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PT Management of SCI - Coggle Diagram
PT Management of SCI
Tetraplegia
C7 Tetra
Functional Outcomes:
- Manual w/c mobility (curbs, ramps and wheelies*)
- Indep mobility (transfers, bed, wt shifts)
- Personal ADLs, no assist
- Household ADLs, min assist
Rehab Focus:
- Bed mobility
- Level AND unlevel transfers
- Depression transfers/floor
- w/c mobility skills
- ADLs (bowel, ICs, dressing, showering, home mgmt)
- Driving
- Education
Important Muscles:
- Triceps (C6-C8*)
- Lats (C6-8)
- Pec major ( C6-T1)
- Pronator teres (C6-7)
- Extensor pollicis longus (C7-8)
- Extensor digitorum (C7-8)
- Serratus anterior (C5-7)
C8 (to T1) Tetra
Available Mvmts:
- Full innervation of UE muscles
- Fine coordination
- Strong Grasp
Important Muscles:
- Wrist flexors
- Flexor digitorum profundus and superficialis (C8-T1)
Functional Capabilities: Same as C7, just easier!
C7, C8, T1:
- still weak cough
- triceps function = improved w/c propulsion
- lat dorsi helps with trunk control -
partial hand function for wheelies
C6 Tetra
Functional Outcomes:
- W/c mobility (power/manual/power assist)
- Indep wt shifts (lateral and forward)
- Limited assistance needed fro transfers and ADLs
Rehab Focus:
- Level Transfers
- Bed mobility
- Higher level balance
- W/c skills
- ADLs (bowel/bladder, IC, dressing and showers)
- Education
- Driving with regular hand controls
Important Muscles:
- Extensor Carpi Radialis Longus (C6-7) - Wrist extensors!
- Biceps (C5-6)
- Lat dorsi (C6-8)
- Pec minor (C6-T1)
- Serratus Anterior (C5-7)
- Supinator (C6-7)
Goals:
- Indep at w/c level and live indep with min attendant care
- FIRST level with the POTENTIAL to be totally independent
- W/c skills very important (may not be ready for wheelies or wheelie on fly)
- Indep pressure relief
- Transfers- level surfaces and car transfers and commode transfers
C4 Tetra
Important Muscles:
- Diaphragm (C3-5*)
- Traps (C3-4, CNXI)
- Scalenes (C2-3, CNXI)
- Infraspinatus (C4-6)
- Rhomboids (C4-6)
Functional Outcomes:
- Vent weaning
- Power w/c mgmt.
- Indep wt shifts
- Indep directing all cares
- Limited self-feeding with MAS , BFO
Rehab Focus:
- Directing cares
- Resp mm training ( improve chest wall expansion)
- Education
- Assistive tech!!
- Mat exercises
- W/c mobility
- PROM LEs and AAROM UEs
Respiratory Hygiene :
- weak diaphragm, no intercostals and no abs
- normal chest expansion should be 2.5-3"
- GPB taught if needed (mainly C1-3)
- Coughing
- Heimlich Type- supine, sidelying, sitting
- Anterior Chest compression - supine
- Costophrenic assist in supine or sidelying
C5 Tetra
Functional Outcomes:
- Power mobility (hand drive/MAS)
- Indep wt shifts
- Indep directing all cares
- Assistance with ADLs
- Self feeding with U-cuff and built up utensils
Rehab Focus: -
Assist with ADLs
- Self-feeding with U-cuff and built-up tools
- Prop sitting
- Education
- Assistive tech
- Driving
- Manual w/c with power assist
- Recovery of upright when motor incomplete
Important Muscles:
- Biceps (C5-6)
- Brachioradialis (C5-6)
- Infraspinatus (C4-6)
- Deltoid (C5-6)
- Supraspinatus (C4-6)
- Pec major (C5-T1)
- Rhomboids ( C4-6
- Serratus (C5-7)
- Supinator (C5-6)
Primary Movements and Concerns:
- elbow flexion and shoulder flex/ABD
- very high risk of shoulder impingement due to poor scapular stability during GH mvmt
- Scapular winging is common
- Watch for elbow flexion contractures
- Need to maintain tenodesis in case of recovery of C6 is possible
C1-C3 Tetra
Functional Outcomes:
- Dependent for all ADLs
- power w/c
- Indep wt shifts
- Indep with directing all cares
- Envi controls
Equipment:
- Power tilt/recline w/c and manual
- Portable Vent
- Full-time attendant
- Life system
- ECU
- Driving is possible
- hoyer lift
- Van with lift
Important Muscles:
- Partial Diaphragm (C3-5*)
- Neck extensors (C1-3)
- Facial mm (CNs)
- SCM (C2-3 and CNXI)
- Scalenes (C2-3, CNXI)
- Traps (C3-5)
- Levator (C3-4)
Diaphragmatic Pacing System (DPS):
- Goal is to wean off ventilator
- Stimulate phrenic nerve or stimulate diaphragm directly (less invasive)
Paraplegia
Muscular Innervation (T and L-Spine:
- Intrinsic muscles of hand (T1)
- iliopsoas (L1-3)
- Quads (L3-4)
- HS (L4-S3)
- Tib anterior (L4-S1)
- Extensor hallucis longus (L4-S1)
- Gluteals (L5-S2)
- Gastro (S1-2)
Thoracic Injuries
T1-6:
- Full UE motion
- No abd function - Indep in all transfers
- Ambulation is usually physiologic walking only
T8-T12:
- Ab muscles (trunk support)
- May be community ambulator (crutches and KAFOs) but very high energy cost
- Usually chose w/c for mobility
Lumbar Injuries
L1-2:
- iliopsoas (active hip flexion)
- community ambulation is realistic
- still need w/c
L3-4:
- Quad activation!
- Indep ambulation (AFOs and crutches/cans)
- Not able to run
PT Management
:forbidden: Early in acute: same ROM restrictions as tetras Lumbar injury= NO SLR >60 deg and NO hip flexion >90 deg
Functional Skills:
- bed mobility
- transfers (level surfaces: lateral approach
- begin with w/ sliding board then do uneven surfaces)
- Floor transfers
- Car transfers
- floor <--> W/c (frog approach), back approach, forward technique
W/C Mobility:
- obstacle negotiation
- Wheelies! (on the fly, 360 turns, down inclines, stairs, curbs
- Wheelie on rough terrain
- Safe falling techniques: tuck and turn head to side, DON'T put arms back, protect face from falling legs
Brace Walking:
- VERY high energy expenditure
- Is it reasonable for that person?
- Consider goals, time frame, length from injury, body type, person skin care and safety
Requirements for Walking :
- SLR 100+ deg to don/doff orthotics
- Tight mid and lower back
- 5-10deg hip ext w/o active hip ext pt leans on Y lig
- Full knee ext required
- 5-10 dege ankle DF
- LE kinesthesia
- LE bone density ( no less than 65-70% of normal)
- Indep in basic mobility