SCI exam and intervention

what do you have to make sure to do within first 1-2 sessions that may result in sacrificing fully finishing the eval?

have to make sure the pt is reasonably comfortable in the chair for full day sitting

exam

-hx

-cause

-surgery

-stabilization device

-complications

-associated injuries

-LOC

-DVT

-time since injury

-social and medical hx

-meds

-B/B

-sexual dysfunction

-goals

exam

-subjective

-orientation

-following instructions

-pain

-motivation

-memory/cognition

exam

-objective

-skin (weight shift)

-vital signs (normally lower)

-consider level for autonomic dysreflexia

what does AOx4 stand for?

-person

-place

-time

-situation

exam

-respiratory

everyone with SCI has respiratory compromise

-method of breathing

-trach

-cough

-vital capacity

-ROM of chest wall and UE's

-scoliosis

how to assess breathing?

full breath in and count 10-14 "alligators"

exam

-sensation

-LT

-pain

-temp

-proprioception

-test distal to prox (be consistent)

exam

-strength

-MMT grades

-AIS key muscle groups and others

-watch for substitutions (external rot for triceps)

-stabilize

exam -tone

-how does it affect function

-alter position

exam

-cognition

-memory

-sequencing

-carry over

-consult with your colleagues

exam

-ROM

orthotics to consider

LE for:

-HS

-ankle DF

-IR/ER of hip

UE for:

-shoulders

-hands

exam

-function

bed/mat mobility (rolling, sit <-> supine, prone)

why is lying in prone important?

-offload sacrum

-change breathing mechanics

-stretches everything

-reduces spasticity

exam

-function

(try to get pt out of chair for exercises)

-transfers: bed, chair, shower chair, toilet, car

-WC propulsion: dist, method surface, type of wc, turning radius

-wc mgmt: brakes, arm and leg rests

-balance: short and long sit, tanding, dynamic and static

-length of time, surface, reach

-ambulation: braces, AD, newer technologies

Tx approaches

-medical celarance and awareness

-goal based and use principles of neuroplasticity

-specificity of taste

-appropriate dosing and variety (RPE 14-16)

tetraplegia

high tetra C1-4: innervated

facial, pharyngeal, laryngeal, neck above level of injury

SCM: C2- partial, C3- full

Lev scap: C3- partial, C4- full

diaphragm (C3,4,5), trap, partial rhomboid (C4)

tetraplegia

high tetra C1-4: functionally

respiration may need vent and trach

BUT

at C4- not vent dependent

tetraplegia

high tetra C1-4: pressure relief

-dependent but able to instruct

-independent with power assistance

tetraplegia

high tetra C1-4: WC

power mobility with attention to head positon

tetraplegia

high tetra C1-4: bed mobility and transfers

dependent

-able to instruct

tetraplegia

high tetra C1-4: goal

-skin and instruction

-mobility

-strengthen what's available

-> esp diaphragm and intercostals

tetraplegia

high tetra C1-4: weight shifts

-manual

tilt back

bend forward or to sides

tetraplegia

high tetra C1-4: weight shifts

-power

-tilt in space

-recline

-drive mechanism

->sip and puff

-> head, chin, or tongue control

-> hand or foot controls

benefits for weight shifts

at least 35 deg decline-> ideally 45 deg

-increases capillary flow and oxygenation

-pressure relief for tissues involved

tetraplegia

C5: what's innervated?

biceps and deltoids, diaphragm

-brachialis

-brachioradialis

-infraspinatus

-rhomboids

tetraplegia

C5: available motion

-elbow flex

-supination

-shoulder ER and abd (to 90)

-> some flex

tetraplegia

C5: function

no vent or trach

weak respiratory system

tetraplegia

C5: pressure relief

lat, forward and assisted

tetraplegia

C5: wc mobiltiy

I in power mobility and if manual use lugs

tetraplegia

C5: bed mobiltiy

-roll if strong

-sit to sup with A

-prop in short sit

-prone on elbows after positioned

tetraplegia

C5: transfers

-dependent but can instruct

-lift may be needed

tetraplegia

C5: goals

-education

-I weight shifts

-equipment

tetraplegia

C6: what is innervated?

-delt

-biceps

-brachioradialis

-pec major clavicular portion

-ser ant

-diaphragm

-ECR

-infraspinatus

-lats

-pronator teres

-teres mino

tetraplegia

C6: available motion

-shoulder flex/ext, internal ROT and add

-scapulae abd and upward ROT

-wrist pron adn ext

-> tenodesis of hands

tetraplegia

C6: pressure relief

lat, forward, and mod pushup

tetraplegia

C6: WC mobility

I power and may not need weight shift mechanism

tetraplegia

C6: bed mobility

-I roll with momentum

-LE's on to mat with difficult

tetraplegia

C6: transfers

-lateral with board

-I level surface

tetraplegia

C6: goals

-I weight shift, rolling, wc propulsion inside for manual and outside with power

-Min A with transfer board

-be able to get to prone on elbows, move supine to long sit

tetraplegia

C7: what's innervated?

-tris, lats

-pec major sternal portion

-diaphragm

-external pollicus longus and brevis

-extrinsic finger flexors

-FCR

tetraplegia

C7: motion available

-elbow and finger ext

-wrist flex

tetraplegia

C7: function

-elbow ext

-work for pulmonary independence

tetraplegia

C7: pressure relief

expect full I, pushup, forward and lat

tetraplegia

C7: WC mobility

-manual and power I (no weight shift mechanism)

-pop up on 2 in curbs (size of a threshold)

tetraplegia

C7: bed mobility

full I

-rolling

-STS (LE's still hard)

tetraplegia

C7: transfers

I for transfer board to level surface

tetraplegia

C7: goals

-I bed mobility, transfers with and without board, min A for LE's

-I with manual and power wc including mgmt

-I weight shifts

tetraplegia

Low C8-T1: what's innervated?

C8- FDP

T1- interossei (pure T1-para)

extrinsic and intrinsic finger flexors

tetraplegia

Low C8-T1: motion available

full UE

tetraplegia

Low C8-T1: function

-respiration gains

-improved function with hand

tetraplegia

Low C8-T1: pressure relief

expect full I, pushup, forward and lat

tetraplegia

Low C8-T1: wc mobility

-manual and power I (no weight shift mechanism)

-pop up on 2 in curbs (size of a threshold)

-now easier with grip-> assists with advanced WC skills

tetraplegia

Low C8-T1: bed mobility

full I

-rolling

-STS (LE's still hard)

tetraplegia

Low C8-T1: transfers

I for transfer board to level surface

-more advanced

-uneven surfaces

-shouldn't need board

tetraplegia

Low C8-T1: goals

-I bed mobility, transfers with and without board, min A for LE's

-I with manual and power wc including mgmt

-I weight shifts

-better outdoor mobility

-advanced W skills

with paraplegia you see

quicker gains as better use of UE, then some trunk muscles

Paraplegia

T2-6: what's innervated

fully innervated

-UE

-errector spinae above level of lesion

T5 (upper rectus abd)

Paraplegia

T7-L1: what's innervated?

fully: UE, erector spinae above level of lesion, T12 (rec abd)

Paraplegia

cauda equina: L2 and below

-what's innervated?

-fully: abd and obliques

-L1: partial iliopsoas and QL

-L3-quads (3/5=KAFO); >3/5= (AFO)

-L4*: ant tib, ext hallucis longus and brevis, extensor digitorum longus and brevis

-S1: gastroc

orthotics-> not braces

paraplegia: ambulation with braces?

-long shot

-usually non-functional

-expensive

-poor follow thru long term

paraplegia: can do/goals

-I for home, then community (outpatient)

-uneven transfers, advanced wc skills, maybe short dist ambulation

-general mobility and I in all these areas

->orthotics for stability may be a limiting factor in initial tx

treatments

-transfers

-head to hip relationship (opp)

-start level then uneven

-floor is possible

treatments

-bed mobility

all levels, including prone

treatments

-wc skills and management-> full independence

-wheeling and curbs

-falling and righting chair from floor

-ramps

-stairs: bumping

WC

-manual

-rigid, folding

-regular, lightweight, ultra lightweight

-power assisted drives attaching to a manual chair

wc

-power

front, mid and rear wheel drives

seat and back cushions

-principles

-maximize SA contact

-maintain proper alignment

-provide stable BOS

-decrease or minimize tonal influences

-sitting

3 principles of walking

-reciprocal stepping

-maintain equilibrium

-able to adapt to environment

locomotion

-neural control

studies from animal models (cats and other primates)

1. control is disturbed across CNS

2. control is hierarchical

neural control

-walking

patterns and rhythm generation and response to the envirrnment

neural control

-rhythm generation

-spinal interneuron/central pattern generator

-> some plasticity within SC

->ability for SC to communicate across and initiate stepping

-located in the gray matter lumbar enlargement of the SC

neural control of locomtion

component of a movement results from a reflex vs what component is generated by the CNS (centrally generated)

-hierarchy of movement types, at least 3 categories must be defined

->voluntary

->automatic

->reflex

reflex

movement in reaction to an external stimulus

caudal

related to tail

rostral

related to head

what determines the letter on the ISNSCI?

sacral sparring

-if any of the following present this is not an A

-> VAC

->DAP

-LT or PPR at S4-5

animal models

locomotor central pattern generator

-reciprocal movement/inhibition of flexor and extensors

-spinalized cats produced rhythmic, but less coordinated movements

->movement controlled by central limb oscillator composed of 2 halves (flexor and extensor motor neurons)

animal models

-is locomotion a reflex

no

-rather its an automatic movement generated by interneurons located in the SC

-> central pattern generators describes this

animal models

-does every motor behavior need its own central pattern generator? (CPG)

no

-by merely altering the thing relationships between the various joints, diverse forms of movements may be produced

locomotion neural connection

-modular organization of the CPG

-interlimb coordination may be achieved via coupling of the hip oscillators BL

-sensory input contributes to the refinement of locomotor output

-ex: hip position, amount of load on limbs manual facilitation

-the stepping pattern becomes more vigorous with training

locomotion neural connection

-basic rhythmiticity is generated by

spinal interneurons (AKA: the locomotor network or CPG) located in the gray matter lumbar enlargement of the SC

locomotion neural connection

-sensory input

-influence of sensory input in the CPG function is phase- dependent emphasizes its importance

-> locomotor output is known to be enhanced by sensory input such as that from load receptors and receptors that signal hip position

role of supraspinal centers in locomotor function

-the SC is much more than a passive conduit for descending motor commands and ascending sensory info

-SC in the generation of locomotor function is that the CPG circuiting manages the rhythm and timing of muscle activity

-supraspinal centers plan an important role in activating the pattern generators in a manner that's consistent with a conscious goal (forward, stop, faster, etc)

locomotor training

-motor incomplete

-sensory related input comes from environment including the trainers, use of braces and AD-> constrained yet controlled

-individuals with chronic (>1 year) SCI benefit

-> acute training unsure

-generally do better than sensory incomplete

locomotor training

-level of injury

-positive C and T

-unclear in low T and L

optimize sensory input training

1. train at fastest rate tolerable (ex: approx normal walk speed)

2. allow as much load on LE as can be sustained

3. maintain upright posture with extended trunk and neck

4. approx normal hip, knee, and ankle movement

5. discourage UE WB while maximizing LE WB

6. synchronize terminal hip extension and unloading in 1 limb with loading of contralateral limb

training

-manual assisted

-stimulation assisted

-robot assisted

-treadmill vs. overground

recovery

-functional anatomy of the SC dictates that the size and location of a spinal injury will have a major impact on the type and extent of the initial deficit, as well as, on the potential for functional recovery

-in humans, this is a varied pic given the multitude of possibilities (age 50 is cut off for recovering gait)`

level of injury and walking

clients with AIS A at their 1st exam (72hrs) have very few chance of neurological recovery below lesion

-80% of initial A remain an A

-~10% convert to B

-~10% convert to C

-> if the 1st exam is performed later % of improvement decreased dramatically to 2.5%

-clients who converted to an incomplete lesion only 14% recovered some walking function

SCI Synd (incomplete) and Walking

-central cord

-characterized by a greater involvement of the UE than LE

-considered to have good prognosis for walking recovery

-> but strongly influenced by age

SCI Synd (incomplete) and Walking

-Brown-Sequard Synd (BSS)

characterized by ipsilateral heiplegia and contralateral hemianalgesia due to spinal hemisection

-good functional prognosis

SCI Synd (incomplete) and Walking

-Ant Cord Syndrome

due to lesion that involves the anterior 2/3 of the SC and preserves the posterior column

-low walking recovery chances

retraining of neural structures

reduce edema first

-> then only 2 ways to promote recovery of function after SCI

1. Neural regeneration to connect structures on either side of lesion

2. retraining: to improve functional recovery using the adapative capacity and plasticity remaining nervous structure

complete transections

incomplete transections

lesion type and response to intervention

when considering the neural circuitry available to control locomotion after a spinal injury, its important to bear in mind that intact neurons in all remaining structures will likely influence the neural reorganization underlying the recovery of function

-this can affect drug therapy

MSK considerations

-limit MSK deterioration after SCI

-plasticity adaptation outcome (PAO) model

MSK considerations

-limit MSK deterioration after SCI

-interventions could limit the noisome secondary complications that develop after SCI

-these interventions may also increase the probability that people who currently have SCI could fully capitalize upon a forthcoming cure

MSK considerations

-PAO Model

-plasticity

-adaptations

-outcomes

MSK considerations

-plasticity

of the neuromuscular system is defined as its underlying capacity to change

-largely determined by its physiological processes and cellular histochemical characteristics

MSK considerations

-adaptations

occur in response to various imposed stimuli