SCI Mgmt Considerations

pain syndrome in people with SCI

-neuropathic pain

-MSK pain

-visceral

-unknown category

-> nociceptive and neuropathic qualities

nueropathic pain

-caused by abnormal signal from SC to brain

-difficult to treat

-often involves meds

MSK Pain

include muscle spasm pain due to strain on muscle due to spasticity

cream: capsaicin and voltaren

visceral pain

thorax, abdomen, and pelvis (dull and cramping)

-usually caused by medical conditions so be cautious

pain syndrome in people with SCI

-Tx

-modification

-alternative therapies (topicals)

-medications (Bacloven: used to decrease spasticity and need to be weened off)

-dorsal column stimulator

-intrathecal pump

dorsal column stimulator

surgical procedure

-treat neuropathic pain due to nerve damage

intrathecal pump

used to treat nueropathic pain

-deliver meds at lower doses

shoulder pain

-reported in as high as 50% of population and may last for a year or more

-> expect SCI pt to have shoulder pain

-intensified with WB thru UE

-often injured RTC and changes in the bone due to chronicity of the SCI

shoulder pain

-Tx options

new: single injection autologous; micro fragmented adipose tissue into affected shoulder jt

could ask for rental power chair temporarily

depression in persons with SCI

-present in 1 in 5 people with SCI and 1 in 20 without SCI

-recommended practice when clients may be seen by non-psychology personal

2PHQ

9PHQ

2 PHQ

brief screen-> summary of interests

2 questions

1. little interest or pleasure in doing things

2. feeling down, depressed or hopeless

-can be read to them or given pencil and paper

- answers other than 0 given 9PHQ

-> discuss results with clietn

9PHQ

more in depth

-discuss results with client

-10 indicates moderate depression

-refer to psych

depression in persons with SCI

-treatment

study participants were found most likely to prefer an exercise program, meds prescribed by primary care provider, and individual counseling in a medical or rehab clinic to treat depression and least likely to prefer group counseling

prevention of bone loss

-rapid bone loss from time of admittance

-increased risk for low trauma fx after a SCI esp in LE

-moderate evidence for tx of bone lose using pharmacology

-continual loss of bone mass 3 y after SCI

-post SCI there's a rapid and extreme loss of bone mass which can't be fully explained by mechanical loading

cardiovascular adverse events with exercise

no evidence to suggest that cardiovascular exercise done according to guidelines and established safety precautions is harmful

-included traditional and aerobic exercise as well as FES cycling

Vent dependent mgmt

-factors that influence survival

1st year: most critical for mortality mgmt

then: age, level of completeness of injury, time since injury (after the 4th survival year not a factor ), family support, concurrent TBI, use of gastrostomy tube

Vent dependent mgmt

-leading causes of death

-pneumonia

-septicemia

-PE

topics to be addressed with persons with high tetraplegia

spinal precautions

high tetra C1-4

-review of available muscle groups

-specific considerations

-therapeutic focus

-respiratory mgmt

-secondary complications

-direction of care and caregiver training

-equipment

-expected functional outcomes

general considerations for SCI

-spinal precautions

-premorbid condition

-comorbid injuries that may have occurred

-body type/size

muscles available at high C spine level

C1-3

facial muscles and cervical muscles with cranial innervation

-talking

-mastication

-sipping

-blowing

muscles available at high C spine level

C4

diaphragm and trap

-respiration

-scapular elevation

specific considerations for high tetra

dependent mobility

joint protection

respiratory function

-often on ventilator

-unable to produce strong cough

-may be unable to voice

-high risk for pneumonia

specific considerations tetra

-clients with lower level levels of injury may be put on a vent such as

-older clients

-more complicated PMH/unstable pulmonary status

-often able to wean more quickly

tracheostomy

-surgically made hole that goes thru the front of your neck into your trachea (tracheostomy)

-breathing tube (trach tube) us placed thru the hole/stoma and directly into your trachea to help you breath (can also help manage secretions)

tracheostomy

-for who?

may be used to help ppl who need to be on vents for more than a couple weeks or who have conditions that block the upper airways

-transition from oral intubator to trach is usually ~1wk or less

trach anatomy and reasons

-diff types and features

-reasons

-> lack of air getting to lungs

-to bypass an obstructed upper airway clear and remove secretions from the airway, to more easily and usually have more safely deliver O2 to the lungs

trach parts

outer cannula

inner cannula

obturator

outer cannula

-outer tube that holds the tracheostomy open

-neck plates extends from the sides and the holes on the plate allow to secure around the neck

inner cannula

-fits in the outer cannula

-has a lock mechanism but can and should be removed when appropriate

obturator

the part to insert the trach tube

-only used during insertion

what type of tube allows for (soft) speech?

fenestrated cuffed trach

reasons for selecting different trach

-cuffed trach with inner cannula

allows positive pressure ventilation and prevents aspiration

-deflate if speaking valve used!!!*

-check pressure at least 2-4x/day

-can create necrosis around the cuff

reasons for selecting different trach

-cuffless

-may be able to eat and speak (without valve)

-usually, longer term use

fenestrated

-permit airflow (cough and phonate)

-difficulty using speaking valve

tracheostomy mgmt

trach size will be reduced over time

once weaned from vent:

1. trial and improve tolerance for Passy Muir Valve (PMV)- must be DELFATED for use)

2. trial and improve tolerance for capping

3. decannulation

4. healing of stoma

vent mgmt for the PT

-transport the client on a vent

-manipulate vent tubing within context of functional mobility

-utilize "silence" button on vent for courtesy and client comfort (facility/ machine specific)

-provide in line or sterile suction (facility specific)

-provide accessory respiratory intervention as ordered by physician

w

vent mgmt for the PT

-what we CANT do

-change vent settings

-manipulate trach (change size)

therapy session to leave the room

gather necessary equipment:

-ambu bag

-portable suction kit and charger

-suction catheters

-yankauer device

-pulse ox

if removing vent from docking station, securely attach vent to wc

if taking the docking station disconnect from nursing call bell system at the wall (be sure to cancel the call bell arm that will sound)

therapy session to leave the room

-if on supplemental O2

-switch from room O2 to portable tank and turn off wall O2 in room

-switch portable O2 to gym O2 source (compressor or large O2 tank) upon arrival to gym

-always adjust to appropriate FiO2

therapy session to return to room

-return vent to docking station or plug docking station into the wall

-assure vent is connected to nurse call system

-plug in portable suction machine to charge

-plug in pulse ox and connect pt if ordered

-provide call system, suction, TV, etc

therapy session to return to room

-if on supplemental O2

-switch portable O2 to wall O2

-turn wall O2 on and adjust to appropriate FiO2

Vent Alarms

-high pressure alarms

indicates increased resistance to air flow within the system (blockage)

Vent Alarms: high pressure

-causes may include

-increased secretions

-kinked tubing

-cough reflex

-suctioning

Vent Alarms

-low pressure alarm

indicates lack of normal resistance to airflow within system (air escaping)

Vent Alarms

-causes may include

disconnection between tubing components

-accidental: vent tubing pops off

-intentional: during a transfer

vent weaning

progression over days/weeks

-inspiratory/expiratory resistive training

-increased time off vent during the day with close monitoring

-continued suctioning as needed

night time vent support is usually last "manipulation"

-not breathing as deeply at night

-muscles are resting and quiet

diaphragmatic breathing

-a nerve stimulator is surgically placed and stimulates the phrenic nerve to cause contraction of the diaphragm

-a functioning phrenic nerve and intact diaphragm is required

diaphragmatic breathing

-several proposed advantages over mechanical ventilator

-more physiologic

-more comfortable for the pt

-less expensive over time

-aesthestics

respiratory interventions

-assisted coughing

-incentive spirometry and other

-pulmonary conditioning and ACT

-FES/NMES: can use external devices to stimualte muscles

-prone positioning and postural drainiage

-> drain to middle to allow bigger airways to clear (percussion)

secondary complications

-orthostatic hypotension

-autonomic dysreflexia

-wounds

-pulmonary issues

-VTE (DVT/PE)

-diff dx is hard: person will get D dimer faster than without SCI

VTE

-recommendation

thromboprophylaxis (mechanical and medicine) in acute phase ASAP for at least 8 weeks and during high risk periods (rehospitalization)

Fam/Carer Instruction For Pts wit High Tetra

-24 hrs support

-multiple caregivers need to be trained

-expect extensive due to dependency of client

-highly focused on prevention of secondary complications

-> skin integrity

->maintenance of PROM

-respiratory health

equipment for client with vent

power wc with tilt mechanism and seating system inclusive of cushion, back and head rest with positioning attachments

-optional features may include chair elevation, power recline/tilt, power leg readjustment

equipment for client with vent

-driving methods may include

head array control, chin control, sip and puff control

equipment for client with vent

-besides wheelchair

-vent and suctioning supplies

-lift mechanism

-home modifications

->ramp or outdoor WC lift

->doorway and hallway width

->overhead lift if able

->electrical safety

long term functional expectation of pt with high tetraplegia

C1-3

-D with all transfers and ADLs

-I with power mobility and weight shifts

-I with environmental control units

long term functional expectation of pt with high tetraplegia

C4

-D with all transfers and ADLs

-I with power mobility and weight shifts

-I with environmental control units

-more likely to have success with chin control PWC, mouth stick use, voice control technology