Cervical cord injury pt assessment and management.pptx

Cervical spine injury
Physiotherapy assessment and rehabilitation

1. CLINICAL CASE PRESENTATION BY PAPAI BAGCHI FINAL YEAR BPT 2020 BATCH NOPANY INSTITUTE OF HEALTHCARE STUDIES

2. DEMOGRAPHICS - NAME- PRONAY PAL AGE/GENDER- 24/MALE OCCUPATION- STUDENT ADRESS- KRISHNANAGAR, NADIA DOMINANT SIDE- RIGHT SIDE PLACE OF ASSESSMENT- ITU,BED NO- 419, INSTITUTE OF NEUROSCIENCES,KOLKATA DATE OF ASSESSMENT- 27 th ,28 th ,29 th MARCH 2024 DATE OF ADMISSION- 23/03/2024

3. CHEIF COMPLAINT - THE PATIENT WAS REFERRED TO PHYSIOTHERAPY WITH THE COMPLAINT OF LEFT SIDE WEAKNESS AND NECK PAIN DUE TO CERVICAL VERTEBRAL FRACTURE.

4. HISTORY OF PRESENT ILLNESS - APPARENTLY THE PATIENT WAS ALRIGHT BEFORE 23 RD MARCH.ON 23 RD MARCH AROUND 1PM, HE WAS BATHING AT GANGES RIVER IN HIS HOMETOWN. DURING THEN, HE DIVED INTO THE RIVER AND INJURED HIS NECK. AFTER THAT, THERE WAS SUDDEN ONSET OF LEFT SIDED WEAKNESS AND HE WAS UNABLE TO STAND. THERE WAS NO HISTORY OF GTCS/LOC/SEIZURE/VOMITING. HE WAS IMMEDIATLY TAKEN TO KRISHNANAGAR DISTRICT SADAR HOSPITAL, THERE A CT SCAN WAS DONE AND FOUND C3,C4,C5 FRACTURE. THE DOCTORS THEN REFERRED HIM TO THE INK HOSPITAL,KOLKATA FOR FURTHER MANAGEMENT. HERE, HE UNDERWENT CERVICAL(C3,C4,C5) LAMINECTOMY WITH C3-C6 FUSION SURGERY. NOW HE IS HAVING POST-OPERATIVE PAIN AT CERVICAL REGION, LEFT SIDED WEAKNESS AND TINGLING SENSATIONS IN BOTH UPPER LIMBS. TILL NOW, HE IS UNDER SUPERVISION OF MEDICAL, PHYSIOTHERAPY AND OCCUPATIONAL THERAPY REHAB TEAM.

5. MEDICAL HISTORY - DRUG HISTORY - PCM 1g PAN 40mg TRANEXA 500mg Syr DUPHALAC DYNALIX 40mg (ENOXAPARIN) AMIKACIN 1g PREGADOC D (PREGABALIN+DULOXETINE 75/20 mg) SURGICAL HISTORY - C3,C4,C5 LAMINECTOMY WITH C3-C6 FUSION SURGERY ON 24 TH MARCH 2024

6. PAST HISTORY - THERE WAS NO SIGNIFICANT PAST MEDICAL OR SURGICAL HISTORY PRESENT.

7. PERSONAL HISTORY - TYPE A PERSONALITY OCCASIONAL SMOKER AND DRINKER BEFORE ACCIDENT- MIX DIET, NOW ON SOFT DIET SLEEP & APPETITE- NORMAL BOWEL & BLADDER- INCONTINENCE MARITAL STATUS- SINGLE EDUCATION- GRADUATE

8. SOCIO-ECONOMIC HISTORY - ACCORDING TO KUPPUSWAMY SCALE, HE BELONGS TO UPPER MIDDLE CLASS FAMILY. SCORE- 24

9. ENVIRONMENTAL HISTORY - IN ITU SPACIOUS AROUND BED. AUTOMATIC ADJUSTABLE BED. PROPER HYGIENE MAINTAINED. IN HOME HIS ROOM IS IN 1 ST FLOOR. HAVE STAIRS ON ENTRANCE. WESTERN TOILET. WELL MAINTAINED ROADS FROM MAIN HIGHWAY TO HOME, SO WHEELCHAIRE ACCESSIBLE .

10. ON OBSERVATION - BODY BUILT- MESOMORPHIC ATTITUDE OF LIMBS- LEFT HIP EXTERNALLY ROTATED AND ANKLE PLANTAR FLEXED. POSTURE- NO SUCH DEVIATIONS SEEN TROPICAL CHANGES- NO VISIBLE TROPICAL CHANGES NO VISIBLE MUSCLE WASTING SURGICAL SCAR PRESENT AT THE POSTERIOR ASPECT OF NECK EXTERNAL APPLIANCES- RYLE’S TUBE, PHILADELPHIA COLLAR, IV LINE, VITAL MONITORING EQUIPEMENTS, URINARY CATHETER, DVT CUFFS( DAY 1). FROM THE NEXT DAY, RYLE’S TUBE WAS REMOVED, AND CERVICAL COLLAR ADDED. MODE OF VENTILATION- INDEPENDENT TYPE OF RESPIRATION- ABDOMINO-THORACIC PATTERN OF RESPIRATION- ASYMMETRICAL

11. ON PALPATION - AFEBRILE CERVICAL LAMINECTOMY SCAR NO EDEMA TENDERNESS AT CERVICAL REGION(GRADE-4)

12. PAIN ASSESSMENT - SITE OF PAIN- POSTERIOR ASPECT OF NECK(CERVICAL REGION) ONSET- SUDDEN ONSET CHARACTER-SHARP SHOOTING RADIATION- NO RADIATION ASSOCIATED SYMPTOMES- TINGLING SENSATION IN BOTH UPPER LIMBS TIMING-MOST OF THE TIME EXACERBATING/ RELEVING FACTORS- WORSEN BY NECK MOVEMENTS AND RELIEVED AT COMPLETE REST SEVERITY- 8

13. ON EXAMINATION - DAY 1 DAY 2 DAY 3 BP- 133/74 mmHG HR- 76/ min SPO2- 95% RR- 16/min BP- 125/65 mmHG HR- 72/ min SPO2- 97% RR- 14/min BP- 109/66 mmHG HR- 76/min SPO2- 98% RR- 17/min VITAL SIGNS

14. HIGHER MENTAL FUNCTION - THE PATIENT WAS AWAKE, ALERT, ATTENTIVE, ORIENTED BOTH LONG TERM AND SHORT TERM MEMORIES INTACT EMOTIONAL STATUS- CALM BEHAVIOR- COOPERATIVE LEVEL OF CONSCIOUSNESS - E4M5V6

15. CRANIAL NERVE EXAMINATION - OLFACTORY- INTACT OPTIC- INTACT OCULOMOTOR- INTACT TROCHEAR- INTACT TRIGEMINAL- INTACT ABDUCENS- INTACT FACIAL- INTACT VESTIBULOCOCHLEAR- NOT TESTABLE GLOSSOPHARYNGEAL- VAGUS- INTACT SPINAL ACCESSORY- NOT TESTABLE DUE TO CERVICAL FRACTURE HYPOGLOSSAL- INTACT

16. SUPERFICIAL SENSATIONS - LIGHT TOUCH AND PIN PRICK AS PER ASIA IMPAIREMENT SCALE. NOTE : C2,C3 WAS NOT TESTABLE DUE TO PHILADELPHIA COLLAR, AND S3,S4,S5 WAS NOT TESTABLE DUE TO PRIVACY REASONS. SENSORY EXAMINATION - LIGHT TOUCH SENSATION IN C4,C5 DERMATOME AT LEFT SIDE IS ABSENT. AND PIN PRICK SENSATION IN C4,C5 DERMATOME AT RIGHT SIDE IS ABSENT. OTHER THAN THAT, BOTH LIGHT TOUCH AND PIN PRICK SENSATIONS ARE INTACT ( CHECKED AT KEY POINTS OF ALL DERMATOMES )

17. DEEP SENSATIONS - PROPRIOCEPTION - INTACT KINESTHESIA - INTACT PRESSURE - INTACT FIRM TOUCH - INTACT

18. COMBINED CORTICAL SENSATIONS - TACTILE LOCALIZATION - NORMAL TWO-POINT DISCRIMINATION - NORMAL STEREOGNOSIS - NORMAL GRAPHESTHESIA - NORMAL BAROGNOSIS - NORMAL

19. MOTOR EXAMINATION - 1) MUSCLE TONE - RIGHT SIDE - NORMAL TONE LEFT SIDE - HYPOTONIA 2) MUSCLE POWER - MRC GRADING SHOULDER MUSCLE GROUP RIGHT LEFT FLEXORS 2 1 EXTENSORS 2 1 ABDUCTORS 2 1 ADDUCTORS 2 1 INTERNAL ROTATORS 2 1 EXTERNAL ROTATORS 2 1

20. MUSCLE GROUP RIGHT LEFT FLEXORS 3 2+ EXTENSORS 3 2+ ELBOW MUSCLE GROUP RIGHT LEFT FLEXORS 3 2+ EXTENSORS 3 2+ WRIST MUSCLE GROUP RIGHT LEFT FLEXORS 4 1 EXTENSORS 4 1 ABDUCTORS 4 1 ADDUCTORS 4 1 INTERNAL ROTATORS 4 1 EXTERNAL ROTATORS 4 1 HIP

21. MUSCLE GROUP RIGHT LEFT FLEXORS 4 2+ EXTENSORS 4 2+ KNEE MUSCLE GROUP RIGHT LEFT DORSIFLEXORS 4 1 PLANTARFLEXORS - - ANKLE

22. 4) REFLEXES SUPERFICIAL - CORNEAL REFLEX- PRESENT ABDOMINAL REFLEX- PRESENT PLANTAR REFLEX- RIGHT SIDE- FLEXION TYPE (NORMAL) LEFT SIDE- EXTENSION TYPE ( BABINSKI POSITIVE) DEEP TENDON REFLEXES - DTR RIGHT LEFT BICEPS ++ + TRICEPS ++ + SUPINATOR ++ + KNEE ++ + ANKLE ++ + JAW JERK- ++

23. ITEM DESCRIPTION SCORE (0-4) SITTING TO STANDING - 0 STANDING UNSUPPORTED - 0 SITTING UNSUPPORTED - 0 STANDING TO SITTING - 0 TRANSFERS - 0 STANDING WITH EYES CLOSED - 0 STANDING WITH FEET TOGETHER - 0 REACHING FORWARD WITH OUTSTRETCHED ARM - 0 RETRIEVING OBJECT FROM FLOOR - 0 TURNING TO LOOK BEHIND - 0 TURNING 360 DEGREES - 0 PLACING ALTERNATE FOOT ON STOOL - 0 STANDING WITH ONE FOOT IN FRONT - 0 STANDING ON ONE FOOT - 0 TOTAL - 0/56 BALANCE - BERG BALANCE SCALE :

24. FUNCTIONAL EVALUATION - MODIFIED BARTHEL INDEX FEEDING - 0 BATHING- 0 GROOMING- 0 DRESSING- 0 BOWEL- 0 BLADDER- 0 TOILET USE- 0 TRANSFERS(BED TO CHAIR AND BACK)- 0 MOBILITY- 0 STAIRS- 0 TOTAL- 0/100, TOTAL DEPENDENCY

25. DIAGNOSIS - TRAUMATIC CERVICAL CORD INJURY ( INCOMPLETE INJURY, LATERAL CORD SYNDROME i.e BROWN-SEQUARD SYNDROME ) ASIA GRADE - C IN PHYSIOTHERAPY POINT OF VIEW, IT IS A CASE OF POST-SURGICAL NECK PAIN AND HEMIPARESIS.

26. PHYSIOTHERAPY MANAGEMENT

27. PROBLEM LIST - PAIN LOSS OF NECK CONTROL LEFT SIDED FLACCID PARALYSIS BALANCE PROBLEM GAIT PROBLEM AIM OF TREATMENT - TO MAKE THE PATIENT STAND INDEPENDENTLY TO MAKE THE PATIENT MOBILE TO MAKE THE PATIENT FUNCTIONALLY INDEPENDENT

28. GOALS OF TREATMENT SHORT TERM GOALS PAIN RELIEF IMPROVE SKIN HYGIENE PREVENT BED SORES AND DVT AVOID CONTRACTURES/DEFORMITY RESTORE LEFT SIDE STRENGHT IMPROVE RIGHT SIDE STRENGHT TEACHING BED MOBILITY IMPROVE STATIC BALANCE FOR BOTH SITTING AND STANDING LONG TERM GOALS PATIENT EDUCATION HELP WITH ASSISTIVE DEVICES SENSORY INTEGRATION MAINTAIN NORMAL MUSCLE TONE IMPROVE DYNAMIC BALANCE GAIT TRAINING TO MAKE THE PATIENT PSYCHO-SOCIALLY INDEPENDENT

29. ACUTE PHASE  THE STAGE OF SPINAL SHOCK GOALS - PREVENTION OF JOINT CONTRACTURES AND DEFORMITIES. IMPROVEMENT OF MUSCLE AND RESPIRATORY FUNCTIONS. PREVENTION OF SECONDARY COMPLICATIONS. PSYCHOLOGICAL SUPPORT AND PATIENT EDUCATION.

30. PREVENTION OF BEDSIDE COMPLICATIONS - TO PREVENT PRESSURE SORES - CHANGING POSITIONS IN EVERY 2 HOURS, USE AIR OR WATER MATTRESSES AND GLOVES FILLED WITH WATER CAN ALSO BE USED. TO PREVENT DVT - DVT STOCKINGS, PASSIVE ANKLE FOOT EXERCISES, INTERMITTENT PNEUMATIC COMPRESSIONS. TO PREVENT CONTRACTURE/ DEFORMITY/ TIGHTNESS - PASSIVE MOVEMENTS AND STRETCHING CAN BE DONE. CHEST PHYSIOTHERAPY - THIS INVOLVES: MAINTAINING LUNG HYGIENE MAXIMIZING VENTILATION MAINTAINING MOBILITY PREVENTING TIGHTNESS OF THORACIC CAGE UTILIZING EFFECTIVE BREATHING STATEGIES

31. TO AID IN THE PRESERVATION OF RESPIRATORY STATUS FOLLOWING TECHNIQUES CAN BE USED : DIAPHRAGMATIC BREATHING EXERCISES GLOSSOPHARYNGEAL BREATHING EXERCICES COUGHING RESPIRATORY MUSCLE TRAINING CHEST PNF ASSISTIVE DEVICES SUCH AS SPIROMETER, ABDOMINAL BINDER ETC. MAINTAINING RANGE OF MOTION - TO AID IN MAINTAINING ROM AND PREVENTING CONTRACTURES THE FOLLOWING CAN BE DONE : ROM EXERCISES POSITIONING SPLINTING STRETCHING

32. RECOVERING PHASE  WEARING OFF SPINAL SHOCK GOALS - PAIN MANAGEMENT MAINTAIN JOINT ROM IMPROVE WEIGHT BEARING MAINTAIN MUSCLE TONE MUSCLE STRENGTHENING CARDIOVASCULAR/ ENDURANCE TRAINING TO TEACH BASIC SKILSS eg. BED MOBILITY, TRANSFERS AND WHEELCHAIR MOBILITY BALANCE TRAINING GAIT TRAINING BLADDER MANAGEMENT SENSORY INTEGRATION

33. 1) PAIN MANAGEMENT - CYOTHERAPY 2) MAINTAIN JOINT ROM - PASSIVE ROM EXERCISES FOR PARALYTIC SIDE AND ACTIVE ROM EXERCISES FOR SOUND SIDE. 3) IMPROVE WEIGHT BEARING - TILT TABLE MOBILIZATION PREVENTS ORTHOSTATIC HYPOTENSION AND THERE IS GRADUAL WEIGHT-BEARING IN SPINE & LIMBS. THE DAILY PROGRESS ON TILT TABLE IS USUALLY 10-15 ⁰ PER DAY.

34. 4) MAINTAIN MUSCLE TONE - IT IS AN UMN TYPE OF LESION, SO TONE WILL INCREASE. TO MANAGE THAT HYPERTONICITY, FOLLOWING METHODS CAN BE APLLIED- GENTLE RHYTHMIC PASSIVE MOVEMENT SUSTAINED GRADUAL STRETCHING PROLONGED ICING 15-20 min FARADIC STIMULATION TO WEAK ANTAGONIST RIP BIOFEEDBACK THERAPY

35. 5) MUSCLE STRENGTHENING - MUSCLE GROUP HAVING POWER 1 & 2  TO USE RE-EDUCATION BOARD TO INCREASE THE POWER TO 3  MUSCLE GROUP HAVING POWER 3  ACTIVE ROM EXERCISES  MUSCLE GROUP HAVING POWER 4  ACTIVE RESISTIVE EXERCISES STRENGTHENING EXERCISES SHOULD BE PERFORMED 2-4 TIMES A WEEK, PERFORMING 2-3 SETS OF 8-12 REPETITIONS AT 60-80% OF 1RM. INITIALLY, STRENGTHENING EXERCISES MAY BE DONE DAILY DURING EARLY REHABILITATION. VARIETY OF METHODS CAN BE USED- PULLEYSYSTEMS, FREE WEIGHTS, THERABANDS, AND WEIGHT CUFFS. EXERCISES TO IMPROVE CERVICAL MUSCLE STRENGTH- NECK ISOMETRIC EXERCISES(SELF-RESISTANCE)  PROGGRES TO STRENGTHENING BY ADDIND MANUAL RESISTANCE. NECK EXERCISES WILL BE STARTED AFTER HEALING THE SURGICAL WOUND. 6)CARDIOVASCULAR/ ENDURANCE TRAINING - ARM ERGOMETRY, WHEELCHAIR PROPULSION AND SWIMIMG ARE MOST COMMON AEROBIC TRAINING. FES-POWERED LE ERGOMETRY IS USED FOR CARDIOVASCULAR TRAINING.

36. 7) BED MOBILITY TRAINING - PREPARING THE PATIENT FOR INDEPENDENT MOBILITY REQUIRES A GREAT DEAL OF MOTOR TRAINING. MAT PROGRAMS SHOULD BE INITIATED PROGRESSING THE PATIENT FROM ROLLING TO VARIOUS HIGHER TASKS SUCH AS SITTING. PNF TECHNIQUES CAN ASLO BE ADDED TO MAT EXERCISES; SPLITING THE WHOLE TASK INTO SUBCOMPONENTS ARE OTHER APPROACHES WHICH CAN FICILITATE THE MOBILITY SKILLS. 8) TRANSFER ACTIVITIES - TRANSFER FROM BED TO/FROM WHEELCHAIR IN A SEATED POSITION IS KNOWN AS SIT-PIVOT TRANSFER AND HAS THREE PHASES- PREPARATORY, LIFT AND DESCENT. HAND POSITION IS VERY IMPORTANT IN TRANSFERS AND HEAD-HIP RELATIONSHIP SHOULD BE SECURED CORRECTLY. USE OF PUSHUP BLOCKS AND WRIST CUFFS CAN BE MADE TO FICILITATE TRANSFER TRAINING. TRANSFERS TO/FROM TOILET SEAT ALSO CAN BE INCLUDED IN TRAINING.

37. 9) BALANCE TRAINING - ■ STATIC BALANCE TRAINING : SITTING BALANCE : INDEPENDENT SITTING BALANCE IN SHORT AND LONG SITTING IS TRAINED FIRST. FOLLOWING THIS, PROGRESSION IS MADE ON VARIOUS SURFACES, e.g. FIRM MAT, BED, SOFT FOAM etc. BALANCE ON WHEELCHAIR SHOULD ALSO BE TRAINED. REACHING ACTIVITIES ON GYMBALL TO IMPROVE BALANCE STANDING BALANCE : TILT TABLE OR STANDING FRAMES CAN BE USED. ORTHOSES SUCH AS POSTERIOR KNEE GUARDS, TOE RISING SPLINTS, STABILIZING BOOTS, AND CRAIG SCOTT ORTHOSIS CAN BE USED TO AID STANDING.

38. STANDING REDUCES THE RISK OF HYPERCALCIURIA AND BONE LOSS, AND ALSO AIDS PRESSURE RELIEF BY PROVIDING WEIGHT BEARING ON JOINTS OF SPINE AND LE. ■ DYNAMIC BALANCE TRAINING : BALANCE TRAINING ON WOBBLE BOARD REACHING ACTIVITIES ON STANDING. THEN PROGRESSED TO ONE LEG STANDING. TANDEM WALKING (WITH AND WITHOUT SUPPORT), CHALLENGES CAN BE ADDED BY ASKING QUESTIONS.

39. 10) GAIT TRAINING - VARIOUS TECHNIQUES USED FOR GAIT TRAINING ARE AS FOLLOWS: BODY-WEIGHT SUPPORT TREADMILL TRAINING GAIT TRAINER WITH HARNESS ROBOTICS (LOKOMAT, HOCOMA AG) FUNCTIONAL ELECTRICAL STIMULATION (FES) ORTHOSES TO ASSIST IN AMBULATION- KNEE-ANKLE-FOOT ORTHOSES, HIP-KNEE-ANKLE- FOOT ORTHOSIS, RECIPROCATING GAIT ORTHOSES, AND PARAWALKERS ARE SOME OF THE WIDELY USED OPTIONS. WALKING IN PARALLEL BARS FOLLOWED BY WALKING WITH ASSISTIVE DEVICES SUCH AS WALKERS OR CRUTCHES SHOULD BE INCORPORATED IN REHABILITATION. APART FROM THIS, PATIENTS WHO HAVE A POTENTIAL TO RECOVER CAN ALSO BE TAUGHT USE OF RAMPS, PUBLIC TRANSPORTATIONS, AND COMMUNITY AMBULATION. HYDROTHERAPY HAS ALSO BEEN SHOWN TO HAVE BENEFITS IN GAIT TRAINING.

40. ■ GAIT TRAINING WITH ASSISTIVE DEVICES : ONCE THE PATIENT REGAIN HIS NECK CONTROL AND ABLE TO BEAR BODY WEIGHT, ASSISTIVE DEVICES CAN BE PRESCRIBED- ACCORDING TO PATIENTS NEED, DIFFERENT TYPES OF WALKING AID CAN BE GIVEN.

41. 11) BLADDER MANAGEMENT - FOR FLACCID BLADDER- INDWELLING CATHETER IS INSERTED AND CAN BE MANAGED BY TIMED VOIDING PROGRAMS. FOR SPASTIC BLADDER- INTERMITTENT CATHETERIZATION IS USED( SELF CATHETERIZATION CAN ALSO BE USED BY SOME INDIVIDUALS ), AND CAN BE MANAGED BY THE SUPRAPUBIC TAPPING( TAPPING OVER THE BLADDER WITH THE FINGER TIPS TO STIMULATE DETRUSOR MUSCLES ). AREFLEXIC BLADDER CAN BE MANAGED WITH CREDE’S METHOD (LEAN FORWARD TO INCREASE PRESSURE IN THE ABDOMEN, THUS TRIGGERING THE DETRUSOR MUSCLES). OTHER TECHNIQUES- LOWER ABDOMINAL STROKING, PINCHING OR PUBIC HAIR PULLING, CLAMPING OF CATHETER, OR USE OF SUPRAPUBIC CATHETER. 12) SENSORY INTEGRATION - STRETCHING, STROKING( WITH DIFFERENT TECTURES AND FABRICS ), SUPERFICIAL AND DEEP PRESSURE, ICING, VIBRATION etc.

42. REFERENCES- SUSAN B.O’SULLIVAN, THOMAS J.SCHMITZ, GEORGE D.FLUK: PHYSICAL REHABILITATION- 7 TH EDITION. S. BRENT BROTZMAN, ROBERT C. MANSKE: CLINICAL ORTHOPAEDIC REHABILITATION- 3 RD EDITION. JAYANT JOSHI, PRAKASH KOTWAL: ESSENTIALS OF ORTHOPAEDICS AND APPLIED PHYSIOTHERAPY- 3 RD EDITION. MEGHA SANDEEP SHETH, PRIYA SINGH RANGEY, NEETA JAYPRAKASH VYAS, SRISHTI SANAT SHARMA, SHIVANI SIDDHARTH SHETH: PHYSIOTHERAPY IN ORTHOPAEDIC AND RHEUMATOLOGIC CONDITIONS- 1 ST EDITION. CAROLYN KISNER, LYNN ALLEN COLBY: THERAPEUTIC EXERCISE- FOUNDATIONS AND TECHNIQUES- 6 TH EDITION. DALE AVERS, MARYBETH BROWN: DANIELS AND WORTHINGHAM’S MUSCLE TESTING- TECHNIQUES OF MANUAL EXAMINATION AND PERFORMANCE TESTING- 10 TH EDITION.

43. THANK YOU