PTRS 853 - Rehabilitation of the Spinal Cord Injury

Factors affecting functional outcomes

- social history

- family support

- work history

- level of education

- home layout (ranch vs multilevel home) -> begin home modifications early if possible

Postural Hypotension

- typically in acute SCI

- presents: lightheadedness, low BP, may yawn, may pass out

- management: ace wrap LE's, binder, TED hose, reclining w/c or cardiac chair, medications when unable to improve with other interventions

Autonomic Dysreflexia

- occurs in both acute and chronic SCI

- acute elevation of SCP of at least 20 mmHg

- +/- bradycardia

- triggered by nonoxious or noxious visceral or somatic stimulation below the level of injury

Symptoms of Autonomic Dysreflexia

- can be asymptomatic

- Severe headache

- Anxiety

- Profuse sweating above LOI

- Flushing and piloerection above LOI

- Dry and pale skin below LOI

- Blurred vision

- Nasal congestion

- Bradycardia, arrhythmias, atrial fibrillation

Face is red...

raise the head

face is pale...

raise the tail

Pain in SCI

can occur in both acute or chronic SCI

- pain at injury site

- nerve root pain

- other injuries not yet identified

- neurogenic pain below level of injury

Management of pain with SCI

•Pain modalities (be cautious of using heat/cold over insensate areas)

•Alternative exercise

•Acupuncture

Shoulder Injuries / Carpal Tunnel Syndrome

- typically in chronic SCI

- presents: pain/weakness in shoulders and/or wrists, both are overuse injuries from wheelchair use, transfers, and vocations

- management: proper WC position and work station setup, use of power chair vs manual, surgical repair is an option but can be very limiting in the recovery phase

ROM limitation may be due to...

HO

Other injury

Premorbid contractures

Arthritis

Contracture from spasticity and insufficient PROM

Heterotrophic Ossification

- typically acute SCI

- presents: sudden limitation of ROM, most commonly over hips, knees, shoulders, elbows, may be warm over the joint

- management: early detection is important so medications can be started, continue with ROM per physician orders, however, no aggressive ROM

Spasticity

- may be acute or chronic SCI

- presents: hypertonicity of extremities denervated distal to the lesion (present with all UMN lesions), determine when it is interfering with function

- management: baclofen, valium, flexeril

Contractures

- chronic SCI

- presents: fixed limitation of ROM over a joint or multiple joints, can lead to pressure areas and difficulties with ADLs

- management: prevention, ROM, proper positioning in bed and wheelchair, for older injuries may beed to consider baclofen pump, surgical releases

Strength and Muscle Tone with SCI

- Intact above level of injury

- Absent below level of injury

- Low tone (flaccidity) initially

- Increased tone (spasticity) after period of spinal shock* has passed

Central Cord Strength and Muscle Tone

LE's stronger than UE's

Brown-Sequard Strength and Muscle Tone

Unilateral differences

Syringomyelia

- chronic SCI

- presents: A progression of weakness proximal to the level of injury, Especially problematic for cervical injuries (where a level can make a big difference in function

- management: surgical management

- due to fluid / blood in SC change above their lesion

Osteoporosis

- chronic SCI

- due to lack of muscle contraction and WB

- presents: Lack of bone density due to lack of weight bearing over time, more susceptible to fractures

- management: medical management

C5 SCI

elbow flexors

C6 SCI

wrist extensors (can use tenodesis grip)

C7 SCI

triceps

C8 SCI

finger flexors (may have weak grip and trouble with fine motor control in hand)

T1-12 SCI

expect full UE motion, varying levels of abdominal function / trunk control based on level of injury

L2 SCI

hip flexors

L3 SCI

knee extensors

L4 SCI

ankle dorsiflexors

L5 SCI

toe extensors

S1 SCI

ankle plantar flexors

Rolling with SCI

- use bedrails / devices / objects to grab

- use of momentum

Supine to sit with SCI

- -onto elbows first, work to extended arms

- roll to sidelying, hook LEs, push up from sidelying

Tenodesis Grip

C6 -> control of wrist flex / ext

- when wrist ext = finger flex

- when wrist flex = finger ext

* only stretch fingers in wrist flex

Balance techniques with SCI in Short Sitting

- static with UE support

- static without UE support

- dynamic reaching over a stable base

Balance techniques with SCI in Long Sitting

- necessary for independent dressing

- usually more easily achieved than short sit due to a larger base of support

- consider hamstring length if having difficulty with obtaining anterior tilt of the pelvis - flexing the knees will help

How should you stretch the hamstrings in a patient with SCI

in supine

Transfers with SCI

- dependent lift

- sliding board

- swing pivot

- car

- commode

- tub bench

- floor to chair

Neurogenic Bladder

bladder will not empty with voluntary control

- hypo-reflexive: does not empty

- hyper-reflexive: empties too often

Bladder function with SCI

- problems with regulating bladder management

- frequent bladder distention can promote UTI

- a full bag on an external catheter does not indicate proper bladder emptying

Neurogenic Bowel

bowel will not empty with volitional control

Bowel Function with SCI

- bowel empties too often

- bowel does not respond well to bowel program

- an obstruction may present as diarrhea with loose stool passing around the obstruction

- Ileus (absent or decreased bowel sounds and no stool or flatus passing) can cause abdominal distention and impair diaphragmatic breathing

SCI have high risk for decubitus ulcers due to...

- impaired / absent sensation

- physiologic changes

- inability to perform pressure relief

- moisture control issues due to incontinence and sweating

Pressure sores present as:

redness that does not fade in 20 minutes which may progress to open wounds

- causes can change as the persons body changes

Pressure sores management

- prevention education

- proper wheelchair and bed positioning

- minimize sheer forces

- pressure relief in bed and wheelchair

- pressure mapping for searing

- proper nutrition

- moisture management

Wheelchair positioning for pressure relief

65 degrees for actual relief, minimal drop in pressure with 35 degree tilt

How often should unloading happen to decrease risk of pressure sores?

3.1 times per hour

Weight shifting

30-90% off-loading of at least one buttock for 15 seconds

Wheelchair & Seating Prescription Considerations

- patients functional level

- patient ability to perform pressure relief independently

- the type of terrain the patient will be on

- amount of time the person will be in the wheelchair

- the transfer technique

Wheelchair considerations

- will the patient be loading the wheelchair into a car by themselves?

- weight of the wheelchair

- positioning desired

- accessibility at home and other destinations

- single vs multiple caregivers

- patient preference regarding style

Spinal Deformities in SCI

- occur in chronic SCI

- scoliosis, pelvic obliquities, kyphosis

- often due to poor wheelchair positioning and support

- over time a deformity develops and increases the chances of pressure sores, overuse syndromes and respiratory compromise

Management of Spinal Deformities with SCI

- proper wheelchair positioning is a key component to prevention

- the only correction of a fixed deformity is a surgical correction

- deformities can be correctable with positioning if caught early

- include spinal stretching with PROM

Tolerance to upright position with SCI

- higher level of injury will have more difficulty with maintaining blood pressure

- patients may require the use of ace bandages and abdominal binder for maintaining vascular support

- patient should progress past the need for these supports

Factors limiting upright position with SCI

- BP

- respiratory status

- endurance

- pain

- dysreflexia

At what level is the diaphragm intact but has limited intercostal musculature?

C6-7

What types of SCI are best candidates for ambulation?

incomplete lesions and lower lesions

Clinical recommendations for ambulation with SCI

- begin gait training asap after incomplete SCI

- use BWS (when necessary) or overground (when feasible)

- higher intensities are more effective

Pros exoskeleton

- the ability to walk while wearing the suit

- decreased pain

- decreased spasm

- improved bowel and bladder function

- decreased incidence of UTI

- cardiovascular function

- psychosocial

- increase steps during therapy time

- decreased therapist workload

Hypothermia / Hyperthermia with SCI

the body is unable to regulate temperature - susceptible to external conditions

- can happen in chronic or acute SCI

management: education, use of proper clothing, dress for the weather, avoid temperature extremes

Sexual Function in SCI - Men

some are able to achieve psychogenic or reflex erections

- psychogenic = T10-L2

- reflexic = S2-S4

infertility is common due to difficulty with temperature regulation and prolonged sitting resulting in increased scrotal temperature

Sexual Function in SCI - Women

- women need to continue birth control when desired - pregnancy is still possible

- pregnancy considerations include difficulties with pressure sores and responsibility compromise from pressure on the diaphragm

- may require additional lubrication as primary intervention for sexual activity

Primary focus of treatment in acute care / early rehab

- prevention of secondary complication

- tolerance to upright position so the patient is ready to begin the rehab phase

- education

Examples of Treatment in acute care / early rehab

- strengthening

- passive ROM

- education for skin care and pressure relief

- teaching methods of pressure relief

Balance in short sitting and long sitting

- generally begin with short sit as a pre-transfer activity

- long sit training is best on a mat

Aerobic training for SCI

progressive aerobic exercise in chronic incomplete SCI using the Nustep has been shown to increase fitness and walking related outcomes

Treatment for SCi post-acute care

- aerobic exercise

- strengthening / stretching

Goal setting considerations

- level of injury and ASIA classification

- body type

- premorbid strength and athleticism

- age

- male v female

- adjustment to injury

- support system

Home evaluation

- entrances (2 accessible are desired)

- doorway widths

- turning radius from hall to rooms

- surfaces over which they are propelling

- financial resources

- height of furniture

- accessibility of kitchen / bathroom appliances

- what is acceptable to the patient

Adaptation suggestions for the home

- ramps

- replace carpet with hardwood or other surface with less friction

- remove throw rugs

- pedestal sink or cut out cabinet in the bathroom

- flat surfaces for bathroom sink for easier access

- put frequently used items or lower shelves in kitchen

- roll out shelves

- lazy susan

- computerized access

- loops on cabinets for easier opening

- lever door handles

- raise the floor of the kitchen

- stackable washer / dryer

rise to run ratio for ramps

one foot of run for one inch of rise