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Spinal Cord Injury - Coggle Diagram
Spinal Cord Injury
Overview and Etiology
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MVA=38% SCIs, Falls=30.5% (less than 38% of all SCI are non-traumatic- most are traumatic)
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Types of SCI :!:
:star:Tetraplegia: Impairment or loss of motor and/or sensory function in cervical segments including arms, trunk, leg and pelvic organs
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:star: Paraplegia: Impairment or loss of motor and/or sensory function in the thoracic, lumbar or sacral segments of the spinal cord
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Designating Lesion Level
How to? :fast_forward: ASIA - American Spinal Injury Association (ISNCSI) and use of AIS (ASIA Impairment Scale)
Sensory:
-28 dermatomes
-testing LT and PP
Scoring
0= if unable to distinguish sharp vs dull
1= can discriminate but not the same as the face (greater or less intensity) (must be 8/10 correct)
2= intensity if sharpness is same as the face
Motor:
-10 key muscles (20 total) (C5-T1 and L2-S1)
-To determine motor level is the lowest myotome with key muscle has 3/5 provided that the muscle function in the key muscle rostral (above) is 5/5 or normal sensory 2/2 if no key muscle there then use that intact sensory level to assume motor intact there too.
If contracture present: if pt exhibits >50% of normal ROM, the muscle function can be graded thru pt available range with same 0-5 scale. If ROM limited to <50% normal ROM, then NT should be documented
:!!:If NLI in C1-C4, T2-L1 and S2-S5 the motor level is defined as the same as the sensory level :!!:
Special Grading = a * on the number indicates non-SCI injured reason for strength difference THEN must explain in comment box
ZPP: only use when absent motor (VAC) OR sensory (no DAP, LT or PP in S4-5) bc means injury is complete
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Clinical Syndromes
Anterior Cord Syndrome: often due to flexion injury of C-spine, Loss of motor function (corticospinal tract) and loss of pain and temperature (spinothalamic tract) but dorsal columns is preserved
Central Cord Syndrome: Most common incomplete injury, caused by hyperextension or narrowing of the spinal canal, the UE are more affected than the LE and pt MAY be able to walk and may have some sacral tract preservation but UE fine motor will remain impaired
Brown Sequard Syndrome: IL sensory loss at and below level of lesion (Dorsal columns) and CL loss of pain and temperature starting a few levels below the lesion (spinothalamic tract)
Cauda Equina Injury: Spinal cord tapers to from Conus medullaris and ends at L1-2 below is the cauda equina
Cauda equina injury is often incomplete due to number of nerve roots running there and large surface area, will result in LMN injury with peripheral nerve damage
There is chance of recovery
Impact of SCI
Spinal Shock:
Define: follow immediately after SCI, period of areflexia
-Absent of all reflex activity, flaccidity, and loss of sensation and motor function below level of injury and may last 72hrs to weeks
-Absence of reflex activity and impaired autonomic regulation
Return of bulbspongious (cavernous) will indicate spinal shock is resolving and will appear much before DTRs retur
Sacral Sparing: signs of perianal sensation (DAP) or external anal sphincter contraction (VAC) and is the first sign an injury is incomplete
Autonomic Dysreflexia
Defined as: Uncontrolled sympathetic response in pt with SCI T6 and above (50-70%) and occurs in BOTH ISCI and Complete SCI. May result from NON-traumatic causes
:anger:Pathophysiology: Dramatic rise in blood pressure, usually due to noxious stimuli and bc loss of signal from brain getting to areas below injury there is unregulated SNS response below NLI there is unregulated PSNS response above the lesion = medical emergency of imbalanced NS drive
:warning: Signs and Symptoms of AD: :warning:
- Hypertension (rise by 20-40mmHg in SBP)
- Bradycardia
- Headache
- Nasal Congestion!
- Flushing and sweating of skin above lesion
- Pale/dry skin below lesion and maybe goosebumps
Things that may cause a pt to go into A.D.:
-Bladder distention = #1 in most cases
-Fecal impaction or rectal distension
-Fractures, dislocations or HO
-Any noxious stimuli --> ingrown toenail, toes cramped in shoes, fold in pants, PDE5 meds,
Intervention:
- Bring them to sitting (if in supine) 90 deg and lower legs
- Check BP every 5 min
- Check bladder and then bowel
- Loosen tight clothing - wraps, abdominal binders, shoes
- Check body for irritating stimuli
- Drug therapy- apply (with gloves) 1 in of nitropaste one inch above injury and wait till BP normalizes and then wipe off! This is now better than sublingual nifedipine since that will decrease BP but then pt passes out
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Spastic Hypertonia
UMN Syndrome: spasticity, muscle spasms, abnormally high tone, hyperactive stretch reflexes and clonus = all terms are INTERCHANGEABLY used
Defined as: imbalance btwn excitation and inhibition, anterior horn cell may become hyperexcitable, descending suprasegmental signals altered/eliminated after SCI and there is changes in afferent input
- There is gradual increase in first 6 mos. after injury but plateau reached at 1 year
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Cardiovascular Impairments:
- in Cervical SCI - loss of sympathetics and PSNS is unreigned
- PSNS causes bradycardia, dilation of peripheral vasculature below level of lesion and often results in orthostatic hypotension during early transitions
-Postural hypotension: caused by loss of vasoconstriction control and lack of muscle tone for muscle pump. Results in dizziness and fainting due to reduced cerebral blood flow-Related to edema of legs/ankles/feet
-Allow slow progression for adaptation --> elevate HOB, reclining w/c,, tilt table, standing frame -Medications: Midodrine used to increase BP by blocking ephedrine for BP
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Pulmonary Impairment
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Primary muscles of inspiration:
- diaphragm (only if at least a C5 injury)
- Scalenes and intercostals
- Accessory muscles: SCM, pecs, serratus, traps, levator, abs
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Without abdominal wall support, abdominal viscera shifts down and so there is a lower resting position of the diaphragm and makes expiration less passive
- Decreased expiratory reserve volume
- Decreased cough effectiveness
- Decreased ability to expel secretions
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Prognosis and Treatment
PT Interventions:
- Inspiratory muscle training
- Self assisted cough
- GPB (higher cervical)
- Pressure relief (every 15 min)
- Strengthening
- Balance
- Transfers
- Mobility
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PT Examination:
- Doc lesion level and AIS Impairment Scale
- Note respiratory exam and function (Normal chest wall expansion= 2.5 to 3 in at xiphoid process
- Cough assessment
- Integumentary
- ROM
- Selective Stretching
- Functional Status