combine week 9-11

Statistics of SCI

Statistics of SCI

12,000 new cases a year

Ages 16-30 years old with the average age of 43

81% male

Life expectancy is less

causes of TBI

MVA 37%

Falls 29%

Acts of violence 14%

Sports related 9%

Etiology of SCI

31 pairs of spinal nerves

More susceptible due to greatest amount of rotation in these areas:

• C1,2,5,6,7

• T12

• L1,2

Naming levels

Named with the area of the spine first

Then the number of the level of the last spinal nerve root segment that is innervated

C6 = cervical vertebra at the 6th level (wrist extensors present)

two naming levels for the limbs

Tetraplegia (quadriplegia)

• Injuries to the cervical area

• UE, LE, trunk, and pelvic areas are affected

Paraplegia

• Injuries to the thoracic, lumbar, and cauda equina areas

• LE, trunk, pelvic areas are affected

American Spinal Injury Association (ASIA) scale

used to classify SCI

neurologic level is defined as the most caudal segment of the cord with intact sensation and muscle movement

Sensory = light touch and pinprick

Motor = lowest key muscle with a manual muscle test of grade Fair (3/5)

Cervical flexion and rotation

Most common

Vertebra displaced over the one below it

Rear-end collision

Cervical hyperflexion

Anterior compression fracture of vertebral body

Wedge-type fracture

Severs the anterior spinal artery causing incomplete anterior cord syndrome

Head-on collision or blow to the back of head

Cervical hyperextension

Rupture of the anterior longitudinal ligament and compresses the intervertebral disc

Spinal cord gets compressed between ligamentum flavum and vertebral body

Central cord injury

Falls where chin strikes a stationary object

Compression

Vertical compressive force and fractures

Vertebral end plate fracture and nucleus pulposus moves into the vertebral body

Bone fragments

Diving accidents

Medical interventions

Immobilization

• Bracing (halo, tortoise shell, Philadelphia collars)

• Skeletal traction

• Surgery (fusion, bone graft, internal fixation devices)

Pharmacologic

• Decrease hemorrhage and ischemia

Methylprednisolone (corticosteroid)

Pathologic changes after injury

Hemorrhage into gray matter —> necrosis of axons —> edema in white matter and puts pressure on nerve fiber tracts —> myelin sheath disintegrates —> axons shrink —> scarring

Secondary tissue damage (ischemia, hypoxia, and biochemical changes) continues and can expand the injured area

Close monitoring of level of injury for 24-48 hours because the level of damage may ascend 1-2 levels due to vascular changes

Spinal shock

Immediately after injury due to interruption of pathways between brain and spinal cord

Characterized by:

• Flaccidity

• Areflexia

• Loss of bowel and bladder function

• Autonomic deficits (decreased arterial blood pressure, poor temperature regulation below the level of the injury)

• Can last from 24 hrs to several weeks

Clinical manifestations of spinal cord injury (SCI)

Motor paralysis/paresis below the level of injury

Sensory loss

Cardiopulmonary dysfunction

Impaired temperature control (autonomic dysfunctions)

• Loss of the ability to shiver below the level of injury

Spasticity

Bowel and bladder dysfunction

Sexual dysfunction

Types of lesions

Complete

Incomplete

Complete

Absent sensory and motor function below the level of injury

Usually caused by complete spinal cord transection, spinal cord compression or vascular impairment

Incomplete

Partial preservation of some motor or sensory function (sacral sparing) below the neurologic level and in the lowest sacral segments of S4-5

Perianal sensation and/or have the ability for voluntary contraction of the external anal sphincter indicates an incomplete injury

Clinical findings to confirm diagnosis

• Sacral sparing

• Abnormal tone or muscle spasticity

Brown-Sequard syndrome

Involves half of the spinal cord

Penetrating injuries (GSW, stab wounds)

Loss of motor function, proprioception and vibration on the same side as injury

Loss of pain and temperature on opposite side of injury

Light touch may or may not be present

Good prognosis (for many, independent with ADLs and continent of bowel and bladder is possible)

Anterior cord syndrome

Flexion injury to cervical spine with a fracture- dislocation of vertebrae

Damage to the anterior spinal cord or the anterior spinal artery

Loss of motor, pain and temperature bilaterally below the level of injury

Intact proprioception and vibration below the injury

Limited prognosis due to motor function loss

Central cord syndrome

Most common

Progressive stenosis (conflicts w/other sources) or compression due to hyperextension injuries

UE more affected

Damage to 3 different motor and sensory tracts (spinothalamic, corticospinal, and dorsal column)

Sensory varies

Intact bowel, bladder, and sexual functions if these areas are spared

Possibly: ambulation and independent ADLs depending on UE

Dorsal column syndrome (aka Posterior cord syndrome)

Rare

Damage to posterior spinal artery due to a tumor or vascular infarct

Loss of proprioception and vibration bilaterally

Intact motor and pain/temperature sensation

Conus medullaris syndrome

Injuries to the lumbar nerve root and sacral cord within the spinal canal

Upper and lower motor neuron injuries

Back pain

Flaccid paralysis

Areflexic bowel and bladder function

Cauda equine syndrome 

Direct trauma from a fracture-dislocation below the L1 vertebrae

LMN symptoms: Flaccidity, areflexia, and loss of bowel and bladder function

Regeneration of peripheral nerve roots is possible but depends on initial damage

Complications following SCI

Pressure ulcers

Autonomic dysreflexia

Postural hypotension

Pain

Contractures

Heterotopic ossification (HO)

Deep vein thrombosis (DVT)

Osteoporosis

Respiratory compromise

Bladder and bowel dysfunction

Spasticity

Male/Female Sexual Dysfunction

Orgasm is controlled at the S3-5 level

Two types of erections:

• Reflexive erection from external stimulation; often preserved w/injuries above T10

• Psychogenic erections through cognitive imaging; typically lost in complete injuries above T10

Sexual dysfunction for men

Limited erections

• Reflexive erections occur at levels S2-4

  • Most men are able to ha a reflex erection unless the S2-4 pathway is damaged

• Psychogenic erections occur at levels T10-L2 when the brain sends messages of arousal

  • Men with incomplete injuries at a lower level are more likely to have psychogenic erections than men with high level incomplete injuries

  • Men with complete injuries are less likely to have psychogenic erections

Limited ejaculations

• Inc ability to ejaculate if an incomplete level injury than complete

• Rarely can a complete injury ejaculate

• Limited ability to sire children at any level of injury due to limited ejaculation and slower sperm mobility

• Treatment

  • Medications (Viagra, Cialis), topical agents, and mechanical devices

Sexual dysfunction for women

No physiological change after paralysis that would prevent sex but may need to add lubrication and asst with positioning

Women still have menstruation and so can get pregnant

May not feel labor and there’s inc risk of autonomic dysreflexia during labor

C1-C2

Facial mm, partial SCM, capital mm

Ventilator dependent

Full time attendant

C3

SCM, partial diaphragm, upper Traps

Portable mechanical ventilation

Totally dependent

Full time attendants

Sip and puff or chin controlled WC

C4

Diaphragm so may not have to be on a ventilator

Partial deltoid, SCM, upper traps

Needs neck ROM

Power wheelchair with chin control or mouth stick

Full time attendants

Dependent for ADL, bed mob, and transfers

C5

Deltoid, biceps, rhomboids, elbow flex

Limited functional ability-usually can feed themselves w/a lot of effort

Power wheelchair with hand control

Possibly manual wheelchair with rim projections (high energy expenditure)

Attendant needed: Dependent with bathing and dressing; possibly independent w/some grooming w/adaptive equipment and set up

Needs assist with bed mobility, transfers, and clearing secretions

Pressure relief

Possibly able to drive a van with adaptive hand controls

C6

Pectoralis major, teres major, wrist extensors

Independent with rolling, feeding, UE dressing but needs assist with other care

Propel a manual wheelchair with rim projections

Possibly independent sliding board transfers, feeding w/adaptive equip, independent UE dressing but needs asst for LE

Able to wt shift independently

Will need an attendant at times

Possibly able to drive with adaptive hand controls

Possibly have employment outside the home

C7

Triceps

Possibly living independently

Independent in self-care and UE/LE dressing

Independent w/pressure relief, transfers with sliding board then sit pivot, self-ROM LE, wc mob but may need asst w/ramps and uneven ground

Limited use of an attendant

Driving a regular vehicle with adapted hand controls

C8

Finger flex

Living independently

Asst w/floor transfers

Wheelies in a wheelchair

T1-T8

Intercostals (upper half), Pect major, hand intrinsics, finger abd

Improved but still limited trunk control

Productive coughing

Independent with all transfers but may need min asst w/floor transfers

Independent with manual wheelchair on all surfaces

Limited standing and therapeutic ambulation in parallel bars with much assist and bracing (T6-8)

T9-11

Abdominals

Independent manual wc mob

Therapeutic ambulation at home with braces and assistive devices

T12-L2

Quadratus lumborum, hip flex, knee ext, ankle dorsiflex, great toe ext

Independent household ambulation with KAFO (orthoses)

WC for community mob

L3-5

Iliopsoas, rectus, quads, hamstrings

Independent household and community ambulation w/AFO and canes (L4-5)

S1-2

Plantar flexors, glut max, anal sphincter

Ambulation w/articulated AFO

Physical therapy intervention: acute careaverage stay and goals

Average stay is 11 days

Goals:

• prevent contractures

• increase muscle and respiratory function

• acclimate to upright position

• prevent secondary complications

• pain management

• pt/family education

*PT treat patient initially then co-treat with PTA until patient is more stable

PT acute care spinal cord levels

C1-4- Allows patient to be off of ventilator for short periods, Lateral expansion

C4-T1- Increase diaphragm and accessory muscle strength due to diaphragmatic breathing pattern, Breathing exercises, Glossopharyngeal breathing

T1-12- Deep breathing with manual resistance, Incentive spirometry, Chest wall stretching, Postural drainage, percussion, and vibration, Cough techniques

ROM- tenodesis grip, PROM

Strengthening- Bilateral UE exercise are beneficial

• Key UE exercise for tetraplegics: anterior deltoids, shoulder extension, and biceps

• Key ex for paraplegics: shoulder depressors, triceps, and latissimus dorsi

Acclimation to upright

PT intervention: inpatient rehabilitation average stay and goals

Average stay is 36 days

Goals:

• Increase strength in key muscle groups

• Independence with skin inspections

• Increase PROM

• Increase vital capacity

• Increase tolerance to upright position

• Increase independent bed mobility, transfers, wheelchair mobility, and exercises

• Independence with driving a motor vehicle if possible

• Continue with patient/family education

inpatient rehab Early treatment interventions

Mat activities- rolling, strengthening, stretching

Prone

Prone on elbows

Prone to supine

Supine on elbows

Long sitting

Transfer for inpatient rehab

Preparation phase

Two-person lift

Sit-pivot transfer

Modified stand-pivot transfer

Airlift (para transfer)

Sliding board transfers

Prone on elbows transfer

Rolling out of the wheelchair

Lateral push-up transfer

Intermediate treatment interventions

Mat activities

• Rolling, supine to prone, supine to long sitting, prone to supine

Independent self range of motion

• Long sitting (trunk to leg or leg to trunk), p. 432

• Gluteus maximus, p. 433

• Hip flexors

• Hip abd, add, IR, ER, p. 433

• Ankle plantar flexors, p.434

Advanced mat activities

• Sitting swing-through

• Hip swayer

• Trunk twisting and raising

• Prone push-ups

• Forward reaching

• Creeping

• Tall kneeling

advanced wheelchair skills

Must readjust sitting balance to do certain activities

Wheelies

Ascending/descending ramps, p.439

Ascending/descending curbs, p. 440

Powered mobility

Wheelchair cushions

Advanced treatment intervention

Cardiopulmonary training

Circuit training

Aquatic therapy

• Pool program

• Pool exercises

• Floating and swimming

Ambulation training Benefits of standing and walking

Decrease risk of osteoporosis

Decrease risk for bladder and kidney stones

Increase circulation

Increase digestion

Decrease muscle spasms

Decrease fatigue

Guidelines for success with ambulation

Motivation

Patient’s weight and body build

PROM at hips, knees, and ankles

Amount of spasticity

Cardiopulmonary status

Status of the integumentary system

T2-11 injury (chest level)

Therapeutic or Functional Ambulation	Assistance	Equipment	Household or Community Ambulator
Therapeutic standing or ambulation possible	Can only stand or ambulate in Physical Therapy	Needs physical assistance for sit to stand and gait; needs bracing; standing frame or a tilt table	Unable

T12-L2 injury (belly button level and down)

Therapeutic or Functional Ambulation	Assistance	Equipment	Household or Community Ambulator
Limited Functional ambulator	Independent for short distances only due to amount of energy expended	Orthosis and assistive device for ambulation; independent transfers	Household ambulatory only; wheelchair for longer distances outside the home

L3-5 injury

Therapeutic or Functional Ambulation	Assistance	Equipment	Household or Community Ambulator
Functional ambulator	Independent	With or without orthosis and assistive device for ambulation; independent transfers	Household and community ambulator

Orthoses

Knee-ankle-foot orthosis –Scott-Craig

Reciprocating gait orthosis – cable system

ReWalk system – robotic exoskeleton

Preparation for ambulation

Should be independent in mat activities, transfers, and wheelchair mobility on level surfaces

Standing in parallel bars

Once the orthotic is on, begin gait in the parallel bars

What should you work on in the parallel bars?

What is a progression in the parallel bars?

gait progression

Swing to

Jack-knife position if patient loses balance during gait

Sitting

Patient should be ~12” away from the chair prior to sitting since orthosis is locked in extension and patient’s buttocks should be in the center of the chair

Ambulation training

Other gait patterns

• Four-point or two-point gait pattern possible with Loftstrand or axcillary crutches

Backing up

Standing from the wheelchair with orthoses, p. 449

Gait training with crutches

• Falling

• Getting up from the floor, p. 451

Negotiating environmental barriers

• Ramps

• Curbs

• Stairs

Discharge planning

Discharge planning conference

• Should be done 1-2 weeks prior to discharge

Procurement of equipment

• Wheelchair/bed and cushion

• ADL adaptive equipment

Home exercise program

Family teaching

• Equipment

• Handling patient

• Safety, complications, precautions, injury

Community reentry – 35% are employed 20 years after injury

Quality of life

Long-term health-care needs

Parkinson’s Disease(PD)

group of disorders

Most common movement disorder in the US

Pathophysiology

• Chronic progressive disorder

• Lack of dopamine-producing neurons

• Disorder of the substantia nigra located in the basal ganglia

Clinical features of PD

Bradykinesia

Rigidity

Resting tremor

Postural instability

Festinating gait

Bradykinesia

Slow movement affects ADLs

Oral movement

• unintelligible speech, soft monotone voice, swallowing difficulties

Akinesia

• trouble initiated movement

Rigidity

Not dependent on movement velocity

Lead pipe and cogwheel

Restricted chest wall that affects breathing and phonation

Tremors

Often 1st sign

Resting tremors

“Pill rolling”

Postural Instability for PD

Loss of postural extension

Flexed posture

• COG is forward

• Loss of extension, rotation, arm swing

Inability to respond to postural disturbances

Increased fall risk

Decrease proprioception

Relies on vision for movement cues

Other features of PD

Masked face

Dysphagia

Festinating gait

• Shuffling feet with progressive increase in speed

Freezing episodes

• Triggered by changing surfaces like doorways or flooring

Fatigue - worsens as the day progresses

Gait

Falls

Cognition

• ½ have dementia and cognitive changes

• Slow thought processes, decreased attention and concentration, depression

Stages of PD

Hoehn and Yahr classification of disability for Parkinson’s

Average person has a life expectancy slightly less than a person without Parkinson’s

Stage 0 to Stage 5

• Stage 0 = no signs of disease

• Stage 5 = needing a wheelchair or is bedridden unless assisted

Surgical management of PD

Deep brain stimulation (DBS)

Electrodes in the sub-thalamic nucleus with a stimulation box placed under the skin by the clavicle

• Pt can turn on/off

• Blocks nerve signals that produce symptoms

Physical therapy management of PD

Gait interventions, p. 466

Postural interventions, p. 466-468

Lee Silverman voice treatment (LSVT) BIG

• Certification

• Motor training principle

• Big movement and big stretches with voice commands

Exercise strategy and results, p. 469, Table 13-3

Multiple Sclerosis (MS) Pathophysiology

Demyelination of white matter in the brain and spinal cord

Axon is unprotected and sclerotic plaques form in the brain and spinal cord

Usually ages 20-40 with females being more prevalent

Areas that are usually affected with MS

Optic nerve- Decreased acuity, diplopia, nystagmus,

Periventricular white matter

Corticospinal tract- Weakness in one or both legs

Posterior columns

• Sensory disturbances are the 1st sign

• “Pins and needles” or “burning/aching”

Cerebellar peduncles

• Clumsiness with reaching (overshooting)

• Impaired coordination of movement

• Poor balance

• Ataxia

Clinical features of MS

Fatigue

• Most common complaint

• Worsens with heat

Cognitive impairment

• ½ will have some kind of impairment (problem solving, short-term memory, visual-spatial perception)

Autonomic dysfunction

• Bowel and bladder problems (urinary frequency, constipation, inadequate emptying)

Disease course

• Variable

• Exacerbations and remissions

Diagnosis of MS

Based on clinical evidence of multiple lesions in the CNS white matter, distinct time intervals, and age of occurrence (10-50 yrs old)

Cerebrospinal fluid examination

• Higher amounts of myelin protein

Magnetic resonance imaging (MRI)

• Best way to diagnosis

Medical management of MS

Purpose is to reduce the frequency and severity of the attacks. All are injectables.

• Avonex

• Betaseron

• Copaxone

New medications (IV):

• Tysabri

• Novantrone

Most common neurologic symptoms of MS

Weakness- Lesions in corticospinal tract or cerebellum, inactivity

Spasticity- UMN damage

• Most often spastic plantar flexors, adductors, and quadriceps

Ataxia

Additional concerns

• Mood swings

• Continuous nystagmus

• Vertigo

Clinical presentation of ALS

A progressive neurodegenerative disease that affects nerve cells in the brain and the spinal cord

Usually patients are 40-70 years old

Muscle weakness – cardinal sign

Distal symptoms occur before proximal

Most have asymmetrical muscle weakness in an arm or leg

Early signs: muscle cramps, weakness, atrophy, and fatigue

May lose the ability to speak, eat, move and breathe

Diagnosis based on S&S, EMG, imaging, nerve and muscle biopsies

No involvement of eye muscle or sensory

½ of the patients will have cognitive impairment

Death is usually from respiratory complications as muscles weaken

Medical management of ALS

No cure

Symptom management

There is one FDA-approved drug, riluzole, that slows the progression of ALS in some people

Physical therapy management of ALS

General initial guidelines:

• Avoid heavy eccentric exercise

• Moderate resistance can increase strength

• Needs to rest in between exercises

Pulmonary care at late stages for aspiration and airway clearance

Later on, need support of weak muscles by using orthosis (neck)

Pressure reducing devices

Pathophysiology of GBS

Autoimmune reaction

Schwann cells destroyed in peripheral nervous system but the axons are intact so after 2-3 weeks, the cells begin to proliferate, inflammation dissipates, and remyelination begins

Clinical features of GBS

Symmetrical ascending progressive disorder

Weakness begins distally and progresses proximally

• Burning and tingling of toes or hyperesthesia distally

• Motor involvement more than sensory

• If progresses to diaphragm, mechanical ventilation is needed

• ½ will have ANS changes (BP and HR)

• ½ oral-motor involvement (dysarthria and dysphagia)

Myalgia

• Throughout the process

DTRs absent due to areflexia (demyelination) of peripheral nerves

Medical management of GBS

Plasmapheresis (PE)

Infusion of IV immunoglobulins

Phases of GBS

Acute phase

• Up to 4 wks

• Symptoms continue to worsen

Plateau phase

• Up to 4 wks

• Stabilzation of symptoms

Recovery phase

• From a few months to a couple of years

• Improvement

• 80% recover in a year but may still have some deficits

Physical therapy management of GBS

Acute phase

• Usually in ICU on a ventilator

• Treat symptoms as they occur

Plateau phase

• Upright positions (slowly)

• Gradually increase ROM and movements as tolerated

Recovery phase

• Muscle strength returns in reverse order (descending)

• Tilt table—>standing—>transfers—>gait training

Chronic Inflammatory Demyelinating Polyradiculoneuropathy (CIDP)

is a slowly developing autoimmune disorder of the peripheral nervous system in which the body's immune system attacks the myelin sheath

Unknown etiology

It’s most common in older adults, and more in men than women.

No specific test to determine diagnosis but weakness must be present for at least 2 months

There are periods of remission and relapse

Common symptoms are gradual weakness or sensation changes in the arms or legs

Symmetrical motor and sensory involvement

Stocking glove distribution of numbness and tingling

Hypo or areflexia

Postural tremor of the hands

Papilledema, vision loss

Facial weakness

CIDP vs GBS

CIDP

• Nerve involvement

• Weakness

• Numbness

• Not linked to illness

• Tends to be a long-term recovery

• Chronic

GBS

• Nerve involvement

• Weakness

• Numbness

• Begins after an illness

• Most recover fairly quickly

• Acute

• May develop into CIDP if it reoccurs

Medical Management of CIDP

Corticosteroids

Plasmaphoresis

Intravenous immunoglobin (IVIG)

Physical Therapy Management of CIDP

ROM

Balance

Aerobic conditioning

Strengthening

Gait training

Avoid overexertion

Post-Polio Syndrome (PPS) Etiology

Most believe that it is caused by increased metabolic demand made on the body by giant motor units that were formed during the recovery process from the original viral infections

Clinical features of Post-Polio Syndrome

Fatigue

New weakness- Hallmark sign

• Asymmetrical proximal weakness and progressive

Pain

Cold intolerance

Decreased function

Medical management of Post-Polio Syndrome

No specific medication

Healthy diet

Sleep apnea treatment

Increase activity

Staying warm

Good pulmonary ventilation

Physical therapy management of Post-Polio Syndrome

Exercise

• General guidelines: avoid overuse and disuse, modify activity level to decrease pain, monitor vitals

• Customize exercise programs with rests periods

Stretching – caution due to joint instability

Pain management- Cramping, musculoskeletal, and biomechanical

Lifestyle modification- Must change and slow down

Energy conservation- Helps to manage fatigue

TBI

“an alteration in brain function…caused by an external force”

Effects of TBI

Impaired cognition

Deficits in movement and sensation

Impaired behavior and emotional responses

Financial

2.2 million Americans treated each year

80K - significant loss of function

52K – die

Acute care and rehab = $10 billion yearly

Ave lifetime expense with caregiving = $1.8 million

Causes of TBI

Falls = 41%

Unknown/other = 19%

Struck by an object = 16%

MVA = 14%

Assaults = 11%

Trivia

More prevalent in men

Ages: (CDC, 2014)

• 1-2 years old

• 15-24 years old

• Over 75 years old

Classification of brain injuries

Open and closed injuries

Subtypes of brain injuries

• Concussion

• Contusion

• Hematomas

Open

Penetrating types of wounds

GSW, Knife, sharp objects

Skull fracture or displaced

Damage to meninges-inc risk of infection

Closed

Subtypes

Impact to head but no open wound, fracture or displacement

Brain tissue damage