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211 exam 1
Traumatic Spinal Cord injuries
| Question | Answer |
|---|---|
| spinal cord injury | Violent, momentary displacement or compression of spinal cord Forceful flexion, extension or rotation force on spine |
| mechanisms of spinal cord injury | Forceful flexion, extension or rotation force on spine Vertebral body can burst, puts pressure on cord Bone fragments can scatter into cord |
| Usually vertebral ____ along with SCI, but can have one without the other | fracture |
| extent of SCI may not be evident initially due to ____ ___ | spinal shock |
| complete vs incomplete SCI | Indicates whether axons in the spinal cord survive |
| Cord does not have to be ____ to sustain a “complete” injury | severed based on ASIA scale: |
| complete: | no motor or sensory at or below S4/5 |
| incomplete: | sensory or motor at or below S4/5 |
| tetraplegia/Quadriplegia | all cervical injuries |
| paraplegia | thoracic and lumbar injuries |
| spinal cord concussion | transient neurological deficit, fully recovers without apparent structural damage |
| causes of traumatic SCI | Vehicular – decreasing Falls – increasing Acts of violence – primarily GSW Recreation/Sports injuries – relatively stable |
| most preventable cause of traumatic SCI | diving into shallow water (4-6 ft deep) ~ 70% of all sports injuries flexion, cervical, accounts for 70% of injuries |
| recreational causes of SCI | Contact sports: football, wrestling High speed sports: snow skiing, surfing Falls from a height: trampoline, horse Diving into shallow water |
| what time of year do most traumatic SCI occur? | spring and summer |
| causes of non-traumatic SCI | Aortic aneurysms Tumors Radiation induced myelopathies Infections AV malformations Scoliosis / congenital OA, spinal stenosis, spinal surgery Spinal hematoma Cardiac arrest |
| transverse myelitis | infection of the spinal cord |
| causes of flexion SCI | Most common Head hits steering wheel/windshield; blow to back of head, trunk (head-on collision) |
| causes of compression SCI | Closely associated with flexion injuries Vertical/axial blow to back of head (diving, surfing, falling objects) |
| causes of hyperextension SCI | Strong posterior force (rear-end collision) Falls with chin hitting stationary object (older adults) |
| causes of flexion-rotation SCI | P-A force hits rotated vertebral column (rear-end collision with passenger rotated toward driver) |
| highest frequency of injury in the C spine | C5-7 |
| highest frequency of injury in T-L spine | T12-L2 |
| NLI | neurologic level of injury |
| ASIA | American spinal cord injury association |
| AIS | ASIA impairment scale |
| SCIs named by ___and assigned an ___ to ‘classify’ injury (letter grade) | NLI, AIS |
| neurologic level of injury (NLI) | lowest (most caudal) single segment of normal sensory AND motor function Must assign motor level, sensory level, R and L (can be asymmetrical) then assign overall LOI |
| complete SCI | no or few axons survive |
| symptoms of complete SCI | Complete loss of sensory and motor below LOI May have zones of partial preservation (ZPP) Small areas of intact motor, sensation Cord does not have to be completely transected |
| causes of complete SCI | Cord does not have to be completely transected GSWs, knife wounds, puncture injuries may lead to transection (and complete injury) |
| incomplete SCI | Sparing of some sensory and/or motor function below LOI Not necessarily meaningful, functional sparing |
| Must have motor and/or sensory function in ____ to be classified as incomplete injury | S4-S5 |
| brown Sequard syndrome | Damage to one side of cord, or greater damage to one side |
| what can cause brown Sequard syndrome | penetrating injury (GSW, stab wounds) Trauma with vertebral burst fracture |
| what is lost below the LOI in brown Sequard syndrome | Ipsilateral Sensory: light touch, deep pressure, proprioception Motor function (with spasticity) Contralateral Sensory: pain and temperature tend to look like a stroke pt |
| Relative ____ of symptoms more common than pure form of brown sequard syndrome | asymmetry |
| Preservation of ____ important for functional recovery | motor function in dominant hand |
| what parts of the cord are damaged in brown sequard syndrome | one half of cord is damaged (L or R) |
| what parts of the cord are damaged in anterior cord syndrome? | Damage to anterior, anterolateral portions of cord, preservation of posterior columns |
| what causes anterior cord syndrome | Trauma to cord itself: flexion and burst fractures Damage to anterior spinal artery |
| what is lost below the LOI in anterior cord syndrome? | Motor function Sensory – pain, temperature |
| what is preserved below the LOI in anterior cord syndrome? | Sensory – proprioception, light touch, deep pressure |
| recovery for anterior cord syndrome | less functional recovery than other syndromes This syndrome is pretty rare |
| central cord syndrome is caused by | Damage to central portion, sparing of peripheral |
| where does central cord syndrome most often occur? | cervical spine |
| who is central cord syndrome more common in? | in older people following neck extension injuries; can occur at any age, and with flexion injuries |
| symptoms of central cord syndrome | Motor weakness in UE > LE, Distal > proximal Sensory loss variable Pain, temperature > proprioception, vibration Dysesthesias (pain, burning) in UE common Sacral (B&B) sensory sparing usually exists |
| prognosis for central cord syndrome | functional recovery is good But hand function recovery is last, may be incomplete Correlated with age, spasticity, level of education |
| posterior cord syndrome | Rare Preservation of motor,sense of pain and light touch Loss of proprioception-wide base steppage gait pattern |
| sacral sparing | Sacral tracts are spared perianal sensation, "saddle area" toe flexors active First signs that cervical lesion is incomplete |
| conus medullaris syndrome | Damage to sacral cord and lumbar nerve roots within spinal canal |
| conus medullaris | Terminal end of cord, T12-L2 levels TERMINATES about L1) |
| what does the conus medullaris contain? | motor neurons of S4,S5 Important implications for B&B control, some sexual function |
| symptoms of conus medullaris syndrome | Variable motor and sensory loss LE Most people have flaccid paralysis in LE and areflexic (flaccid) bowel and bladder Some retain sacral reflexes Involvement usually bilateral, symmetric |
| conus medullaris syndrome is typically classified as ____ damage | LMN |
| upper motor neuron lesion | above T12, below T12 is LMN |
| characteristics of UMN | spastic injury, usually bowel and bladder maintence |
| characteristics of LMN | no spasticity, areflexive bowel and bladder=just leaks out Changed to LMN damage, usually not mixed |
| cauda equina syndrome is caused by | Injury to bundle of nerve roots (from L2-S5 levels) that extend through canal distal to conus medullaris (may have injury to both) Trauma or compression narrows vertebral canal Lumbar disc herniation, spondylosis |
| cauda equina is typically a ____ nerve root injury, but can affect cord too (UMN) | peripheral (LMN) |
| variability of cauda equina syndrome | Most have flaccid paralysis of LE, areflexic (flaccid) B&B Typically asymmetrical and incomplete |
| Outcomes with cauda equine syndrome depend on extent of injury, but greater potential for ___ nerve recovery than central | peripheral |
| spinal shock | no reflex or sensation or motor activity below lesion |
| how is temp control impaired with SCI? | hypothalamus can no longer control level of sweating. loss of internal thermometer. excessive diaphoresis above the level of lesion. |
| what level of SCI may need ventilator? | C1-3 (spontaneous resp), maybe C4 |
| what affects spasticity? | increased positional changes, increased temp, tight clothing, UTI |
| most common SCI complication | UTI often due to self cathing in unsterile environment |
| signs and symptoms of UTI | cloudy urine, incontinence, AD, Smelly, increases spasticity, chunky urine |
| bowel dysfunction treatment | digital stim-nursing |
| sexual dysfunction after SCI | very few men can sire children after SCI, women however, have no problem with fertility. Women may not be able to perceive labor. Psychologist usually discusses sexual issues. |
| what LOI does autonomic dysreflexia occur in? | lesions above T-6 |
| how long does AD last? | subsides after 3 years following injury |
| what causes AD | noxious stimulus below level of injury |
| signs and symptoms of AD | increased BP headache, bradycardia, profuse sweating, increased spasticity, HTN. |
| tx for AD | SIT UP, emergency, get rid of noxious stim, do not lie down |
| what can help with postural hypotension after SCI | compression stockings or wraps, abdominal binder |
| what causes heterotopic bone formation after SCI | related to microtrauma, over aggressive ROM |
| where does HO form? | extraarticular and extracapsular adjacent to large joints- hips knees, elbows and shoulders |
| early symptoms of HO | resemble thrombophlebitis-swelling, decrease ROM, erythema, local warmth |
| complications of SCI | contractures, DVT, pain, OA |
| what are contractures inlfuenced by? | spasticity |
| when is DVT most risk after SCI? | first 2 months |
| pain tx after SCI | TENS |
| what causes pain after SCI | damage to nerve roots dysesthesia-painful sensations below level of lesion Musculoskeletal pain |
| AD signs | slide 29 |
| AD intervention | Immediately bring patient to upright Identify and remove noxious stimuli Check clothing and catheter tubing for constriction, perform bowel program if impaction suspected |
| medical intervention for AD | Pharmacological management if BP > 150mmHg Address unmet medical need |
| when can upright activities be started after cervical injury? | once fracture site is stable |
| immobilization for cervical injuries | Tongs-Traction device attached to skull-12 weeks Turning frames and beds Stryker Frame-contraind-cardiac or respiratory secondary to being turned prone |
| roto rest kinetic treatment table | Table-continuous side to side rotation; Contraind.-claustrophobic or motion sickness. |
| halo | used the most-12 weeks, than cervical orthosis applied for 6 weeks (also Minerva cervical orthosis) |
| TSLO | Surgical intervention- restore alignment, prevention and stabilize Fx site. Decompression or fusion |
| 3 devices used for spinal alignment, stability, and internal fixation | Harrington compression rods Harrington distraction rods Weiss compression springs |
| respiratory assessment for SCI | Chest expansion-circumference at axilla and xiphoid -> Max Inhalation-max exhalation=normal (2.5-3 inches) Breathing pattern-check if using accessory neck muscles Cough (functional, weak functional, nonfunctional) Vital capacity-handheld spirometer |
| skin assessment for SCI | requent position changes and skin inspection, observation and palpation for increase in skin temp. Check also around halo orthotic |
| how are tone and DTR's measured? | 0 = absent 1+ = slight but depressed, low normal 2+ = normal 3+ = Brisk, may not be abnormal 4+ = very brisk, abnormal, clonus |
| C5,6 tendon reflex | biceps, brachioradialis |
| C7 tendon reflex | triceps |
| C6-T1 tendon reflex | finger flexors |
| L5, S1, S2 tendon reflex | hamstrings |
| L2, L3, L4 tendon reflex | quad |
| S1, S2 tendon reflex | Achilles |
| modified ashworth scale 0 | no increase in tone |
| modified ashworth scale 1 | Slight ↑, catch and release, min resistance at end range |
| modified ashworth scale 1+ | Slight ↑, catch, min resistance of < ½ motion |
| modified ashworth scale 2 | Marked ↑ in tone through most ROM but affected parts move easily |
| modified ashworth scale 3 | Considerable ↑ in tone, PROM difficult |
| modified ashworth scale 4 | Rigid flex or extension |
| MMT restrictions for quads | extreme cautions with shoulders |
| MMT restrictions for paras | hips |
| ROM restrictions for SCI | restriction for shoulders past 90 |
| diaphragmatic breathing | facilitate expiration-manual contacts on thorax |
| glossopharyngeal breathing | sipping or gulping using facial and neck muscles |
| lesions above ___ will have paralysis of inspiratory mm | C5 - require artificial ventilation |
| lesions from ___-___ will loose mm of expiration (abs, intercostals) and forced cough to expel secretions (external obliques) | C6-T12 (position of diaphragm compromised too) |
| airshift maneuver | max inhalation, close glottis, relax diaphragm allowing air into upper thorax- increase chest expansion by .5-2 inches – Christopher Reeves- |
| assisted cough | therapist pushes quickly inward and upward from epigastric area |
| ROM contraindications for paras | Trunk and hips motion (SLR > 60 degrees and hip flex >90 degrees with knee flex) contraindicated. Acutely |
| positioning for SCI pts | to prone if possible, and position shoulders out of patterns of comfort (IR,Add, Ext of shld; Flex of elbows, Prone of forearm and flex of wrists). May prone people with halo if okay with doc. They need pillows under the chest. |
| what not to range in SCI pts | Low back of Quads- helps with trunk balance Tight finger flexors-tenodesis |
| how much HS ROM needed for xfers and sitting balance | 100 deg |
| mm to strengthen with caution in quads | scap and shoulders |
| mm to strengthen with caution in paras | hips and trunk |
| mm to strengthen in tetras | emphasize ant deltoid, shoulder extensors, biceps and low traps, if present radial wrist ext. triceps and pects |
| mm to strengthen in quads | shoulder depressors, triceps and lat dorsi |
| benefits of mat programs | -improve strength, postural stability, balance and helps determine which functional method will work for specific tasks |
| requirements for functional ambulation for paras | have abdominals and erector spinae MMT grade 3/5 or better. (T-2 -T-8) are excluded usually. Full hip extension is essential. Adequate cardiovascular endurance Not obese |
| ambulation orthotics for T9-T12 | KAFO |
| ambulation orthotics for L3 and below | AFO |
| SCI standardized tests for pain, tone, ambulation, mobility | Pain- VAS, W/C User’s Pain Index Tone – Modified Ashworth Ambulating SCI – SCI-FAI: SCI Functional Ambulation Inventory (copy in Text) Mobility – FIM, SCIM - SCI Independence Measure |
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bdavis53102
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