Spinal cord injury (sci) Rehab

Rehabilitation for spinal cord injury

1. Spinal Cord Injury (SCI) [Part 1: Brief Overview] By: Gan Quan Fu, PT

2. Contents Introduction Overview of Spinal Cord Classification and Symptoms in Patient’s with Spinal Cord Lesion Clinical Manifestations Physiotherapy Examination Physiotherapy Intervention Summary References By: Gan Quan Fu, PT

3. Introduction Low incidence, high-cost disability requiring tremendous changes in an individual lifestyle Divided into 2 categories: Traumatic injuries (MVA, Fall, Gunshot etc.) Nontraumatic damage (Thrombosis, embolus etc.) Typically divided into 2 broad functional categories: Tetraplegia Paraplegia By: Gan Quan Fu, PT

4. Overview of Spinal Cord By: Gan Quan Fu, PT

5. Anatomy 31 pairs spinal nerve 8 Cervical 12 Thoracic 5 Lumbar 5 Sacral 1 Coccygeal Spinal Tracts Ascending Tracts (Sensory) Spinothalamic Dorsal Column Tract Spinocerebellar Tract Descending Tracts (Motor) Lateral Corticospinal Anterior Corticospinal By: Gan Quan Fu, PT

6. Spinal Tracts By: Gan Quan Fu, PT

7. Spinal Tracts By: Gan Quan Fu, PT

8. Spinal Tracts By: Gan Quan Fu, PT

9. Ascending Tracts Tracts Function Spinothalamic Tracts (Lateral) Pain & Temperature Spinothalamic Tracts (Anterior) Light Touch & Pressure Posterior Column Pathway Deep touch & pressure Proprioception Vibration sensation Spinocerebellar Tracts Posture and Coordination By: Gan Quan Fu, PT

10. Ascending Tracts By: Gan Quan Fu, PT

11. Descending Tracts By: Gan Quan Fu, PT

12. Classification and Symptoms in Patient’s with Spinal Cord Lesion By: Gan Quan Fu, PT

13. Designation of Lesion Level Important for clinician to accurately determine the extent of neurological impairment in terms of motor and sensory loss. American Spinal Injury Association (ASIA) had created the International Standards of Neurological Classification of Spinal Cord Injury. Standardize the way in which severity is determined and documented. Better communication between and among professionals Provide guidance for establishing prognosis Important tools for clinical research trials By: Gan Quan Fu, PT

14. Dermatome By: Gan Quan Fu, PT

15. Myotome By: Gan Quan Fu, PT

16. Myotome By: Gan Quan Fu, PT

17. Complete Injury, Incomplete Injury and Zone of Partial Preservation Complete Injury No sensory or motor function in lowest sacral segments (Determine by Anal Sensation and Voluntary External Anal Sphincter). Incomplete Injury Having motor and /or sensory function below the neurological level including S4 & S5 . Zones of Partial Preservation Having motor and /or sensory function below the neurological level but no function at S4 & S5 . By: Gan Quan Fu, PT

18. ASIA Impairment Scale By: Gan Quan Fu, PT

19. Clinical Syndromes Central Cord Brown- Sequard Anterior Cord By: Gan Quan Fu, PT

20. Central Cord Syndrome Result of compressive forces which give rise to hemorrhage and edema in central aspect of cord. More severe neurological involvement of upper extremities than lower extremities. Varying degrees of sensory impairment but less severe than motor deficits . Normal sexual, bowel and bladder function Typically recover the ability to ambulate with some remaining distal upper extremities weakness By: Gan Quan Fu, PT

21. Brown- Sequard Syndrome Damage to one side (causes: Penetration wound) Asymmetrical clinical features. Ipsilateral side of lesion  Loss of sensation in dermatome segment in the level of lesion (depending on area involve) Contralateral side of lesion  Loss of pain and temperature if damage to spinothalamic tracts, loss begins several dermatome segments below. By: Gan Quan Fu, PT

22. Anterior Cord Loss of motor function ( corticospinal tract); Loss of sense of pain and temperature ( spinothalamic tract) Proprioception, Kinesthesia and vibratory sense are generally preserved By: Gan Quan Fu, PT

23. Clinical Manisfestation By: Gan Quan Fu, PT

24. Spinal Shock Period of areflexia after SCI Relates to the loss of all neurological activity below the level of injury. This loss of neurological activity include loss of motor, sensory, reflex and autonomic function . The mechanism for spinal shock involves the sudden loss of conduction in the spinal cord as a result of the migration of potassium ions from the intracellular to extracellular spaces. Return of reflexes between 1-12 months post injury are characterised by hyper- reflexia , or abnormally strong reflexes usually produced with minimal stimulation. Inter neurons and lower motor neurons below the SCI begin sprouting, attempting to re-establish synapses. By: Gan Quan Fu, PT

25. Autonomic Dysreflexia Also known as hyperreflexia , O ver-active Autonomic Nervous System, which causes an abrupt onset of excessively high blood pressure . Usually due to compression of anterior cord By: Gan Quan Fu, PT

26. Other Direct Clinical Manisfestation Postural Hypotension Impaired Temperature Control Respiratory Impairment Spasticity Bladder and Bowel Dysfunction Sexual Dysfunction By: Gan Quan Fu, PT

27. Indirect Impairments and Complications Respiratory complication (such as pneumonia) Pressure sores Deep Vein Thrombosis Contractures By: Gan Quan Fu, PT

28. Prognosis By: Gan Quan Fu, PT

29. Prognosis Influences on potential for recovery: Degree of pathological changes imposed by trauma Precaution taken to prevent further damage ( eg during rescue) Prevention of additional compromise of neural tissue from hypoxia and hypertension during acute management. Formulation of prognosis is initiated after spinal shock has subside and is guided by whether or not the lesion is complete (in complete lesion, no motor improvement is expected other than which may occur from nerve root return.) Good prognosis for incomplete lesion. Improvement usually begins after the cessation of spinal shock. In time, rate of recovery will decrease and plateau will be reached. When no new muscle activity is observed for several weeks or months, no additional recovery can be expected. By: Gan Quan Fu, PT

30. Physiotherapy Examination By: Gan Quan Fu, PT

31. Physiotherapy Examination Respiratory Examination Function of respiratory muscles Chest Expansion Breathing Pattern Cough Vital Capacity Integument Sensation Tone and Deep Tendon Reflex Manual Muscle Test and Range of Motion Functional Status By: Gan Quan Fu, PT

32. Physiotherapy Intervention By: Gan Quan Fu, PT

33. Physiotherapy Intervention(Acute Phase) Emphasis on respiratory management Prevention of indirect impairments and complications Maintaining ROM Facilitate active movement in available musculature By: Gan Quan Fu, PT

34. Physiotherapy Intervention(Acute Phase) Respiratory Management Deep Breathing Glossopharyngeal Breathing Airshift Maneuver Strengthening Exercise Assisted Cough Abdominal Support Stretching, chest physiotherapy etc. Range of Motion and Positioning Selective Strengthening Orientation to the Vertical Position By: Gan Quan Fu, PT

35. Physiotherapy Intervention (Active Phase) Emphasis of treatment on maximizing functional independence Initially includes basic skills eg : bed mobility, transfer and wheelchair mobility Progress to skills necessary for work, home and community reentry. Individuals who are not able to accomplish specific functional task should be educated on how to instruct another person to perform task for them ( eg : those with high cervical lesion) By: Gan Quan Fu, PT

36. Physiotherapy Intervention (Active Phase) Continue Rx as in acute phase Educate patient on self skin inspection (with mirror) Mat Activities Rolling Prone on elbows Sitting Transfers, etc. Prescriptive wheelchair Wheelchair Skills Ambulation Functional Electrical Stimulation Educate on prevention, health promotion, fitness and wellness. By: Gan Quan Fu, PT

37. Take Home Message There is no specific recipe of treatment for SCI patients. ‘All intervention planned comes with appropriate reasoning and justification base on your assessment/examination’ By: Gan Quan Fu, PT

38. References O’Sullivan. S.B. and Schmitz. T.J. (2008) ‘Physical Rehabilitation’, 5 th edn . Philadelphia; F.A. DAVIS COMPANY. By: Gan Quan Fu, PT

39. By: Gan Quan Fu, PT