemia?

hypotension and hypoxemia secondary to cardiac malformations and trauma

in adults what are causes of spinal cord ischemia?

stenosis or an embolic phenomenon secondary to atherosclerosis

other causes of spinal cord ischemia include

aortic dissection, aortic aneurysm, aortic surgery, systemic hypotension or shock, major thoracic surgery (CABG), disk compression of radicular artery, cocaine abuse, sickle cell disease

overtime, what has changed about SCI rehabilitation

the age at injury as increased, the length of hospital and rehab stays have decreased

what should be considered when a SCI is discharged from IPR nowadays?

because their stay is shorter now, they are less functional when they leave meaning more basics will be worked on in an outpatient setting

the pathophysiology of SCI can be from...

primary or secondary injury

what is primary injury?

damage to the neural tissue due to direct trauma and is irreversible

what is secondary injury?

injury to adjacent tissue due to decreased perfusion

lipid peroxidation releasing cytokines leading to cell death

tetraplegia

injury to the cervical spinal cord leading to impairment of function in the arms, trunk, legs, and pelvic organs

paraplegia

injury to the thoracic, lumbar segments leading to impairment of function in the trunk, legs, pelvic organs depending on the level of injury. Arm function is preserved

ASIA A

Complete. injury is complete spinal cord injury with no sensory or motor function preserved

ASIA B

Sensory Incomplete. a sensory incomplete injury with complete motor function loss

ASIA C

Motor Incomplete. a motor incomplete injury where there is some movement, but less than half the muscle groups are anti-gravity

ASIA D

Motor Incomplete. a motor incomplete injury with more than half of the muscle groups are anti-gravity

ASIA E

Normal. If sensation and motor function as tested are graded as normal in all segments and the patient had prior deficits

what is important when giving an ASIA grade?

patient must have recovered from spinal shock before an injury can be determined as complete or classified as ASIA A

the first reliable ASIA score is at

72 hours

neurological level of injury (NLI)

the most caudal segment of the spinal cord with normal sensory and antigravity motor function on both sides of the body, provided that there is an intact sensory and motor function rostrally

incomplete injury

an injury with some preserved motor or sensory function below the level of injury

what are some classic incomplete syndromes

anterior cord syndrome

brown-sequard syndrome

central cord syndrome

posterior cord syndrome

conus medullaris syndromes

cauda equina syndrome

anterior cord syndrome

an incomplete injury that spares the dorsal columns. The lesion will effect the CST, STT, anterior horn motor neurons and autonomic center.

Complete motor deficiency below level of lesion, loss of pain, temp, and crude touch sensations. Orthostatic HoTN, bladder and/or bowel incontinence and sexual dysfunction

brown-sequard syndrome

ipsilateral loss of fine touch, proprioception and vibration sensations

contralateral loss of pain and temp

central cord syndrome

motor weakness: UE > LE

sensory loss: vary degrees, usually in the hand

intact rectal tone

bladder definition - retention

ASIA C or D

mechanism of injury: hyperextension injury with pre-existing spondylosis

what is the most common incomplete syndrome due to injury/lesions around the central canal (commonly due to trauma)

central cord syndrome

Posterior Cord Syndrome

injury resulting in loss of fine-touch, vibration and proprioception sensations. Sensory ataxia, dizziness, unsteady gait and frequent falls. Positive Romberg sign

conus medullaris syndrome

injury or lesions of the conus (T12-L2)

common causes of conus medullaris syndrome

disk herniation, trauma, intramedullary tumor, infection, spinal dural AV fistulas, cord infarction

conus medullaris syndrome clinical presentation

severe back pain, LE weakness, saddle anesthesia or hypoesthesia, early bladder and rectal sphincter dysfunction and impotence

when do you intubate a cervical spinal cord injury?

loss of innervation to diaphragm (C3-5)

overtime fatigue of accessory muscles of respiration

associated injuries

over secretion and lack of clearance

ventilation/perfusion mismatch

hypoventilation

cough function of SCI

C1-3: absent

C4: non-functional

C5-T1: non-functional

T2-4: weak

T4-T10: poor

T11 and below: normal

vital capacity of SCI

C1-3: 0-5%

C4: 10-15%

C5-T1: 30-40%

T2-T4: 40-50%

T5-T11: 75-100%

T11 and below: normal

evolution of treatment of SCI

begins at scene of accident

rigid collar and transport on spine board

log roll techniques

decubitus ulcers can occur after only 30-60 min on a backboard

medical management of SCI via steroids

debate in the literature on the use of steroids

hypothermia in SCI

systemic and local, evidence is weak and limited and is currently not recommended due to increased complications

low threshold surgery in SCI

will depend on the injury, early decompression and stabilization. decompression may facilitate nerve root function return at the level of injury

surgery for traumatic central cord syndrome

within

early surgery is suggested < 24 hours post injury as a treatment option in

adult traumatic central cord syndrome patients

neurogenic shock

characterized by hypotension and relative bradycardia in patient with acute SCI, can be fatal

what happens in neurogenic shock?

circulatory collapse from loss of sympathetic tone

disruption of autonomic pathway within the SC leading to lack of sympathetic tone

decreased systemic vascular resistance

pooling of blood in extremities

HoTN

treatment for neurogenic shock

Swan-Ganz monitoring for careful fluid management

Pressors to treat HoTN

spinal shock

temporary loss of spinal cord function and reflex activity below the level of a SCI

characteristics of spinal shock

flaccid areflexic paralysis, bradycardia and HoTN

absent bulbocavernosus reflex

recovery potential for spinal shock

variable, usually resolves within 48 hours, its conclusion spasticity, hyperreflexia, and clonus slowly progress over days to weeks

mechanism of spinal shock

neurons become hyperpolarized and unresponsive to stimuli from brain

how do you know spinal shock is over

return of bulbocavernous reflex, conus or cauda equina injuries may lead to permanent loss of bulbocavernous reflex

spinal shock summary

HoTN

Bradycardia

Absent bulbocavernosus reflex

flaccid paralysis

48-72 hours after SCI

peripheral neurons become temporarily unresponsive to brain stimuli

neurogenic shock summary

HoTN

Bradycardia

variable/independent reflexes

variable/independent motor

48-72 hours after SCI

disruption of autonomic pathway leads to loss of sympathetic tone and decreased systemic vascular resistance

complications of SCI

decubitus ulcers

venous thromboembolism

urosepsis

major depressive disorder

acute complications of SCI

cardiovascular

respiratory

venous thromboembolism

autonomic dysreflexia

an acute elevation of arterial blood pressure >20-30 mmHg rise in systolic. basically an over activity of the sympathetic nervous system in response to a strong sensory stimuli that can result in intracranial hemorrhage, cardiac complications, retinal detachments, seizures, and death

signs and symptoms of autonomic dysreflexia

sudden rise in SBP

change in HR

pounding or throbbing headache

blurred vision

profuse sweating

goosebumps

dry and pale skin below level of injury

anxious feeling

nasal congestion

nausea

difficulty breathing or a feeling of chest tightness

what should you do if a patient has autonomic dysreflexia

move pt into an upright sitting position

check BP and recheck every 5 minutes

loosen tight clothing

search for and eliminate the cause of the incident

seek medical attention if there is no reduction in BP after following these steps

complete or higher level cervical injuries (C4 and above) are risk factors for

necessitating intubation during the acute phase post SCI

thoracic level injuries can have a weakened or absent cough, this is due to

denervation of external and internal intercostals and abdominal musculature

pressure ulcers

localized injury to the skin and/or underlying tissue typically over a bony prominence as a result of pressure, or a pressure in combination with shear

what are prevention strategies for pressure ulcers

pressure distribution through proper positioning

caution with skin during mobility

pressure relief techniques (turning in bed)

education

why are SCI's higher risk for venous thromboembolism

due to venous stasis

pharmacologic treatments for venous thromboembolism

heparin in combination with compression devices

heterotopic ossification

the development of bone formation in non-skeletal tissues commonly at the hip, knee, elbow, shoulder, and thigh. pain and stiffening, fever, warmth and swelling locally, increased spasticity

what should you not due with someone with HO?

aggressive stretching at joints with HO

bladder function during spinal shock

bladder is flaccid

function sphincter at the bladder's outlet is closed causing retention requiring an indwelling catheter

bladder function with an areflexic bladder

the bladder fills without emptying

bladder function with a reflexic bladder

individuals with cervical and thoracic injuries have reflexic bowels where the bladder is overactive and spastic

prognostic indicators for walking in SCI

age

completeness

level of injury

pain and temp sensation in sacral region

clinical prediction rule

determinants of health outside of the individual

the Van Middendorp prediction rule assessed what variables?

age >65

motor score at L3

motor score at S1

light touch score at L3

light touch score at S1

a higher prediction rule score was related to...

higher likelihood for walking again

prognosis for complete spinal cord injuries

improvement of one nerve root level expected in 80% of pts

improvement of 2 nerve root levels expected in 20% of pts

only 1% have a complete recovery at time of hospital dx

ASIA A injuries have the least chance for marked recovery

prognosis for incomplete SCI

the greater the sacral sparing the greater the recovery

pts that show more rapid recovery have better prognosis

when recovery plateaus it rarely resumes improvement

pts with complete injuries at T7 and below have

the potential for ambulation with bracing

pts with a complete injury at C7 or below are

more independent because they have the strength to transfer

key muscles gained at C1-3

head/neck extensors, SCM

key muscles gained at C4

upper trap, diaphragm

key muscles gained at C5

delts, biceps, partial rotator cuff

key muscles gained at C6

extensor carpi radialis, serratus, full rotator cuff

why is C6 so big for muscles?

having extensor carpi radialis means that tenodesis can occur allowing these individuals to be able to grab things

key muscles gained at C7

triceps, lats, FDS, extensor digitorum

key muscles gained at C8

flexor digitorum, FCU, ECU, partial lumbricals

key muscles gained at T1-6

PADs and DABs, full lumbricals, erector spinae of upper back, upper intercostals

key muscles gained T7-T12

partial to full abdominals, partial quadratus lumborum

key muscles gained at L1-2

iliopsoas

key muscles gained at L3-4

quads, lower erector spinae, adductors, weak anterior tib

projected functional outcomes for motor complete SCI at 1 year (C1-4)

bed mob: dependent

transfers: dependent

WC propulsion: maybe indep; power WC w/ head array

projected functional outcomes for motor complete SCI at 1 year (C5)

bed mob: requires assist

transfers: max assist

WC propulsion: indep w/ power WC; some assist with manual wc

projected functional outcomes for motor complete SCI at 1 year (C6)

bed mob: requires assist

transfers: some assist to indep on level surfaces

WC propulsion: indep w/ manual wc, level surfaces

projected functional outcomes for motor complete SCI at 1 year (C7)

bed mob: indep to some assist

transfers: indep w/ or w/o transfer board to level surfaces

WC propulsion: indep except for curbs or uneven terrain

projected functional outcomes for motor complete SCI at 1 year (C8-T1)

bed mob: indep

transfers: indep

WC propulsion: indep

projected functional outcomes for motor complete SCI at 1 year (T2-9)

ADLS bowel and bladder: independent

Transfers: independent

Amb: physiologic standing only

Bracing: bilat KAFOs, HKAFOs, RGOs w/ forearm crutches or walker

projected functional outcomes for motor complete SCI at 1 year (T10-L2)

ADLS bowel and bladder: independent

Transfers: independent

Amb: household w/ orthoses

Bracing: bilat KAFO's, HKAFO's, or RGO's w/ forearm crutches; robotic exoskeleton

projected functional outcomes for motor complete SCI at 1 year (L3-S5)

ADLS bowel and bladder: independent

Transfers: independent

Amb: community amb possible

Bracing: possibly KAFO or AFOs w/ canes or crutches

What should examination of postural control include?

both quantitative and qualitative assessment

postural control

regulating the body's position in space for the dual purposes of stability and orientation

postural stability

the ability to control the center of mass (COM) in relationship to the base of support (BOS)

center of mass

a point that is at the center of the total body mass, which is determined by finding the weighted average of the COM of each body segment

center of gravity

the vertical projection of the COM

base of support

the area of the body that is in contact with the support surface

center of pressure

the center of the distribution of the total force applied to the supporting surface

why is postural control/stability important?

overall it helps to prevent falls! falls lead to fractures, injuries and fear of falling that cause individuals to be immobilized.