Concorde Career College Physical Therapist Assistant

Concorde Career College Physical Therapist Assistant
PTA 150: Fundamentals of Treatment II Day 13 & 14 Spinal Cord Injury Concorde Career College

Concorde Career College
Lesson Objectives Describe the pathophysiology of spinal cord injury Describe physical and neurological disorders associated with spinal cord injury Identify functional outcomes for patients with spinal cord injury at various spinal cord lesion levels Describe physical therapy treatment interventions for patients with spinal cord injury Concorde Career College

Spinal Cord Injury 11,000 new SCI cases in the US yearly Etiology: traumatic vs. nontraumatic Traumatic is most common – MVA, fall, GSW Nontraumatic – usually result from disease or pathological influence Vascular malfunctions (AVM, thrombosis, embolis…) Vertebral subluxations (secondary to RA or DJD) Infections such as syphilis or transverse myelitis Spinal neoplasms Multiple sclerosis, amyotrophic lateral sclerosis MVA account for almost 46% Vascular malformations include arteriovenous malformations, thrombosis, embolus or hemorrhage. Vertebral subluxations may be secondary to DJD or RA Concorde Career College

Mechanism of Injury Indirect force produced by head or trunk movement Flexion force (head-on collision; blow to back of head) Lateral flexion force Compression force (diving, falling objects…) Hyperextension force (strong rear-end collision, fall hitting chin …) Flexion and rotational force (rear-end collision with passenger rotated towards driver) Direct force trauma Stats: Ratio of 4 to 1 men to women; more than ½ of the population are between the ages of 16 to 30 yrs of age Ethnic distributions: whites 66.6%, AA 21%, hispanics 9.7% and others 3.5% Cx lesions: 51%; thoracic lesions: 34.6%; 10.8% had L-S lesions Spinal Cord Review: 31 pairs of spinal nerves: 8 cx, 12 th, 5 lumb, 5 sacral, 1 coccyx Refer to table 23.2 in O’Sullivan, pg 942 for more details. Concorde Career College

Types of Injury Complete (ISNCSCI) No motor or sensory functions is preserved in the sacral segments S4 to S5 (anal sensation and voluntary external and sphincter contraction) Partial/Incomplete Partial motor or sensory functions below the level of lesion According to the International Standards of Neurological Classification of SCI (ISNCSCI); different from previously taught and from what most clinicians will tell you! Concorde Career College

Spinal Cord Injury (SCI)
Partial or complete spinal cord lesion may result in: Paralysis Paresis Sensory loss Altered autonomic nervous system function Altered reflex activity Concorde Career College

Spinal Cord Injury (SCI)
Injury often accompanied by: Fracture of the vertebra, body, laminae, spinous process Stretched or torn ligaments Disc herniation Disk compression Malalignment of spinal vertebrae Concorde Career College

Designation of Lesion Level
American Spinal Injury Association (ASIA) International Standards of Neurological Classification of Spinal Cord Injury (ISNCSCI) – standardizes the way in which severity of injury is determined Neurological Level – most caudal level of spinal cord w/ normal motor & sensory function bilaterally Motor Level – most caudal level of spinal cord w/ normal motor function bilaterally Sensory Level – most caudal level of spinal cord w/ normal sensory function bilaterally Concorde Career College

ISNCSCI Scoring Motor Most caudal segment with normal motor function (B) Uses the same scale as MMT Cannot test one muscle and assume this represents an entire myotome Sensation Defined in the same way in terms of sensory function Usually tested with light touch and pin prick 0 = absent,1 = impaired, 2 = normal Concorde Career College

ASIA Impairment Scale Concorde Career College

SCI Classification Tetraplegia/Quadriplegia Complete paralysis of all 4 extremities & trunk Upper Motor Lesion C1 – C8 (Trunk, Limbs) Paraplegia Complete paralysis of all or part of trunk & both LEs T 1 – T12, L1 Lower Motor Lesion Below L1 Concorde Career College

Clinical Syndromes Brown-Sequard Syndrome (incomplete) Hemisection of spinal cord Usually secondary to penetration wound – GSW, stab Ipsilateral sensory loss of sensation, reflexes, vibration and position sense (lateral and dorsal columns) Contralateral sensory loss of pain and temperature sense (spinothalamic tract) Cauda Equina Injury Lesion is below L1 vertebra Peripheral injury (lower motor neuron injury) Flaccidity, absent reflexes Brown Sequard Syndrome—Hemisection of the cord; usually caused by penetration wounds (GSW or stabbings). ; Loss of motor and dorsal column sensations; loss of pain and temp on opposite side Cauda Equina: LMN; have the potential to grow back, however full re-innervationis not common because of the large distance from lesion to point of innervation; axonal regeneration isn’t exact; end organ may no longer functioning once re-innervated Concorde Career College

Clinical Syndromes Anterior cord syndrome Injury site: anterior spinal cord or ant. spinal artery Usually related to flexion injuries, compression from fracture, dislocation or cervical disc protrusion) Characterized by loss of motor function (corticospinal tract) & pain and temp (spinothalamic tract) Central cord syndrome Injury site: center of the spinal cord Most commonly occurs because of hyperextension; congenital or degenerative narrowing of spinal canal Most common with hyperextension of cx region Posterior cord syndrome Injury site: posterior spinal cord or posterior spinal artery ACS: loss of motor and spinothalamic function below level of injury; dorsal columns spared CCS: the compressive forces can lead to hemorrhage and edema to central area of cord; injury tends to be more in UE’s than LE’s due to placement of info in tract. Motor deficits > sensory. Surgery to de-compress areas can lead to a lessening of the symptoms. PCS: Rare; greatest deficit in dorsal columns; wide based steppage gait seen. Concorde Career College

Clinical Syndromes Posterior cord syndrome Injury site: posterior spinal cord or posterior spinal artery Characterized by preserved motor function, sense of pain and temperature and light touch; loss of proprioception and epicritic sensations (ie: 2 point discrimination) below the level of the lesion Sacral Sparing refers to incomplete lesion; clinical signs include perianal sensation and external anal sphincter contraction Epicritic: ability to discriminate; dorsal column sensations Concorde Career College

Clinical Manifestations
Spinal Shock Motor and Sensory Impairments Autonomic Dysreflexia Postural hypotension Impaired temperature control Respiratory Impairment Spasticity Bowel and Bladder dysfunction (Micturition; Crede maneuver) Sexual Dysfunction Spinal shock: Period of areflexia May last several days or several weeks Motor and sensory impairments: below level of injury; depends on completeness of lesion Autonomic Dysreflexia: seen in lesions above C6 (above sympathetic outflow) ; episodes gradually subside and are relatively rare after 3 yrs. Seen with complete and incomplete injury. It produces an acute onset of autonomic activity; is a mass reflex response resulting in increase BP (normally, peripheral resistance would adjust, but impulses do not pass the lesion to cause vasodilitation. Death can result. most common cause is bladder distention; rectal distention, pressure sores, urinary stones, kidney malfunction, etc… (pg 943) symptoms: HTN, bradycardia, HA profuse sweating, increased spastiity, restlessness, vasoconstriction below level of lesion, vasodilation above the level of the lesion Intervention: medical emergency; sit pt up, exapmine drainage system (catheter); unclamp catheter if clamped; clothing checked to make sure not blocking tubes; If none of these situations exist, call 911; medical personnel need to be notified so that pt can be monitored more closely. Postural Hypotension: occurs when pt becomes vertical; minimized by letting the cardiovascular system adapt slowly (elevated head, progressing to reclining WC, use of tilt table; compressive stockings and an abdominal binder Impaired temperature control: autonomic dysfunction (hypothalamus) cannot influence below level of lesion; have to avoid extreme weather conditions and monitor environment Diaphram: innervated by phrenic nerve (c3,C4, c5), intercostals, abdominals also involved in respiration and can be involved. A release of higher control on intact spinal reflexes. Tone increases over the first 6 months and plateau’s around 1 yr post. Injected meds can be used to help decrease. B&B: spinal center that controls urination (micturition) located in the conus medularis S2-4 Can have a hypotonic bladder (usually T12 and below) Bowel dysf: spastic (UMN) above conus medularis; LMN flaccid/nonreflex bowel; (consider diet, fluid intake, stool softeners, suppositories, digital stimulation, manual evacuation. Sexual dysf: complicated issue; need to have someone trained to address these issues. Concorde Career College

Acute Medical Care Stabilize respiratory status C1 to C4 lesions effect the phrenic nerve & diaphragm Patient placed on respiratory ventilator Minimize spinal shock and edema that results from the injury Steroids Control of hydration and nutrition to avoid over hydration and further cord necrosis Spinal shock is the immediate suppression of reflexes, motor and sensory functions, bowel and bladder functions; not clearly understood why this happens. Spinal shock wears off 2 weeks to 2 years. Average 3 months. Emergency personnel have to be able to assess and stabilize Concorde Career College

Acute Medical Care Catheterization bladder Spinal stabilization Surgery to realign vertebra & spinal cord Insertion of halo to head & spine Rigid to semi-rigid cervical collar Thoracolumbarsacral Orthoses (TLSO) Immobilize patient in bed Stryker Frame, air support beds satimulation--enema Concorde Career College

TLSO Concorde Career College

Spinal Cord Injury Disorders
Respiratory Impairment Impairment is directly related to: Lesion level Residual respiratory muscle function Additional trauma at time of injury Premorbid respiratory status Will be dependent on artificial ventilation or phrenic nerve stimulation with C1 – C3 injury Low respiratory endurance (C4 to T12) Higher level lesions may result in difficulty with coughing Respiratory –prone to infections and pneumonia T 12 - Diaphragm, intercostals, lower abdominals Additional trauma may include fractures (ribs, sternum, extremities), lung contusions, soft tissue damage Concorde Career College

Complete to partial motor and sensory dysfunction below the level of the lesion Autonomic Dysreflexia (Hyperreflexia) Deep Vein Thrombosis Inactivity & diminished muscle contraction effect circulation Sympathetic Pain, Phantom Pain Dyesthesia Heterotrophic bone formation in soft tissue Orthostatic Hypotension (aka Postural Hypotension) ↓ in BP when assuming an erect or vertical position Caused by loss of sympathetic vasoconstriction and lack of muscle tone Example: supine to sitting, sit to stand Symptoms of AD – HTN, bradycardia, headache, profuse sweating, increased spasticity, restlessness, constricted pupils, blurred vision Hyperreflexia– Sit patient up. Examine patient and remove noxious stimulation. Concorde Career College

Pressure Sores/Decubitis Ulcer 2 ˚↓ sensation, difficulty w/ positional changes Motor Impairment Spasticity Varies in range, mild to severe Influence by internal and external stimuli Can be managed via drug therapy, injections, surgery Flaccidity Muscle weakness Muscle atrophy Spasticity may be influenced by positional changes, cutaneous stimuli, environmental temperatures, tight clothing, bladder or kidney infection, fecal impactions, catheter blockage, UTI, emotional stress, decubitis ulcer. Severe spasticity effects bed positioning and WC Spasticity– remove stimulus to stop firing of spasm (bed clothing, shoes, braces etc) Must weigh the benefits of drug therapy, does the patient have increased function as a result of the spasticity? Surgery includes myotomy, neurectomy, tenotomy, rhizotomy, myelotomy Concorde Career College

Bladder and Bowel Dysfunction UTIs are a common early complication Lesions above conus medullaris typically develop a reflexive/spastic bladder & bowel (automatic bladder & bowel) Conus Medullaris and Cauda Equina lesions typically develop a nonreflex/flaccid bladder & bowel (autonomic bladder & bowel) Calcium Absorption (renal calculi) Osteoporosis During spinal shock period, muscle tone and bladder reflexes are absent. Protein depleted from muscle and directed toward healing. High protein diets/ Production of adrenocortical hormone . Imbalance of protein and fat. Anemia Concorde Career College

Contractures Autonomic Nervous System Disturbances Loss of thermal regulation Vasodilation does not occur in response to heat Vasoconstriction does not occur in response to cold Absence of sweating Often associated with compensatory excessive sweating above the level of the lesion- diaphoresis Flushing, headaches Sexual Dysfunction Hypothalamus can no longer control thermoregulation (cutaneous blood flow or level of sweating) Concorde Career College

Spinal Cord Lesion Level & Functional Outcomes
Refer to O’Sullivan, Table 23.6, page 961 Concorde Career College

C1 to C3 Muscles preserved: Face and Neck Muscles Respiration: Ventilator dependent Bed Mobility: Dependent Transfers: Dependent Self Care: Dependent (Groom, Dress, Bath, Feed) - Full time attendant Wheelchair: Power, microswitch or sip-and-puff controls Most of us can relate this injury to Christopher Reeves. Usually a portable ventilator is attached to the wheelchair Concorde Career College

Muscles preserved: All of above Diaphragm, Trapezius Endurance: Low Bed Mobility: Dependent Transfers: Dependent Self Care: Dependent Wheelchair: Powered; head/chin/mouth control or sip-and-puff control Attendant Care Concorde Career College

Movement preserved: All of the above Scapula elevation, adduction Shoulder abduction, ER, flexion (limited) Elbow flexion & supination Endurance: Low Bed Mobility: Dependent Transfers: Dependent → Assistance Self Care: Dependent Wheelchair: Powered with joystick or adapted UE controls or manual with hand rim projections Trapezius, Deltoid, biceps (Partial), SCM, Upper cervical extensors, SITS (partial), Rhomoids (partial) Concorde Career College

Hand Rim Projections Joystick Concorde Career College

Muscles preserved: All of the above Scapular abduction & upward rotation Shoulder flexion, extension, IR and adduction Forearm pronation Wrist extension (Tenodesis grasp) Endurance: Low Bed Mobility: Assistance (Rolling, Sit, Mobility) Transfers: Assistance→Independent (Slide board) Self Care: Assistance Wheelchair: Powered or manual with projections or friction surface hand rims The wrist is held in hyperextension. When the wrist is flexed, fingers extended and ready to release or grip object. When the wrist is extended,, fingers flex in order to close or grasp an object, (Feed) LATISSMUS Dorsi, Pectoral Muscles, SITS, Biceps, radial extensors Concorde Career College

Movement preserved: All of the above Elbow extension Wrist flexion Fingers extension Endurance: Low Bed Mobility: Independent Transfers: Assistance → Independent (Slide board) Self Care: Assistance → Independent Wheelchair: Manual with friction surface hand rims Triceps, Finger extensors, Finger flexors Concorde Career College

C7 Continued Ambulation: Spinal Orthoses, Long leg braces, Pelvic Band Drag to gait Concorde Career College

C8 to T1 Movement preserved: All of the above Full UE innervations including fine coordination & strong grasp Endurance: Low Bed Mobility: Independent Transfers: Independent Self Care: Assistance/Independent Wheelchair: Independent with manual chair Ambulation: Spinal Orthoses, Long leg braces, Pelvic Band, Drag to gait Lack Trunk Stability Concorde Career College

T4 toT6 Movement preserved: All of the above Improved trunk control Pectoral girdle stabilization Endurance: Increased Bed Mobility: Independent Transfers: Independent Self Care: Independent Wheelchair: Independent, improved skills Ambulation: Minimal distances with assist; bilateral knee-ankle-foot orthoses with spinal attachment Concorde Career College

T9 to T12 Movement preserved: All of the above Thoracic Extensors, Lower Abdominal Muscles (Flexion); Improved trunk control Endurance: Increased Bed Mobility: Independent Transfers: Independent Self Care: Independent Wheelchair: Independent, used to conserve energy Ambulation: Functional with bilateral long leg braces; walker or crutches; swing thru, 4 point, 2 point gait Concorde Career College

L2 to L4 Muscles preserved: All of the above Hip flexion and adduction Knee extension (quadriceps) Endurance: Increased Bed Mobility: Independent Transfers: Independent Self Care: Independent Wheelchair: Independent, used to conserve energy Ambulation: Functional with bilateral KAFO and crutches; 4 point, 2 point gait Concorde Career College

L4 to L5 Muscles preserved: All of the above Stronger hip flexion Stronger knee extension, weak knee flexion Improved trunk control Endurance: Increased Bed Mobility: Independent Transfers: Independent Self Care: Independent Wheelchair: Independent; used to conserve energy Ambulation: (B) AFO w/ crutch or cane, 2 pt. gait Concorde Career College

PT Examination Respiratory Examination Integumentary examination Sensation Tone and DTR MMT ROM Functional Status Concorde Career College

SCI – Outcome Measures Functional Independence Measure (FIM) Wheelchair Skills Test (O’Sullivan, pg 966) Examining walking ability: SCI Functional Ambulation Inventory SCI-FAI (O’Sullivan, pg 967) Walking Index for Spinal Cord Injury (WISCI) Concorde Career College

Physical Therapy Intervention
Respiratory Management Diaphragmatic breathing Glossopharyngeal breathing Assisted coughing Abdominal support Stretching pectorals and chest wall muscles Postural draining Glossopharyngeal breathing – appropriate for patients with high level c-lesions; utilizes accessory muscles and involves sipping or gulping small amounts of air repeatedly; improves chest expansion despite paralysis of primary respiratory muscles Abdominal support- improves the resting position of the diaphragm; maintains intrathoracic pressure and decreases postural hypotension Concorde Career College

Physical Therapy Intervention
ROM Spinal motion is normal in the acute phase depending on the level of injury ROM in supine & prone (if cleared by MD) Less than full ROM of joints is often beneficial Limited ROM of lower trunk muscles with tetraplegia assists with sitting & trunk stability; tightness of the long finger flexors improve tenodesis grip On the other hand, stretching the hamstrings to achieve 100 degree SLR is important for functional activities such as dressing and transferring Concorde Career College

Physical Therapy Interventions
Positioning Splints for wrist, hands & fingers Ankle boots or splints Once cleared, tolerance to prone position is important Therapeutic Exercise Passive, Active Assistive, Active, Strengthening & Functional exercises Must be aware of contraindications in acute phase Prone position is important for maintaining skin integrity and decreasing flexor tightness of hips and knees. Contraindications in acute phase include avoiding asymmetric, rotational stresses on the spine Concorde Career College

Orientation to vertical position Mat/Bed Exercises Achievement of stability within a posture ⇓ Controlled mobility Skill in functional use When orienting to the vertical position it is helpful to use compression stockings and an abdominal binder. Long sitting and hamstring length are so important for function – dressing (putting on pants and socks/shoes) Concorde Career College

Mat/Bed exercises Often individual components of a functional skill Sequenced from easiest to most difficult Complete mastery of one skill is not always required to move on to the next skill Degree of independence and rate of progression depends on level of spinal lesion and the individual Concorde Career College

Mat Programs Progression Rolling (Prone, Supine, Sidelying) Prone on elbows Prone on hands (paraplegia) Supine on elbows Pull ups (tetraplegia) Sitting (long sitting & sitting at edge of bed) Quadruped Kneeling Transfers Concorde Career College

Rolling Easiest to begin supine to prone If applicable, easier to roll towards weaker side Should always encourage independence, however adaptive devices may be used if unable to perform activity independently Bed rails, ropes, canvas “ladders”, trapeze Images shows a canvas ladder often utilized with performing bed mobility and other functional tasks. Concorde Career College

Rolling assists with bed mobility, pressure relief and dressing Rolling techniques Flexion of head & neck w/ rotation for supine→prone Extension of head & neck w/rotation for prone→supine Pendular motion with outstretched UEs Crossing the ankles Place pillows under the patient’s pelvis PNF patterns – UE D1 Flexion, D2 Extension O’Sullivan pg. 968 Concorde Career College

Prone on elbows Assists with improved bed mobility & preps for quadruped and sitting later Facilitates head, neck and shoulder girdle strength May need assistance from therapist initially Caution with thoracic and lumbar injuries! Concorde Career College

Prone on elbows activities Weightbearing improves shoulder stability Weightshifting – lateral 1st, progressing to anterior and posterior movements Rhythmic stabilization Manually applied approximation Unilateral weightbearing on one elbow Strengthening the serratus anterior & other scapular muscles Rhythmic stabilization includes applied resistance in different directions. Strengthening of the serratus anterior and scapular muscles is achieved by having the patient tuck his/her head and chin while lifting and rounding the shoulders and upper thorax (cat/camel). Concorde Career College

Prone-on-Hands Promotes extension of the hips and low back Assists with standing and ambulation Can use bolster, wedge, pillows to assist with tolerance and independence with position Activities may include weight shifting, approximation, scapular depression and prone push ups Concorde Career College

Supine-on-Elbows Assists with bed mobility and preparing for long sitting, strengthens shoulder extensors and scapular adductors Assuming the position can be accomplished by: Using abdominals if sufficient strength Wedging hands under hips, hooking thumbs into belt loops and pull up while lateral weight shifting Can be done from sidelying, lower elbow positioned first and then roll supine extending the opposite arm and landing on the elbow Concorde Career College

Supine-on-Elbows activities: Lateral weight shifting Side-to-side movement assists with aligning the trunk and LEs necessary for positional changes Be cautious of shoulder pain, ↑ pressure placed on the anterior shoulder joint capsule in this position Concorde Career College

Pull-Ups Strengthens the biceps & shoulder flexors necessary for wheelchair propulsion Patient is supine while therapist is squatting over the patient, therapist grabs the patient’s supinated forearms just above the wrists, patient pulls to sitting and then lowers back to the mat May also use a trapeze bar Concorde Career College

Sitting Long and short sitting are essential for daily activities (dressing, transfers, WC mobility) Good sitting balance (static and dynamic) is necessary to progress to standing Sitting posture varies depending on level of lesion What does sitting look like for these patients? Patient with triceps and abdominal muscles initially find stability through shoulder hyperextension and ER, elbows and wrists extended and fingers flexed W/o tricep function, patients lock the elbows Individuals with lower cervical and higher thoracic lesions will usually maintain sitting by forward head displacement and trunk flexion. Concorde Career College

How to get to a sitting position Start in supine-on-elbows, shift weight from side-to-side, with sufficient momentum the patient tosses one arm behind and bears weight on the hand, repeats with opposite arm; pt. then “walks” the arms forward Start in prone-on-elbows, pt. creeps sideward using elbows and forearms, trunk in flexion allows the forearm to hook under knees and pulls them forward; pt. tosses the opposite UE behind followed by the 2nd UE; patient then “walks” arms forward Concorde Career College

Sitting activities Initially, focus on maintaining the position; mirror may provide helpful visual feedback Manual approximation at the shoulder Decrease UE support PNF Challenge limits of stability – balloon tapping, ball throwing, reaching for cones Sitting push ups Movement within the sitting posture Concorde Career College

Quadruped Important for progression to ambulation Initially position is assumed from the prone-on-elbows position Quadruped activities Maintaining the position Manual approximation Weight shifting in all directions Rocking Decreasing UE support Movement within the position Allows for weight bearing through the hips Concorde Career College

Kneeling Position Promotes trunk and pelvic control, good for upright balance and progression to ambulation Easiest to assume position from quadruped Patient can initially find UE support using a wall ladder, therapists shoulders and eventually mat crutches Kneeling activities Maintain the position Decrease UE support Weight shifting Hip Hiking Concorde Career College

Transfers Initiated with achievement of adequate sitting balance Mat/bed to wheelchair Progression: WC to toilet, shower chair, car, floor, stairs Lateral scoot transfer w/ or w/o slide board 3 important components of transfer: Momentum Muscle substitution Head-hips relationship Helpful exercise to improve transfers: push-ups Concorde Career College

Wheelchair Mobilization/Prescription Manual or Powered, Tilt-in-space, Standing frame, Sport chairs Fitting the wheelchair Wheelchair skills Setting and releasing locks Removing foot and arm rests Forward, backward, turns, surfaces, wheelies for curbs Pressure relief techniques (discussed later in lecture) Fitting the wheelchair – see O’Sullivan, page Concorde Career College

Standing Progression Compression: (corset) trunk and lower extremities Tilt Table **Monitor Blood Pressure** Start at 15 degrees Purpose of Tilt Table Aids circulation & skin integrity Assists bowel and bladder function Weight bearing, diminishes bone demineralization May improve sleep Psychological benefits to be upright Concorde Career College

Donning and doffing braces on mat/bed Sit to Stand Activities Practiced in parallel bars initially Progress from pulling up on bars to using arm rests on wheelchair to push to standing In upright position, patient pushes down on hands and tilts pelvis forward Concorde Career College

Standing in Parallel Bars (braces) Balance Exercises Maintaining static balance in hips extended position Trunk flexion, trunk extension (with MD clearance) Weight shifting Eyes closed Releasing 1 hand support from the bar Placing hands in front of and behind the body Push up Push up and drag or swing body forward (beginning gait training) All exercises in the parallel bars will obviously depend upon the level of injury and whether the injury is complete vs. incomplete. Concorde Career College

Wheelchair that transitions to standing position Standing Frame Concorde Career College

Gait Training Be realistic with the patient Consider orthotic devices, assistive devices, adequate ROM, strength & CV endurance Consider incomplete vs. complete SCI Other limiting factors: spasticity, loss of PPC, pain Is the patient motivated? Start in parallel bars Does the patient have adequate hip extension to perform ambulation activities? Energy cost of walking for an individual with paraplegia is 2-4X greater than normal walking Concorde Career College

Gait training: Parallel Bar Activities Achieve adequate level of standing balance first Turning around Jack knifing Practice various gait patterns: swing to, swing through, 2 point, 4 point Concorde Career College

Progressing ambulation outside the parallel bars Choosing an AD Forearm crutches, walker, cane(s) Standing from wheelchair with AD Balancing with AD (crutches, walker w/incomplete) Practice different gait patterns, progress timing & speed Travel activities Sideways, backward, turning, negotiating doorways/ elevators Practice with variable surfaces, indoors & outdoors Stairs, curbs Forearm crutches are often the best choice because they are lightweight, allow for freedom to use hands, fit easily into automobiles, improve opportunity for stair negotiation; allow full hip extension and movement at the shoulders. Concorde Career College

Ambulation after SCI: Videos
T3 injury with RGOs Concorde Career College

Fall & Recovery training Locomotor Training Means of intensely practicing the distinct and specific task of walking (O’Sullivan, pg. 983) Provides the sensory experience of walking Body weight support treadmill training Means of progression: Decrease body weight supported percentage Treadmill speed Amount of manual assistance Most important is that this practices allows for transition and application to community ambulation. Further research is needed in this area. Concorde Career College

Body Weight Support Systems
Lite Gait Body weight supported treadmill training Concorde Career College

Ambulation after SCI: Videos
Concorde Career College

Reinforcement of Bowel and Bladder Program Education regarding skin inspection Gradually the patient becomes more responsible for regular inspection Involves both visual inspection and palpation daily Use of a long handled mirror, wall mirrors Pressure relief 10-15 seconds of relief for every 10 minutes of sitting Techniques: WC push ups, hook & lean forward or sideways Concorde Career College

Areas Susceptible to Pressure
Supine Prone Sidelying Occiput Scapulae Vertebrae Elbows Sacrum Coccyx Heels Ears Shoulders Iliac Crest Male genital region Patella Dorsum of feet Ears Shoulders Greater Trochanter Head of Fibula Knees Lateral Malleolus Medial Malleolus O’Sullivan, pg. 957 Table 23.5 Concorde Career College

Reinforcement of Self Care Activities Grooming, Bathing, Dressing, Feeding, Recreation, Sports Energy Conservation Cardiovascular training Aquatic Exercises Patient and Family Education Concorde Career College

Assess for Understanding:
What is the effect of Autonomic Dysreflexia (Hyperreflexia) and how does the therapist handle the situation? What are the symptoms of Autonomic Nervous System Disturbances/ increased sympathetic activity? Upper motor neuron spinal lesions are located between which spinal segments? Lower motor neuron spinal lesions are located between which spinal segments? Concorde Career College

References Physical Rehabilitation, 5th ed., Susan B. O’Sullivan and Thomas J. Schmitz, 2007; F.A. Davis, Company. Chapter 23 PTA Exam The Complete Study Guide, Scott M. Giles, 2011; Scorebuilders. PTA Examination Review and Study Guide, Karen Ryan and Becky McKnight, 2010; International Educational Resources. Functional Significance of Spinal Cord Lesion Level, C. Long MD E. Lawton PT, MA, Archives of Physical Medicine and Rehabilitation, September, 1955. Concorde Career College

Peripheral Nerve System Disorders
PTA 150: Fundamentals of Treatment II Day 12

Lesson Objectives Define peripheral nerve
Discussing major functions of peripheral nerves List and describe the major peripheral neuropathies and their pathogenesis Discuss entrapment syndromes specifically naming each, identifying the structural considerations that are involved Discuss the fundamental rehabilitation of LMN lesions

Peripheral Nerve Defined
Nerves outside the Central Nervous System Connects CNS to limbs and organs Provide motor and sensory function Cranial nerves and spinal nerves 31 pairs of spinal nerves

Terminology Neuropathies Myopathy Polyneuropathy Mononeuropathy
Radiculopathy Causalgia Entrapment syndrome

Major Pathologies Bell’s palsy – swelling/inflammation of facial nerve (CN VII) Usually caused by a viral infection S&S: facial droop, weakened taste, sound sensitivity, weak facial expressions Trigeminal neuralgia - compression of trigeminal nerve (CN V) AKA tic douloureux S&S: episodes of intense pain (like electric shock) in the face CN V – sensation in the face as well as some motor function such as biting, chewing and swallowing

Major Pathologies Poliomyelitis Post-polio syndrome Viral infection
S&S: flu like symptoms, loss of reflex, muscle ache/spasm, flaccid limbs Post-polio syndrome New onset of weakness and severe fatigue occurring years after recovery from acute poliomyelitis S&S: severe long lasting fatigue that does not go away with rest, new onset of weakness in muscles thought to be strong, new loss of functional abilities

Major Pathologies Guillian-Barre Syndrome
Associated with autoimmune attack; often occurs after recovery from an infectious disease Demyelinating LMN motor: cranial and peripheral nerves S&S: weakness, tingling, loss of sensation, difficulty breathing; progresses from lower extremities to upper extremities and from distal to proximal; may result in quadriplegia and respiratory failure

Major Pathologies Myasthenia gravis Grave muscular weakness
Autoimmune disorder in which there is a production of antibodies that combine with acetylcholine receptors at motor end plates; destroys the receptor sites S&S: fluctuating weakness, usually affects eye movements first, more noticeable in proximal muscles, dysphagia, gagging, muscle function better after rest, fatigue, double vision When the nerve impulse originating in the brain arrives at the nerve ending, it releases a chemical called acetylcholine. Acetylcholine travels across the space to the muscle fiber side of the neuromuscular junction where it attaches to many receptor sites. The muscle contracts when enough of the receptor sites have been activated by the acetylcholine. In MG, there can be as much as an 80% reduction in the number of these receptor sites. The reduction in the number of receptor sites is caused by an antibody that destroys or blocks the receptor site.

Major Pathologies Complex regional pain syndrome - vasomotor dysfunction to chronic sensory stimulus S&S: severe pain, swelling, changes in the skin, loss of motion AKA reflex sympathetic dystrophy Diabetic neuropathy/Peripheral Nerve Neuropathy - occurs with advanced diabetes mellitus, occurring in limbs Capillary fragility with diminished distal circulation Hypoesthesia of the feet and hands

Radicular pathology Foraminal stenosis - intervertebral foramen is narrowed by something such as osteophytes (bone spurs) Structural Functional Postural Activity dependent – overhead work – computer use

Entrapment syndromes Thoracic outlet syndrome Cubital tunnel syndrome
Compression of the subclavian artery and vein, brachial plexus Neurovascular compression Cervical rib Postural and overuse of anterior chest wall muscles Cubital tunnel syndrome Entrapment of the ulnar nerve at the elbow

Entrapment syndromes Pronator teres entrapment
AKA Pronator syndrome Median nerve compression at the pronator teres muscle Carpal tunnel syndrome (CTS) Entrapment median nerve at the wrist Usually caused by repetitive motions of the wrist S&S: numbness, tingling, pain, clumsiness with hand activity, weak grip, swelling

Entrapment syndromes Piriformis syndrome Tarsal Tunnel Syndrome
Entrapment of the sciatic nerve through or under the piriformis muscle Tarsal Tunnel Syndrome Tibial nerve entrapment at the medial aspect of the ankle “Burning” pain and paresthesias behind the medial malleolus that radiate to the plantar surface of foot

Rehabilitation P.R.I.C.E Protection from nerve compression
Padding, positioning, splinting Resolve acute inflammation in area of nerve compression Cool to warm Gentle massage for swelling (instruct patient) Gentle compression wrapping

Rehabilitation Control repetitive motions and continuous pressures
Normalize poor ergonomics and biomechanics of work, ADL and recreation Normalize posture and utilize assistive supporting devices as necessary

Rehabilitation Restore normal ROM and strength
Take care not to overstretch nerve as this will increase symptoms Passive ROM to active resistive strengthening Maintain stability Support co-contraction and coordinated patterning EMG biofeedback Electrical stimulation for muscle re-education

Rehabilitation Normalize soft tissue mobility and resolve binding/entrapping scars Be very careful not to aggravate nerve Conditions that are long standing often require longer periods of rehab Ergonomic and biomechanics training

Rehabilitation Postural training Strategies for postural awareness
Alignment - static using supportive devices Alignment – dynamic; stabilization within movement Proper alignment enhances proprioception, balance and economy of energy

Rehabilitation Sensory considerations
Monitor skin for pressure and irritation in patients with hypoesthesia Pad and protect skin from pressure Frequent changes in position Aerobics training for enhanced skin circulation

Rehabilitation Sensory integration Desensitization
TENS Increase sensory input of varying types and intensities Recognize normal by comparative contralateral awareness Recognize appropriate response and level Comparison to norms Comparison to functional ability

Summary Define peripheral nerve
Discussing major functions of peripheral nerves List and describe the major peripheral neuropathies and their pathogenesis Discuss entrapment syndromes specifically naming each, identifying the structural considerations that are involved Discuss the fundamental rehabilitation of LMN lesions

Questions

References Physical Rehabilitation, 5th ed., Susan B. O’Sullivan and Thomas J. Schmitz, 2007; F.A. Davis, Company. Chapter 13

Concorde Career College Physical Therapist Assistant

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