nullPhysical Therapy for Adults with Traumatic Spinal Cord InjuryPhysical Therapy for Adults with Traumatic Spinal Cord InjuryAcknowledgement:
International educators for the
China Self-Directed Learning Modules MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjuryTraumatic Spinal Cord Injury (SCI) Traumatic Spinal Cord Injury (SCI) Majority of traumatic SCI occurs in young adult males
Traumatic spinal cord injury is a non-progressive pathology
Motor and sensory function on both right and left sides is determined by the level of injury
A patient with C6 level injury has intact motor and sensory function bilaterally at and above the C6 level MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjurynullMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjuryTraumatic Spinal Cord Injury Traumatic Spinal Cord Injury Based on the International Standards for Neurological Classification of Spinal Cord Injury (published by the American Spinal Injury Association, ASIA), patients can be grouped in five categories depending on the severity of impairment from A to E
A is complete spinal cord injury with no motor or sensory function below the level
E is normal even though patient may have initially exhibited symptoms of spinal cord injury, but is now normal
MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjurynullASIA Impairment Scale MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjuryTraumatic Spinal Cord Injury Traumatic Spinal Cord Injury Definitions
Paraplegia – is defined as an impairment or loss of motor and/or sensory function of all or part of the trunk and both lower extremities
Tetraplegia – is defined as an impairment or loss of motor and/or sensory function in both upper extremities in addition to trunk and both lower extremities; respiration is often affected MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjurySpinal Cord AnatomySpinal Cord AnatomySpine has 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal spinal nerves (levels)
Spinal cord ends around L1 vertebral level
The cervical spinal levels control sensory and motor function of head/neck and upper extremities and the diaphragm (phrenic nerve, C3-5)
The thoracic spinal levels control chest and abdominal muscles and sensory function of the trunk
The lumbar spinal levels control motor and sensory function of the lower extremities
The sacral spinal levels control the sensory function of the back of lower extremity and buttocks, bowel and bladder control, and sexual functionMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjurySymptoms of Spinal Cord InjurySymptoms of Spinal Cord InjuryMotor impairment
Paralysis or weakness of affected muscles (following the myotomes)
Sensory impairment
Loss or impaired sensation of affected areas (following the dermatomes)MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjurynullDermatomesMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjurySymptoms of Spinal Cord InjurySymptoms of Spinal Cord InjuryAutonomic dysreflexia
Often occurs in patients with high level spinal cord injury (lesion level above T5)
Caused by distended bladder, distended rectum, blocked catheter, or other stimuli about the sacral innervated area
Patient shows flushed face, pounding headache, very high blood pressure, sweating above the level of injury, piloerection, slow pulse, and nasal obstruction (nasal voice)
Autonomic dysreflexia is a medical emergencyMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjuryPiloerection or goosebumps on a human arm http://en.wikipedia.org/wiki/Goose_bumps Symptoms of Spinal Cord InjurySymptoms of Spinal Cord InjuryAutonomic dysreflexia is managed in the following way
Don’t let the patient lie down
Position the patient in sitting
Check the catheter or tube for blockage
Check the feet positions for twisted ankles or pinched toes
Empty leg bag for urine if it is full
Obtain immediate medical help
MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjurySymptoms of Spinal Cord InjurySymptoms of Spinal Cord InjurySpasticity
Most common in patients with cervical and thoracic level injuries
Occurs below the level of lesion after the spinal shock period
Poor venous return below the level of lesion that may result in orthostatic hypotension
Bradycardia
Impaired body temperature control
Unable to regulate body temperature in response to environmental changes (stay under sun)
Impaired ability to sweat below the level of lesion
Impaired respiratory function
Decreased tidal volume and vital capacity
Impaired cough
MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjurySymptoms of Spinal Cord InjurySymptoms of Spinal Cord InjuryBladder and bowel dysfunction for those patients with S2-4 involvement
If not managed properly, patient will have urinary tract infections and ultimately kidney failure
Must drink sufficient fluid and eat a high fiber diet
Most patients can be trained to manage their bladder and bowel problems, including a schedule to void (every 4 hours) and to move bowel (once a day or once every other day)
Sexual dysfunctionMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjurySymptoms of Spinal Cord InjurySymptoms of Spinal Cord InjurySecondary complications
Pressure sores
Deep vein thrombosis
Pain
Contracture
Heterotopic ossification
Osteoporosis
MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjuryPrognosisPrognosisAfter stabilizing the spinal (vertebral column) injury, the patient should begin a comprehensive rehabilitation program
Life expectancy is related to the severity of impairment
Individuals with spinal cord injury classified between the *ASIA A to C levels and those with tetraplegia have shorter life expectancies
Ref: American Spinal Cord Injury Association (ASIA) Classification
http://www.asia-spinalinjury.org/elearning/ISNCSCI_Exam_Sheet_r4.pdf MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjurynullMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjuryMedical ManagementMedical ManagementEmergency care
Keep the neck and trunk stabilized (use a cervical collar and back board) during transportation
Surgery to stabilize fracture
Often involves immobilization after the surgery (Halo device for cervical spine and body cast/jacket for thoracic or lumbar spine)
Drugs
To manage spasticity and pain
To manage infectionsMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjuryPhysical Therapist’s ConcernsPhysical Therapist’s ConcernsPatients with traumatic spinal cord injury often develop pneumonia, urinary tract infection, and pressure sores
Physical therapists must teach patients
Ways to achieve a productive cough
Proper bladder management program
Daily skin inspection
MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury物理治疗检查评估物理治疗检查评估确保脊髓损伤的位置是固定好的
病人可能存在其他损伤部位
确保病人在医学上是稳定的
关注生命体征
评估患者末梢循环情况,特备注意足部(桡动脉与足上动脉对比)
评估呼吸功能(肺活量)
吸气时相关肌肉 - 膈肌(膈神经, C3-5), 肋间外肌和辅助呼吸肌(T1-11), 腹肌
呼气时相关肌肉 - 腹肌, 肋间内肌, 膈肌
辅助呼吸肌对呼吸的影响 - 分别检查坐位、卧位下的情况
判断患者是否有呼吸机依赖MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury物理治疗检查评估物理治疗检查评估评估是否能够产生有效的咳嗽
咳嗽需要声门和呼吸肌的协调运动
评估 会话情况(发声情况)
评估 言语功能
患者可能在事故后存在脑外损伤,所以其言语功能可能受到损害
评估 感觉功能
基于感觉评估结果
遵循ASIA量
MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury物理治疗检查评估物理治疗检查评估评估 肌力
基于肌力评估结果
使用MMT检查10块关键肌
MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury物理治疗检查评估物理治疗检查评估评估 肌张力
检查损伤节段以下的痉挛情况
颈髓或高位胸髓损伤患者常有痉挛
评估 运动范围
踝关节必须能背屈达一半以确保可以站立
腘绳肌必须有足够长度才能确保能穿裤子 (伸膝起码达110度 )
髋关节后伸必须达到10度才能确保步行
必须要有全范围的肩关节后伸、外旋、内收,肘关节伸,前臂旋后,腕关节的背伸来确保能坐起
MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury物理治疗检查评估物理治疗检查评估肌腱的检查
查看指屈肌腱是否紧张短缩
当病人伸腕时,手指会有自动的屈曲(功能性抓握)
MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injurynull有效长度的指屈肌腱才能允许患者有功能性抓握MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury物理治疗检查评估物理治疗检查评估评估 皮肤完整性
是否发红
局部温度升高、肿胀
开放性伤口
对于长期坐在轮椅上患者必须检查:
双侧坐骨结节
骶骨
尾骨
对皮肤易产生压疮部位要尤为关注(下一张幻灯片) MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injurynull容易产生压疮部位MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury物理治疗检查评估物理治疗检查评估直肠和膀胱功能
患者能否自己管理大小便或者自己通过辅助用品来清洁?
功能性技能
翻身
坐起
床-轮椅转移
站立
步行-取决于损伤程度
MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury物理治疗检查评估物理治疗检查评估评估患者出院
和家庭生活辅助用品
使用FIM量表或其他合适量表
* Ref: http://www.rehabmeasures.org/lists/rehabmeasures/dispform.aspx?id=889 MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjurynullMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury创伤性脊髓损伤患者一般管理规则创伤性脊髓损伤患者一般管理规则持续监测生命体征和循环情况来防止体位性低血压
强化损伤平面以上的肌肉力量
教会患者头部/躯干和上肢对于功能性活动的关系
患者积极寻找新的方式来达到完成功能性活动的目的
患者有体温自我调节障碍--当病人训练时保持治疗区域舒适MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury物理治疗师干预的目标物理治疗师干预的目标患者功能上独立
高位颈段损伤患者应当教会其直接照顾者
腰段和低胸段损伤的患者以独自转移为目标
慢性脊髓损伤患者,不管损伤平面在哪,都应选择轮椅来作为移动的主要工具来节省体力
患者应知道所有技能来预防压疮的发生与发展MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury物理治疗师的干预物理治疗师的干预呼吸功能管理
皮肤护理
早期肌力训练和关节活动度训练
床上运动
转移
坐起及坐位时活动
站立及站立时活动
步行
MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury呼吸功能管理呼吸功能管理如果可以,安静状态下使用腹式呼吸模式
深呼吸训练
吞咽呼吸 – 使用声门来吞咽一口空气到肺里面,以此增加吸气量。对于呼吸机依赖的患者可能有用
胸壁活动
在坐位下考虑腹肌的支持 (举例, 用一根绳索) 来改善静脉回流和增加血容量
体位引流,叩诊,振动排痰,吸痰
人工辅助咳嗽
治疗师或者患者把手放在上腹部
咳嗽随着手向上向内的压力同时快速进行MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjurynullAssisted CoughMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury呼吸功能管理呼吸功能管理高位颈段损伤患者( C3 及以上) 将依赖呼吸机进行呼吸
C3-5 损伤患者可能要在夜间睡眠时使用呼吸机 MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury皮肤护理皮肤护理患者(或护工)应该检查有压疮倾向的皮肤区域,至少一天一次
高位颈段损伤患者应当两小时翻身一次
轮椅应该有恰当的压力缓冲垫
骨盆应该放置在中立对称的位置上
在轮椅上患者应该每15分钟缓解下受压部位的压力(独自或者依靠帮助)
撑起
侧倾
前倾MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injurynull侧倾Side Lean撑起Push Up前倾Forward LeanMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjurySkin CareSkin CareIf the patient develops an ulcer, the patient should be referred to a wound care specialist to facilitate healing and to prevent infection
Patient should not put pressure on the ulcer until it is healed - for example, a patient with a right greater trochanter ulcer cannot lie on the right side until the wound is healedMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjuryEarly Strengthening and Range of Motion ExercisesEarly Strengthening and Range of Motion ExercisesStrengthen all innervated muscles
Watch for substitution
For example, patient may use shoulder external rotators to substitute for elbow extensors
Do not stretch
Finger flexors to protect tenodesis
Lower trunk muscles so that patient can lean on ligaments for sitting
Stretch
Hamstrings - to assure a straight leg raise to 100 degrees
Hip flexors – to assure patient has 10 degrees of hip extension
Ankle plantar flexors – to assure patient has 10 degrees of dorsiflexion
MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjurySitting Sitting Patient usually experiences postural hypotension in sitting or standing
Initially, bring the patient to sitting slowly
Use an abdominal binder and elastic (pressure) stockings to assist venous return
Gradually elevate the head and upper trunk in bed
May also use a tilt-in-place wheelchair with elevating leg rests or a tilt table
Biomechanical principles for mat activities
Head-hips relationship
Unweight the body part first before moving it
Use momentum MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjurySittingSittingBe aware that the patient is using very small muscles (in upper extremities) to move a heavy load (the whole body)
Protect patient’s shoulders and wrists from Day 1 of physical therapy - patients with chronic spinal cord injury often experience shoulder problems
For scooting sideways or up and down in bed (or on mat), patients need to clear buttocks from the supporting surface in order to move - hence, patients with short arms and a long trunk will need push-up blocks for mat activities
Patient need to learn the new center of mass for functional movementsMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjurySitting Sitting After the patient can tolerate sitting in the upright position, the patient can begin mat activities that may include
Rolling from supine to prone
Prone position
Prone on elbows
Prone to supine
Supine to long sitting
Scooting side to side in long sitting
Scooting up and down in long sitting
MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjurynullLong sitting, lean on upper extremities, shoulders in extension and external rotation, and elbows extended MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjurynullMoving sideways in long sittingMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjurySitting – Balance TrainingSitting – Balance TrainingPatient learns to use trunk ligaments
Patient in long sitting on mat
Lift one arm first
Lift both arms
Catch a ball with both arms
Patient sits on a bench with feet flat on the floor and then
Lift one arm
Lift both arms
Try to catch a ball
MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjuryTransfer Mat to WheelchairTransfer Mat to WheelchairTetraplegia
Usually needs a sliding board
Paraplegia
Often may do without a sliding board
Park wheelchair at 45 degree angle to the mat and lock the wheels
Remove arm rest and leg rest next to mat
Use momentum to assist transfer
Push down on supporting surface with both arms and at the same time twist head and trunk away from wheelchair
Patient with lower extremity spasticity can bear weight on legs to ease weight on upper extremitiesMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjurynullPatient with paraplegia transferring from mat to wheelchair at the same heightMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjurynullPatient with paraplegia transferring from mat to wheelchair to a higher surface MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjurynullPatient assisted sliding board transfer: #1 - therapist assists the patient; #2 - patient place left hand on sliding boardMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjuryStandingStandingStanding program is good for the skeletal system and the cardiovascular system
Check patient’s blood pressure in sitting first
Patient may need abdominal binder and elastic stockings
Start in parallel bars
Patient may need lower extremity orthotics and/or spinal orthotic
Patient first presses down on parallel bars, lifts one arm, and then lifts both armsMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjuryWalkingWalkingMust determine if walking is a reasonable goal
For patients with a spinal cord injury, walking consumes a tremendous amount of energy
Patients have strong upper extremity muscles, no contractures, and strong motivation are candidates for walking training
Most patients are not going to be community ambulators
Potential gait patterns
Swing to
Swing through
Four point
Two pointMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjuryWalkingWalkingPatients with a T12 above level will need bilateral knee and ankle orthoses (e.g. Craig Scott orthoses) to walk using a swing through or swing to gait
Patients with a T12 or below level will need bilateral knee and ankle orthoses and can walk with a reciprocal gait pattern (four point or two point)
Patients with an L4-5 level or below will need ankle foot lorthoses to walk reciprocally and are best candidates for reciprocal gait training
Ref:
Uustal H. and Baerga E Orthotics in Physical Medicine and Rehabilitation Board Review Cuccurullo S, Editor. New York: Demos Medical Publishing; 2004
MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjuryWheelchair Wheelchair Patients with a high cervical level injury may have difficulty sitting upright, due to postural hypotension, and will need a wheelchair with a reclining backrestMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjuryWheelchair Wheelchair Wheelchair should be fitted for each patient. It is not one size fits all patients.
Patient should have a proper cushion providing sufficient pressure relief to ischial tuberosities.
For patients who manually propel wheelchairs, lightweight and durability are two main considerations. MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjuryWheelchair Propulsion Techniques Wheelchair Propulsion Techniques Use a semicircular pattern
Let the hand fall below the push rim during recovery
Take a long, smooth propulsive stroke that the patient grasps and pushes as much of the push rim as possible
Minimize the cadence and peak forces applied - slow, long pushes
Manual wheelchair users often develop shoulder and wrist problems due to repetitive use
Prevent these injuries by teaching the patient correct and biomechanically efficient propulsion techniques
Reduce shoulder forces and moments during propulsion (protect shoulders)
Use of all upper extremity muscles for propulsion (shoulder, elbow, wrist, and fingers)MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjurynullSemi-circular method of propulsionMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury