sci eval and treat

What are the cardiovascular changes that occur after SCI

• impaired adjustments/responses

• autonomic dysreflexia

• neurogenic shock

• hypotension/orthostatic hypostension

Why are the CV changes

HR, BP, and vascular tone are affected

Why are SCI pts at more risk for cardiac events

loss of balance between SNS and PSNS

what is autonomic dysreflexia

noxious input below the level of injury casing a mass SNS reflex response to be initiated from the lower SC, which would normally be adjusted by carotid sinus and aorta but signals dont make it past the lesion

Why do we get the symptoms associated with autonomic dysreflexia

impulses from the vasomotor center to cause vasodilation cannot pass lesion to counteract hypertension

Who does this typically occur to

those with lesions above T6

2 main causes of autonomic dysreflexia

1. bladder distension/irritation

2. bowel distention/irritation

What are some other causes of autonomic dysreflexia

• painful stim

• GI upset

• sexual activity

• labor

• fx

• estim

main symptoms of autonomic dysreflexia

• hypertension

• bradycardia

• pounding headache

• profuse sweating

What do we categorize as hypertension associated with autonomic dysreflexia

SBP increase of 20-30

management of autonomic dysreflexia

lower the BP in some way (sitting them up)

What if sitting the pt up doesnt work in controling autonomic dysreflexia

find and remove the trigger quickly

define hypovolemic shock

loss of a large amount of blood

s/s of hypovolemic shock

• low central venous pressure

• decreased hematocrit

• tachycardia

• loss of blood

define neurogenic shock

sudden loss of NS signals due to a significant impact on SC

s/s of neurogenic shock

• bradycardia

• cervical cord dysfunction

• loss of peripheral vascular tone

treatment for hypovolemic shock

large amounts of IV fluid

treatments for neurogenic shock

monitor fluids

keep head down (lay flat)

who is at risk for hypotension

• deconditioned

• lack of upright tolerance

• T6 and above

symptoms of hypotension

• blurred vision

• ringing

• light-headedness

treatment for hypotension

compression!

building tolerance to upright

education on symptoms

considerations for hypotension

consistent assessment of vitals

sensory/integ changes after SCI

• temperature control

• pain perception

cause causes the impaired temperature regulation

• loss of hypothalamic control

• lack of vasomotor control

treatment of impaired temperature control

need to be aware of weather and ambient temperatures to dress accordingly

cause of neuropathic pain

injury to central/peripheral NS

types of neuropathic pain

allodynia

hyperalgesia

define hyperalgesia

extreme pain from a typically mild pain stimulus

define allodynia

pain from a nonpainful stimulus

types of nociceptive pain

shoulder pain

cause of shoulder pain

1. overuse

2. muscular imbalance

3. seating position

how do sensory changes lead to skin integrity issues

• risk for breakdown secondary to pressure

• dependent LE position

  • decreased mobility and increased dependency

positioning tactics for skin integrity

• variety of positions

• pressure relief schedule

• cushions/support

When should pressure relief schedule be when in bed

every 2 hrs

When should pressure relief schedule be when in sitting

15-20 mins

how long should pressure relief be

1 min for every 15 mins of pressure

supine pressure susceptable areas

• occiput

• scap

• vert

• elbows

• coccyx

• sacrum

• heels

prone pressure susceptable areas

• ears

• shoulders

• iliac crest

• genitals (men)

• patella

• dorsum of feet

sidelying pressure susceptable areas

• ears

• shoulders

• greater troch

• head of fibula

• medial knees

• malleoli

MSK changes after SCI

spasticity

osteoporosis

heterotopic ossification

DVT/PEs

contractures

Where is the spasticity

below level of inury

what exacerbates spasticity

UTI

skin breakdown

environment

emotional stress

positional changes

how many people with SCI experience spasticity

65%

purpose of functional spasticity

• compensates for weak muscles

• serves as early warning system for health problems

• potential benefits of bone health and circulation

Why would someone want to keep their spasticity

functional spasticity for transfers or tenodesis

treatment options for spasticity

• medications

• intrathecal baclofen

• stretching

• botox

what outcome is helpful for determining affects of spasticity as a subjective assessment

Penn Spasm frequency score

what outcome is helpful for determining affects of spasticity as a objective assessment

• modified ashworth scale

• SCAT

what outcome is helpful for determining affects of spasticity as a functional assessment

mobility

why would SCI have difficulty with osteoporosis

changes in Ca metabolism and degenerative joint changes secondary to mechanical stress

What are the evaluation components

• motor/sensory

• vitals and respiratory

• integ

• ROM

• mobility skills

• bowel and bladder

general principles for pts with SCI

• muscle substitution

• momentum

• head-hip relationship

• task modification

• “working in and out of the task”

define muscle substitution

compensation techniques for weak muscles

muscle substitution techniques

• gravity provides resistance for small movements

• tension in passive structures to maintain stability

• fixation of distal extremity to incorp prox joint will allow movement in intermediate joint

describe wrist tenodesis

active wrist ext simultaneously produces passive finger flexion and can be used to achieve a functional grasp

define momentum

an object in motion stays in motion in the same direction

higher velocity = ____ momentum

more

longer moment arm = ___ leverage

increased

define head-hips relationship

the hips will follow the opposite direction of the head and shoulders are rotated

What is the key for functional mobility

head-hips relationship

define selective stretching

greater than normal ROM requirements might be needed for functional mobility, however some structures you want to have tighter for stability in certain postures

ROM targets for UEs

full elbow, forearm supination, wrist ext

tightness in finger flexors

Why do we care about elbow ROM

required for most functional activities

Why do we care about forearm supination ROM

needed to provide ext lock at elbows

Why do we care about wrist ext ROM

required to lock elbows and for tenodesis grasp

When are we worried about UE ROM

cervical spine injuries

Why do we care about finger flexor ROM

allows tenodesis grasp

ROM targets for LE

mild tightness in low back

full ext of hips

Why do we care about low back/hamstrings ROM

tightness is indicated for transfers and mat activities

Why do we care about hip ext ROM

required for ambulation or standing

target ROM for hamstrings

110 of SLR

target ROM for DF

full

Why do we care about DF ROM

ambulation, transfers, standing

stability

Why is strengthening/motor control important

higher than normal strength demands on intact muscle groups

What area do we want to focus on strengthening/motor control

shoulders

What is the program for shoulders

STOMPS (strengthening and optimal movements for painful shoulders)

What is incorporated in STOMPS

stretches

active movements

strengthening

Mobility interventions

• repeated task practice

• balance/functional tasks in long and short sitting

• transfers

Wheelchair mobility interventions

• increase tolerance to upright

• independent sitting in chair

• independent transfers to/from chair

Levels for w/c propulsion

• level ground

• negotiate architectural barriers

• uneven and elevated surfaces

mobility interventions for ambulation

HIIT

AFOs/KAFOs