SPINAL CORD INJURIES AND PT REHABILITATION

A COMPREHENSIVE OVERVIEW OF SPINAL CORD INJURIES, ITS MEDICAL AND PHYSIOTHERAPY REHAB

1. SPINAL CORD INJURIES BY : NITYA CHOPHLA MPT NEUROLOGY

2. CONTENTS Introduction to spinal cord injuries(SCI) Causes of SCI Brief anatomy of spinal cord Tracts of spinal cord Classification of SCI Pathophysiology of SCI Clinical Cord Syndromes Complications of SCI Diagnosis of SCI Management of spinal cord injuries Emergency care Definitive care Rehabilitative care

3. INTRODUCTION TO SPINAL CORD INJURY A spinal cord injury (SCI) is damage to the spinal cord that causes paralysis of the muscles below the level of the injury can lead to limited and altered mobility, self-care, and ability to participate in valued social activities.

4. Spinal Cord Injury (SCI) is a sudden onset disruption to the neuronal tissue within the spinal canal resulting in spinal cord damage, which occurs as a result of trauma, disease or degeneration. It can present as either an upper motor neuron lesion or lower motor neuron lesion with varying loss of motor, sensory and autonomic function, either temporary or permanent depending on the level and type of injury to the Spinal Cord or Cauda Equina .

5. CAUSES OF SPINAL CORD INJURY TRAUMATIC CAUSES Road traffic accident Fall from height Sports injury Violence- blow at the back , gunshot injury NON TRAUMATIC CAUSES Vascular causes: Arteriovenous Malformation, Thrombus & Emboli, Hemorrhage in Spinal Artery Vertebral subluxation secondary to Rheumatoid Arthritis Spinal neoplasm Infection: Transverse Myelitis , Syphilis Inflammatory disease : MS, ALS Arnold Chiari Malformation, Syringomyelia Abscess of spinal cord

6. BRIEF ANATOMY OF SPINAL CORD The spinal cord is a long, thin, tubular structure made up of nervous tissue, which extends from the medulla oblongata in the brainstem to the L1 vertebra of vertebral column. It encloses the central canal of the spinal cord, which contains cerebrospinal fluid. It contains white matter, which consists of ascending sensory tracts, descending motor tracts, and an H-shaped central area of grey matter.

7. ANATOMY OF SPINE

8. Each  Spinal nerve  is a mixed nerve, formed from the combination of nerve fibers from its dorsal and ventral roots. The dorsal root is the afferent sensory root and carries sensory information to the brain. The ventral root is the efferent motor root and carries motor information from the brain.

9. There are 31 pairs of spinal nerves in a human spinal cord: 8 Cervical 12 Thoracic 5 Lumbar 5 Sacral 1 Coccygeal

10. TRACTS OF SPINAL CORD

11. FUNCTIONAL CLASSIFICATION OF SCI TETRAPLEGIA Complete paralysis of all four extremities & trunk including respiratory muscles and result from lesion of Cervical Cord PARAPLEGIA Complete paralysis of all or part of trunk and both lower extremities resulting from lesion of Thoracic or Lumbar Cord or Cauda Equina

12. FUNCTIONAL CLASSIFICATION OF SCI

13. CLASSIFICATION ACCORDING TO LESION LEVEL COMPLETE LESION INCOMPLETE LESION A complete injury is defined as having no sensory or motor function in the lowest sacral segments (S4 and S5). An incomplete injury is classified as having motor and/or sensory function below the neurological level including sensory and/or motor function at S4 and S5. If an individual has motor and/or sensory function below the neurological level but does not have function at S4 and S5, then the areas of intact motor and/or sensory function below the neurological level are termed ZONES OF PARTIAL PRESERVATION.

14. ISNSCI DESIGNATION OF LESION LEVEL The NEUROLOGICAL LEVEL is defined as the most caudal level of the spinal cord with normal motor and sensory function on both the left and right sides of the body. The MOTOR LEVEL is referred to as the most caudal segment of the spinal cord with normal motor function bilaterally. The SENSORY LEVEL is referred to as the most caudal segment of the spinal cord with normal sensory function bilaterally.

15. PATHOPHYSIOLOGY OF SPINAL CORD INJURY

16. CLINICAL SYNDROMES BROWN SEQUARD SYNDROME ANTERIOR CORD SYNDROME POSTERIOR CORD SYNDROME CENTRAL CORD SYNDROME CAUDA EQUINA INJURY

17. BROWN SEQUARD SYNDROME It occurs due to hemi section of spinal cord (damage to one side). CAUSES: Penetration injury ( Gunshot/ Stab wound) Lateral cord compression due to disc protrusion, hematomas, bone injury or tumors.

18. BROWN SEQUARD SYNDROME IPSILATERAL SIDE Paralysis Loss of sensation in dermatome segment corresponding to level of lesion Lateral column damage causing decreased reflexes, lack of superficial reflexes, clonus and positive babinski sign Dorsal column damage cause loss of proprioception, kinesthesia & vibration sense CONTRALATERAL SIDE Damage to Spinothalamic Tract (STT) causing loss of pain & temperature sensations. Loss begins several dermatome segments below level of lesion as lateral STT ascend 2-4 segments on same side before crossing. CLINICAL FEATURES

19. ANTERIOR CORD SYNDROME It is related to flexion injuries of cervical region causing resultant damage to anterior portion of cord and its vascular supply.

20. ANTERIOR CORD SYNDROME CAUSES Compression of anterior cord from fracture, dislocation or cervical disc protrusion. Direct injury to anterior cord. Flexion injury of cervical spine causing cord contusion. Bony injury causing secondary SCI Thrombosis of Anterior Spinal Artery CLINICAL FEATURES Loss of motor function due to CST damage. Loss of pain and temperature due to damage of STT below level of lesion Functions of posterior column are spared

21. CENTRAL CORD SYNDROME CAUSES: Hyperextension injuries to cervical region of spine. Associated with congenital (syringomyelia & degenerative narrowing of spinal cord. Pre existing cervical spondylosis. Injury that affects central cord more than peripheral Compressive forces causing hemorrhage & edema that damage the central aspects of cord.

22. CENTRAL CORD SYNDROME CLINICAL FEATURES More severe involvement of UE as cervical tracts are more centrally located than those of LE ( lumbar & sacral tracts are more peripheral) Patient presents with decreased strength & sensations in UE more than LE, spastic paraparesis or quadriparesis. Varying degrees of sensory impairment occur but tends to be less severe than motor. With preservation of sacral tracts, normal sexual & bowel & bladder functions are preserved.

23. POSTERIOR CORD SYNDROME CAUSES: Trauma to neck Occlusion of Posterior Spinal Artery Tumours of posterior column Neurosyphilis Multiple sclerosis

24. POSTERIOR CORD SYNDROME CLINICAL FEATURES: Preservation of motor function, sense of pain & touch. Loss of proprioception & epicritic sensations(graphesthesia, steriognosis) Sacral sparring present ( C/F: Perianal sensations. Rectal sphincter contraction, Cutaneous sensation in saddle area, Active contraction of sacrally innervated toe flexors) Patient walks with wide BOS and staggering gait.

25. CAUDA EQUINA SYNDROME

26. CAUDA EQUINA SYNDROME It is frequently anatomically incomplete owing to great number of nerve roots involved & comparatively large surface area they encompass CLINICAL FEATURES Signs of LMN lesion are seen Areflexive bowel & bladder Saddle anesthesia LE paralysis or paresis to variable degree

27. NEUROLOGICAL COMPLICATIONS SPINAL SHOCK MOTOR & SENSORY IMPAIRMENT AUTONOMIC DYSREFLEXIA SPASTIC HYPERTONIA CARDIOVASCULAR IMPAIRMENT IMPAIRED TEMPERATURE CONTROL PULMONARY IMPAIRMENT BLADDER & BOWEL DYSFUNCTION SEXUAL DYSFUNCTION

28. SECONDARY COMPLICATIONS PRESSURE SORES DEEP VEIN THROMBOSIS NEUROPATHIC PAIN CONTRACTURES HETEROTROPHIC OSSIFICATION OSTEOPOROSIS & SKELETAL FRACTURES

29. AUTONOMIC DYSREFLEXIA PRESSURE SORES

30. DEEP VEIN THROMBOSIS OSTEOPOROSIS MYOSITIS OSSIFICATIONS

31. POSTURAL HYPOTENSION BLADDER DYSFUNCTION

32. DIAGNOSTIC PROCEDURES Imaging technology is an important part of the diagnostic process of acute or chronic spinal cord injuries. Spinal cord injuries can be detected using different types of imaging, which depends on the type of underlying pathology.. These include Plain Radiographs Computed Tomography(CT)  Magnetic Resonance Imaging (MRI)

33. PLAIN X-RAY This is helpful in: ( i ) confirmation of diagnosis ; (ii) assessment of mechanism of injury; and (iii) assessment of the stability of the spine . Following are some of the radiological features suggestive of an unstable injury: • Wedging of the body with the anterior height of the vertebra reduced more than half of the posterior height . • A fracture-dislocation on X-ray. • Rotational displacement of the spine. • Injury to the facet joints, pedicle or lamina. • An increase in the space between the adjacent spinous processes as seen on a lateral X-ray .

34. X- RAY OF SPINE

35. COMPUTED TOMOGRAPHY(CT) Spinal fractures and bony lesions are well characterized by Computed Tomography (CT), which can also detect soft-tissue changes with cord oedema , infarction, demyelination , cysts, or abscesses producing reduced signal density, while haemorrhages and calcifications increase signal density . Combination of computed tomography and myelography better defines abnormalities in the spinal canal. Canal compromise and extradural lesions ( tumour , arteriovenous malformations) are especially well defined in computed tomography myelograms .

36. CT SCAN OF SPINE

37. MAGNETIC RESONANCE IMAGING (MRI) MRI has become the gold standard for imaging neurological tissues such as the spinal cord, ligaments, discs and other soft tissues and can provide better definition of bony structures than radiography, especially when radiographs suggest injury or include poorly visualized areas . It very well shows the anatomy of cord and details of injured bones & soft tissues.

38. MRI OF SPINE

39. MANAGEMENT OF SPINAL CORD INJURIES

40. 1. ACUTE PHASE MANAGEMENT EMERGENCY CARE CAN BE DIVIDED INTO: MANAGEMENT AT THE SITE OF ACCIDENT MANAGEMENT IN EMERGENCY DEPARTMENT DEFINITIVE CARE IN EMERGENCY DEPARTMENT OR WARD

41. EMERGENCY CARE: SITE OF ACCIDENT Look for signs of SCI after a traumatic event Paresthesias Lack of or impaired movement or sensation in extremities Spinal pain Altered cognitive status or level of alertness If SCI is suspected, efforts are made to avoid both active & passive movements of spine.

42. More than one person should help the patient While moving a person with a suspected cervical spine injury, one person should hold the neck in traction by keeping the head pulled . The rest of the body is supported at the shoulder, pelvis and legs by three other people. Whenever required, the whole body is to be moved in one go so that no movement occurs at the spine . The same precaution is observed in a case with suspected dorso -lumbar injury.

43. Movement of the spine is minimized by strapping the patient to a spinal backboard or a full-body adjustable backboard , using a supporting cervical collar, immobilizing the head, and obtaining assistance from multiple personnel in moving the patient. Maintain the spine in a neutral, anatomical position to prevent further neurological damage.

44. IN THE EMERGENCY DEPARTMENT On arrival to emergency department, stabilize patients ABC of life Check orientation to self and surroundings. In cases with cervical spine injury, two sand bags should be used on either side of the neck in order to avoid any movement of the neck. A quick general examination of the patient is carried out in order to detect any other associated injuries to the chest, abdomen , pelvis, limbs etc. A thorough neurological examination of the limbs is performed . Physical & neurological examination of spine is done by X-Ray, CT, MRI to check the extent of damage & planning medical management. Urinary catheterization is done.

45. IMMEDIATE MEDICAL MANAGEMENT If the patient presents within 8 hours of injury, IV methylprednisolone is administered as a bolus dose followed by maintenance dose. It has an anti inflammatory effect & helps in decreasing secondary damage due to inflammatory processes Naloxone , thyrotropin -releasing hormones may be used .

46. DEFINITIVE CARE AIMS To avoid any deterioration of the neurological status To stabilize the spinal column to prevent further damage to the cord. T o achieve stability of the spine by conservative or operative methods. To rehabilitate the paralyzed patient to the best possible extent.

47. CONSERVATIVE MANAGEMENT OF SCI Individuals managed conservatively are generally confined to bed rest with the spine immobilized for a period of 6 - 12 weeks. Depending on the degree of instability, they may have to be maintained in spinal alignment by skull traction (cervical lesions), or some type of pillow wedge (for thoracic, lumbar and sacral lesions) with tight restrictions placed on therapies, which may cause movement at the injury site, and patients are turned and moved only under strict medical supervision. Post this period of immobilization the individual is mobilized in a wheelchair, often with a spinal orthosis or bracing that is applied for a further few months.

48. SURGICAL MANAGEMENT OF SCI Surgical approach aims to minimize neurological deterioration, restore alignment and stabilization, facilitate early mobilization, reduce pain, minimize hospital stay and prevent secondary complications.  [ Decompression of the spinal cord is suggested in the setting of acute spinal cord injury with progressive neurologic deterioration, facet dislocation, or bilateral locked facets or in spinal nerve impingement with progressive radiculopathy Typically vertebrae are realigned and surgical stabilization is achieved by anterior or posterior fixation, or a combination of the two, with or without spinal decompression. Patients managed surgically are often permitted to mobilize much more rapidly than those managed conservatively. Patients are confined to bed for a shorter period, and so experience fewer complications associated with immobilization.

49. SURGICAL MANAGEMENT OF SCI INDICATIONS: Unstable fracture site Gross M al alignment Cord Compression Deteriorating neurological status

50. PHARMACOLOGICAL MANAGEMENT OF SCI Following drugs are used in treatement of patient with SCI Glucocorticoids ( Methylprednisolone ),  which suppress secondary inflammatory events of spinal cord injury. Thyrotropin -releasing Hormone (TRH)  shows antagonistic effects against the secondary injury mediators. Polyunsaturated Fatty Acids ( PUFA ) such as Docosahexanoic Acid ( DHA ) is said to improve neurological recovery through increased neuronal and oligodendrocyte survival and decreased microglia/macrophage responses, which causes increased synaptic connectivity. Eicosapentaenoic Acid (EPA) is also thought to increase synaptic connectivity, to restore neuro -plasticity.  [

51. MANAGEMENT OF SPECIFIC SPINAL CORD INJURIES

52. CERVICAL SPINE INJURIES Aim of treatment is to achieve proper alignment of vertebrae, and maintain it in that position till the vertebral column stabilises . Reduction is achieved by skull traction applied through skull calipers – Crutchfield tongs. A weight of up to 10 kg is applied and check X-rays taken every 12 hours. A close watch is kept on the patient’s neurological status. When it is confirmed on X-rays that reduction has been achieved, light traction is continued for 6 weeks. This is followed by immobilisation of the neck in a moulded PoP cast or a plastic collar. In about 3-4 months, a bony bridge forms between the subluxed vertebrae, and the spine stabilises . The collar can then be discarded.

53. COMMON CERVICAL SPINE INJURIES AND THEIR MANAGEMENT Wedge compression fracture of the vertebral body: This results from a flexion force. The posterior elements are usually intact so that the injury is stable. Reduction is not required. The neck is kept immobilised with the help of skull traction/ sling traction. Once pain and muscle spasm subside, the neck is supported in a cervical collar. Exercises of the neck are started after 8-12 weeks.

54. Burst fracture of the vertebral body: This results from a vertical compression force. The posterior elements are usually intact but because of the severity of crushing of the vertebra, fracture is considered unstable. It may be associated with a neurological deficit if a broken fragment from the body gets displaced inside the spinal canal. When there is no neurological deficit, neck is kept immobilised with the help of skull traction/ sling traction for 6 weeks & then neck is supported in a cervical collar. Later exercises are started. When there is a neurological deficit treatment comprise of decomposition & ORIF .

55. Subluxation or dislocation of the cervical spine : A flexion rotation force or a severe flexion force may result in the forward displacement of one vertebra over the other (commonly C5 over C6). The displacement may be partial or complete. These are unstable injuries. Surgical stabilization is the treatment of choice but some cases can be treated conservatively. The aim of treatment is to achieve reduction of the subluxed vertebra and maintain it in a reduced position until the spine becomes stable.

56. UNCOMMON CERVICAL SPINE INJURIES AND THEIR MANAGEMENT Fracture of the atlas : A ‘burst’ fracture where both, anterior and posterior arches of the atlas, are fractured by a vertical force acting through the skull is a common atlas fracture (Jefferson’s fracture). Treatment consists of traction, followed by immobilisation in Minerva jacket or halopelvic device Atlanto -axial fracture-dislocation : A fracture dislocation of the atlanto -axial joint is more common than pure dislocation. Treatment consists of skull traction, followed by immobilisation in a Minerva jacket. In due course, the fracture unites and a bridge of bone joins C1 to C2 anteriorly , thereby stabilising the spine. Displacement of intervertebral disc : A violent flexion-compression force can sometimes result in sudden prolapse of the nucleus pulposus of a cervical disc into the vertebral canal resulting in quadriplegia. An early decompression may give good results .

57. SURGERIES FOR CERVICAL SPINE INJURIES Surgery may be particularly required for: irreducible subluxation because of ‘locking’ of the articular processes (ii) persistent instability. FUSION SURGERY :Inter-body fusion (anterior fusion) or fusion of the spinous processes and laminae (posterior fusion) may be done. Internal fixation may be required.

58. CERVICAL IMMOBILIZATION ORTHOSIS Following reduction of the fracture site, through either conservative or surgical means, the spine is immobilized for a period of time through the use of spinal orthoses and recumbent positioning. Halos. Minerva jacket Sterno –Occipital– Mandibular Immobilizer ( SOMI ) Philadelphia collar Miami J collar Aspen collar Foam soft collar. SOMI PHILDELPHIA COLLAR

59. THORACIC & LUMBAR SPINE INJURIES Definitive treatment of a thoracic spine injury depends upon the presence of neurological deficit and on the type of vertebral injury i.e.,whether it is stable or unstable.

60. ANTERIOR SPINAL HYPEREXTENSION (ASH) BRACE

61. SURGERIES FOR LUMBAR SPINE INJURIES INDICATIONS a) Partial neurological deficit with CT or MRI proven compromise of the spinal canal. b) Worsening of the neurological deficit. c) Multiple injured patient. OPERATIVE METHODS Harrington instrumentation – bilateral Luque instrumentation Hartshill rectangle fixation Pedicle screw fixation Moss Miami system

62. HARRINGTON INSTRUMENTATION HARTSHILL RECTANGLE FIXATION

63. THORACOLUMBAR IMMOBILIZATION ORTHOSIS Thoracolumbosacral orthosis ( TLSO ) Jewett orthosis

64. PHYSIOTHERAPEUTIC ASSESSMENT & MANAGEMENT OF SPINAL CORD INJURIES

65. ACUTE PHASE PHYSIOTHERAPEUTIC ASSESSMENT File review Any precautions (Spinal instability, orthotic devices, concomitant injuries, and need for medical support or restriction of certain movements or positions) Areas of primary focus are: Examination of sensory and motor function Examination of respiratory function Examination of skin integrity Examination of PROM Performance of early mobility skills.

66. 1. SENSORY AND MOTOR FUNCTION

67. DERMATOMES

68. MYOTOMES

69. HOW TO SCORE ASIA SCALE SCORING 0- ABSENT 1- IMPAIRED 2- NORMAL

70. SCORING DONE ON 6 POINT MMT SCALE ( by MEDICAL RESEARCH COUNCIL)

71. Assess strength of diaphragm and intercostal muscles through observation. Normally, the epigastric region should rise and the chest wall expands during inhalation while in supine. Contractions of the sternocleidomastoids and scalenes or paradoxical breathing patterns indicate weakness of the diaphragm or ntercostal muscles. Check Respiratory Rate ( Normal :12-20 breathes per min) Maximal chest expansion assessed using a tape measure with the patient supine. At both the level of the axilla and xiphoid process, the physical therapist should measure the chest’s diameter at maximal exhalation and inhalation. Chest expansion measurements are the difference between chest measurements at maximal exhalation and at maximal inhalation.( Normal chest expansion ranges from 2.5 to 3 in (6- 7 cm) Vital capacity (VC) can be measured with a handheld spirometer Check ability to effectively cough that is vital for the removal of secretions. 2. RESPIRATORY FUNCTION

72. Assess skin condition Assess area prone to pressure ulcers Check factors causing skin breakdown. If Ulcer is present note the location, shape, size & stage. 3. INTEGUMENT AREAS PRONE TO PRESSURE SORES IN VARIOUS POSITIONS ARE SHOWN IN THE FIGURE.

73. Goniometry can be used to assess joint ROM. Shoulder ROM is particularly important for patients with tetraplegia . Hamstring length, hip extension, and ankle dorsiflexion are important to measure due to the potential for contractures in these joints. 4. PASSIVE RANGE OF MOTION

74. ACUTE PHASE PHYSIOTHERAPEUTIC MANAGEMENT GOALS • Airway clearance is improved. • Aerobic capacity is increased. • Integumentary integrity is improved. • Muscle performance is increased. • Risk of secondary impairments is reduced.

75. GOALS: Improved ventilation Increased effectiveness of cough Prevention of chest tightness and ineffective substitute breathing patterns. INTERVENTIONS vary according to level of lesion Individuals with cervical injuries at and above C5 often require ventilatory support using an Intermittent Positive Pressure Ventilator ( IPPV ). Deep breathing exercises Glossophayngeal breathing in high cervical region Air shift maneuvers Respiratory muscle strenghthening exercises Manually assisted coughing techniques Abdominal binders Modified postural drainage & percussion RESPIRATORY MANAGEMENT

76. Intermittent Positive Pressure Ventilator ( IPPV ). Deep breathing exercises Glossophayngeal breathing Inspiratory Muscle Trainer

77. Manually assisted coughing techniques Abdominal binders Postural drainage Percussion

78. Prevention is the most effective intervention for skin care; this entails positioning, consistent and effective pressure relief, skin inspection, and education. Areas that are susceptible to skin breakdown should be adequately protected when the patient is in bed by using pillows, foam, and positioning devices. When in bed, patients should be repositioned at least every 2 hours.136 Increased and consistent pressure over bony prominences, shear forces, heat, and moisture should be minimized. Use of special beds, fluid mattresses and special boots can be done. In wheelchair special cushion types assist in positioning and redistribution of pressure example foam, gel, air, and flexible matrix. Patients should perform a pressure relief maneuver every 15 minutes when in the wheelchair, either with assistance or independently. Patients who are not able to perform these maneuvers can be assisted or their wheelchair can be tilted back at least 65 degrees. A tilt-in-space or reclining wheelchair can also be used to redistribute pressure. Regular inspection and patient education play an important role Pressure sores if developed can be managed with appropriate measures. SKIN CARE INTERVENTIONS

79. Positioning should be used to prevent development of joint contractures and secondary pulmonary complications. A patient with a C5-level injury may tend to position the shoulder in adduction and the elbow in flexion. When positioning this patient the shoulders should be abducted and elbows extended when possible. Alignment of the fingers, thumb, and wrist must be maintained for functional activities or possible future splinting. Individuals with functional, active wrist extension can learn to use a tenodesis grasp to use the hand and fingers to perform ADLs . When the wrist is actively extended, the tendons of the fingers are shortened causing the fingers to passively flex and grasp and vice versa. An intrinsic plus splint can be used to position the wrist and hand in functional position. This position helps reduce edema, preserve tenodesis function, and prevent contractures. Wedges can be placed between toes & cones in hands & knees maintained in slight fllexion with help of pillow under knees. PROPER POSITIONING

80. Range of motion exercises should be completed daily except in those areas that are contraindicated. Motion of the trunk and some motions of the hip may be contraindicated depending on the location of the SCI. When the injury is in the lumbar spine, straight leg raises more than approximately 60 degrees and hip flexion beyond 90 degrees (during combined hip and knee flexion) should be avoided. With tetraplegia , motion of the head and neck is contraindicated. Generally, shoulder flexion and abduction beyond 90 degrees is contraindicated until orthopedic clearance is received Patients with SCIs do not require full ROM in all joints. Some joints benefit from allowing tightness to develop in certain muscles to enhance function. For example, with tetraplegia , tightness of the lower trunk musculature may improve sitting posture by increasing trunk stability; tightness in the long finger flexors will provide an improved tenodesis grasp. Some muscles require a fully lengthened range. After the acute phase, the hamstrings will require stretching to achieve a SLR of approximately 100 degrees. This ROM is required for many functional activities such as long sitting and LE dressing. Care should be taken not to overstretch the hamstring muscles because some tightness in this muscle group provides passive pelvic stabilization in sitting. his process of under-stretching some muscles and full stretching of others to improve function is referred to as selective stretching. RANGE OF MOTION (ROM)

81. Once radiographic findings have established stability of the fracture site, the patient is cleared for upright, functional activities. A gradual acclimation to upright postures is necessary. Use of an abdominal binder and elastic stockings may reduce venous pooling and prevent orthostatic hypotension. Start with slowly elevating the head of the bed and progressing to a reclining or tilt-in-space wheelchair with elevating leg rests. Tilt-table may be used Vital signs should be monitored carefully and documented during this acclimation period. ORIENTATION TO VERTICAL POSITION

82. Living with a SCI requires significant adaptations and changes on the part of the patient and his or her family. In order to meet the challenges presented by a SCI, patients must fully understand all the consequences of the injury. Patient and family/caregiver education should begin early after injury about the impact of SCI on the different body systems, secondary complications, and prognosis. Later in the recovery process it may be particularly helpful to have the patient meet individuals with long-standing SCI who have completed rehabilitation and are functioning in the community to gain an appreciation of the impact of the injury on day-to-day life. EDUCATION OF PATIENT & FAMILY

83. REHABILITATIVE PHASE PHYSIOTHERAPEUTIC ASSESSMENT DEMOGRAPHIC DATA NAME: AGE & GENDER: PRIMARY LANGUAGE: OCCUPATION: HAND DOMINANCE: CHIEF COMPLAINTS:

84. PATIENT HISTORY HISTORY OF PRESENT ILLNESS Mechanism of injury Onset & pattern of symptoms neurological symptoms Course of events MEDICAL HISTORY SURGICAL HISTORY PHARMACOLOGICAL HISTORY GENERAL HEALTH STATUS PERSONAL & FAMILY HISTORY

85. ON OBSERVATION Built, Posture, Deformities, Gait Pattern Orthotics, Wheelchair, Stick, Posture, KAFOs ON EXAMINATION PAIN ASSESSMENT Visual Analogue Scale : used to identify the intensity of pain. International Spinal Cord Injury Basic Pain Data Set : Self-report measure poses a series of questions related to impact of pain on various aspects of daily activities and life satisfaction, location of pain, intensity of pain, and duration of pain Wheelchair users Shoulder Pain index: Wheelchair users rate the amount of pain they experience while performing different activities on a scale from 0 to 10. Total score ranges from 0 to 150, with higher scores indicating a greater impact of pain.

86. HIGHER MENTAL FUNCTIONS Orientation Attention Memory Communication Cognition Calculation Spatial Perception SPECIAL SCALES Mini Mental State Exam Montreal Cognitive Assessment

87. SPECIAL SCALES MMSE ( Total Score = 30) Montreal Trail Making

88. MOTOR FUNCTION ASIA ISNCSCI standards should be used to determine the level of lesion and intact motor function. TONE ASSESSMENT The presence of spastic hypertonia should be assessed as part of the motor function examination. Modified Ashworth Scale (MAS) is commonly used to assess tone. Spinal Cord Injury Spasticity Evaluation Tool (SCI-SET) is a selfreport measure of the impact of spasticity on everyday life activities. Individual rates how spasticity has affected 35 different areas on a 7-point ordinal scale that ranges from -3 (extremely problematic) to +3 (extremely helpful).

89. MODIFIED ASHWORTH SCALE

90. RANGE OF MOTION (ROM) Measure AROM & PROM Record using goniometry or within funtional limits

91. MUSCLE PERFORMANCE ASIA ISNCSCI Manual Muscle Test Handheld Dynamometer REFLEXES

92. AEROBIC CAPACITY/ENDURANCE A 6-minute arm test (6MAT) can be used to assess aerobic capacity and cardiovascular endurance. This requires the patient to perform 6 minutes of submaximal cycling on an arm ergometer at a single, steady-state power output. It is a valid and reliable measure for people with either tetraplegia or paraplegia. Steady-state power output for clients with tetraplegia should be set between 10 and 30 watts depending on use of manual versus power wheelchair and activity level. For clients with paraplegia the power output should be set between 30 and 60 watts depending on gender and activity level

93. ENVIRONMENTAL OR WORK BARRIERS GAIT, LOCOMOTION, AND BALANCE Wheelchair Skills Test Wheelchair Circuit Modified Functional Reach Test Berg Balance Scale, Walking Index for Spinal Cord Injury Spinal Cord Injury Functional Ambulation Inventory 10-Meter Walk Test 6-Minute Walk Test Neuromuscular Recovery Scale FUNCTIONAL REACH TEST

94. INTEGUMENT • Braden Scale • Spinal Cord Injury Pressure Ulcer Scale • Spinal Cord Injury Pressure Ulcer Scale–Acute

95. SELF-CARE AND HOME MANAGEMENT Functional Independence Measure Spinal Cord Injury Independence Measure Capabilities of Upper Extremity Instrument

96. VENTILATION • Chest circumference with measuring tape Ask patient to do forceful expiration, take a tape & encircle around chest at nipple level and note the level. Ask patient to do full inspiration and again check circumference. Normal is 5-7 cm increase. • Vital capacity with handheld dynamometer • Respiratory rate ( Normal- 14-20/min) WORK, COMMUNITY, AND LEISURE INTEGRATION Craig Handicap Assessment and Reporting Technique Assessment of Life Habits Reintegration to Normal Living Index

97. REHABILITATIVE PHASE PHYSIOTHERAPEUTIC MANAGEMENT GOALS • Aerobic capacity is increased. • Integumentary integrity is improved. • Muscle performance is increased. • Tolerates upright sitting posture. • Independence in ADL . • Independence transfers. • Independence in wheelchair propulsion. • Independence in self-directing care. • Independence with pressure relief.

98. Strengthen innervated musculature. Key UE muscles to strengthen include serratus anterior, latissimus dorsi, pectoralis major, rotator cuff muscles, and triceps brachii as they are important for independent transfers. Strengthening exercises should be performed 2 to 4 times a week, performing 2 to 3 sets of 8 to 12 repetitions. Methods that can be used to implement strengthening exercises include pulley systems, free weights, elastic bands, and weight cuffs. With very weak muscles (grade ≤2) strengthening can be performed in gravity-reduced positions on a powder board or with active assistive ROM. Strengthening can be done in functional postures. SELECTIVE STRENGTHENING

99. A number of research studies have shown that endurance training can improve aerobic fitness. Upper extremity–based exercises such as arm ergometry , wheelchair propulsion, and swimming are the most common method of aerobic training. In people with incomplete SCI with sufficient walking capacity locomotor training on a TM with or without BWS is another method of endurance training. American College of Sports Medicine ( ACSM ) recommends endurance training 3 to 5 days a week, with a total duration per day of 20 to 60 minutes at 50% to 80% of peak heart rate. Surface Functional Electrical Stimulation (FES)–induced cycling or walking is also an effective means of improving cardiovascular fitness.227-229 Surface electrodes are attached bilaterally to the hamstrings, quadriceps, and gluteal muscles; a computer controls the intensity of the muscle stimulation and cadence based on the position of the pedals. CARDIO VASCULAR ENDURANCE TRAINING

100. BED MOBILITY SKILLS MAT EXERCISE PROGRAM

101. MAT ACTIVITIES To improve bed mobility, skills are learned and practiced on an exercise mat, which is firmer and larger than a typical bed . However, as skill improves they should be practiced on a bed similar to that used at home. A patient may be independent performing these skills on a mat, but still require more practice to become independent performing the same task on a bed due to the softer and smaller surface. Mat exercises are included in the treatment programme as soon as weight bearing to spine is permitted. Mat activities are given to: Facilitate balance Promote stability Mobilize and strengthen the trunk and limb. Train for functional activities

102. ROLLING

103. PRONE ON ELBOWS

104. PRONE ON HANDS

105. QUADRUPED POSITION

106. KNEELING POSITION

107. SUPINE ON ELBOWS

108. SUPINE TO SIT

109. PRONE TO SIT

110. LONG SITTING

111. SHORT SITTING

112. SKILLS PRACTICE

113. TRANSFER SKILLS

114. The term ‘transfer’ refers to movement between surfaces while maintaining a seated upright position Transfer skills are initiated once the patient achives sitting balance.

115. SKILLS NECESSARY FOR INDEPENDENCE WITH TRANSFERS • Position wheelchair • Set wheel locks • Remove and replace arm rests on wheelchair • Remove and replace leg rests on wheelchair • Manage transfer board • Manage lower extremities • Manage body position in wheelchair

116. TRANSFER SKILLS WHEELCHAIR TO BED TRANSFERS TRANSFER BETWEEN TWO PLINTHS WHEELCHAIR TO FLOOR TRANSFERS WHEELCHAIR TO TOILET SEATS WHEELCHAIR TO CAR TRANSFER

117. WHEELCHAIR TO BED TRANSFERS

118. TRANSFER USING SLIDE BOARD

119. SIT PIVOT TRANSFER

120. TRANSFER TO HIGHER SURFACE (LEGS UP TECHNIQUE)

121. FLOOR TO WHEELCHAIR TRANSFERS

122. SIDEWAYS APPROACH

123. BACKWARD APPROACH

124. FRONTWARD APPROACH

125. TRANSFER BETWEEN TWO PLINTHS

126. WHEELCHAIR TO TOILET SEATS

127. WHEELCHAIR TO CAR TRANSFER

128. GAIT TRAINING

129. COMPLETE SPINAL CORD INJURY Training emphasis is on strengthening of available musculature, using assistive & orthotic devices, learning compensatory methods of walking. Prescription of Orthosis is to be done . AFO KAFO

130. STANDING : A PREREQUISITE FOR LOCOMOTOR TRAINING TILT TABLE STANDING FRAME PARALLEL BARS

131. Paraplegic patients with lesion in lumbar or lower thoracic region can become functional ambulators.

132. LOCOMOTOR TRAINING STRATEGIES PUTTING ON & REMOVING ORTHOSIS ASSISTIVE DEVICE SIT TO STAND ACTIVITIES STATIC STANDING BALANCE WEIGHT SHIFTING IN STANDING SWING THROUGH PATTERN FOUR POINT GAIT

133. Teach patient procedure of putting on and removing orthoses initially done in supine & then sitting. Prescription of Assistive device . Forearm crutches are most often selected for patients with paraplegia. Advantages: lightweight, allow use of the hand without the crutch becoming disengaged, they fit easily into an automobile, improve function in ambulation and stair climbing Sit-to-stand activities should be practiced in the parallel bars using a wheelchair, then progressed to using the forearm crutches. Initially the patient is taught to pull to standing, using the parallel bars (a progression is made to using the wheelchair armrests to push to standing). Once in an upright position, the patient pushes down on the hands and tilts the pelvis forward in front of the shoulders. Return to sitting is the reversal of this position.

134. Standing from wheelchair with crutches : To begin this activity the patient first places the crutches behind the chair, leaning against the push handle. To assume a standing position with crutches, the patient moves forward in the chair, locks both knee joints, crosses one leg over the other, & then rotates the trunk and pelvis. Hand Placements on the armrests are reversed and the patient pushes to standing by pivoting around to face the chair. The reverse of this technique is used to return to the chair.

135. Static standing balance: The patient learns to balance in standing with the hips in hyperextension and the upper trunk, head, feet, and arms behind the pelvis. The feet are 3 to 5 inches apart. Weight shifting in standing: Patient tries controlling the pelvic position using UE support and positioning the head and shoulders forward ahead of the pelvis. Teach recovery to overcome and/or to prevent jackknifing from happening during ambulation. Jackknifing occurs when the patient’s center of mass (COM) falls anterior to the hips causing the patient to flex forward suddenly. Push-ups includes lifting the body off the floor using elbow extension and scapulae depression and protraction, tucking the head to gain added height, and controlled lowering of the body.

136. Swing-through pattern . From a balanced standing position with the hands posterior to the pelvis, the patient moves the hands forward causing the trunk to flex. Then the patient lifts up by extending the elbows and protracting/depressing the scapula and tucking the head. Gravity will cause the trunk and legs to swing forward. When the heels strike the ground the patient quickly extends the upper trunk and head, and pushes the pelvis forward to comeback to the starting position

137. Four-point pattern. This gait pattern is slower but safer than a swing-through pattern; three points are always in contact with the ground, as opposed to a swing-through pattern, in which there are times when only two points are in contact with the ground.

138. INCOMPLETE SPINAL CORD INJURY Guidelines for training: The LEs are maximally loaded for weight-bearing, minimizing or eliminating loading of the arms. Sensory cues provided are consistent with the task of walking (e.g., TM speed, manual cues to facilitate flexor or extensor muscle activation ). The posture, trunk, pelvis, and limb kinematics are coordinated and specific to the task of walking . Compensatory strategies for movement (i.e., hip hiking ) are minimized or eliminated with recovery of preinjury movement patterns as the goal.

139. It is difficult to provide task- and context-specific practice of stepping and walking for patients with the potential to walk but with extensive lower limb weakness. Ideally, practice needs to involve stepping and walking in an upright and weight bearing position. However, this may be difficult for patients with significant lower limb paralysis because often they require extensive physical assistance to remain upright and move their legs. Providing this assistance can be strenuous for physiotherapists and can cause injury to patients and therapists.

140. BODY WEIGHT SUPPORTED TREADMILL TRAINING ( BWS- TM) Overhead suspension with partial body weight support can be used to provide a more normal walking pattern without the need for physiotherapists to physically hold patients upright. It provides a way of enabling very disabled patients to engage in intensive gait practice using a relatively normal walking pattern. Electrical stimulation and robotics can be used to drive the legs. Alternatively, there are gait training devices incorporating motor-driven footplates which move the legs backwards and forwards on the spot in standing Walking with partial body weight support can be done overground or on a treadmill. Overground walking is achieved with a mobile suspension system which moves as the patient walks. These systems generally provide less stability because the entire apparatus moves with the patient in any direction. In contrast, the treadmill suspension system is fixed in place over the belt of the treadmill so there is usually no need to control the direction in which the patient walks. The speed and incline of the treadmill can be changed to accommodate a patient’s skill level. Treadmill walking reduces reliance of more independent walkers on physiotherapists, thus increasing the opportunity for practice.It also provides a means of encouraging patients to walk faster and with a more appropriate inter-limb coordination.

141. RECENT APPROACH - ROBOTICS REHABILITATION locomat RE- WALK ROBOTIC HAND EXOSKELETON

142. Physical Rehabilitation – Susan B. O’ Sullivan : 6 th Edition Essential Orthopedics – Maheshwari : 6 th Edition Management of SCI – Lisa Harvey https://www.physio-pedia.com/Spinal_Cord_Injury https://asia-spinalinjury.org/international-standards-neurological-classification-sci-isncsci-worksheet/ www.slideshare.net www.iscos.org.uk scireproject.com https://netvaerk.socialstyrelsen.dk/media/Kirby_NSS2018.pdf Neurogen SCI webinar(28/04/2020) REFERENCES

143. Thank You