PTA 100 Day16
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Transcript PTA 100 Day16
Concorde Career College
Physical Therapist Assistant
PTA 150: Fundamentals of Treatment II
Day 13 & 14
Spinal Cord Injury
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Lesson Objectives
Describe the pathophysiology of spinal cord injury
Describe physical and neurological disorders
associated with spinal cord injury
Identify functional outcomes for patients with spinal
cord injury at various spinal cord lesion levels
Describe physical therapy treatment interventions
for patients with spinal cord injury
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Spinal Cord Injury
11,000 new SCI cases in the US yearly
Etiology: traumatic vs. nontraumatic
Traumatic is most common – MVA, fall, GSW
Nontraumatic – usually result from disease or
pathological influence
Vascular malfunctions (AVM, thrombosis, embolis…)
Vertebral subluxations (secondary to RA or DJD)
Infections such as syphilis or transverse myelitis
Spinal neoplasms
Multiple sclerosis, amyotrophic lateral sclerosis
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Mechanism of Injury
Indirect force produced by head or trunk movement
Flexion force (head-on collision; blow to back of
head)
Lateral flexion force
Compression force (diving, falling objects…)
Hyperextension force (strong rear-end collision, fall
hitting chin …)
Flexion and rotational force (rear-end collision with
passenger rotated towards driver)
Direct force trauma
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Types of Injury
Complete (ISNCSCI)
No motor or sensory functions is preserved in the
sacral segments S4 to S5 (anal sensation and
voluntary external and sphincter contraction)
Partial/Incomplete
Partial motor or sensory functions below the level of
lesion
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Spinal Cord Injury (SCI)
Partial or complete
spinal cord lesion may
result in:
Paralysis
Paresis
Sensory loss
Altered autonomic
nervous system
function
Altered reflex activity
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Spinal Cord Injury (SCI)
Injury often accompanied by:
Fracture of the vertebra, body, laminae, spinous
process
Stretched or torn ligaments
Disc herniation
Disk compression
Malalignment of spinal vertebrae
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Designation of Lesion Level
American Spinal Injury Association (ASIA)
International Standards of Neurological Classification
of Spinal Cord Injury (ISNCSCI) – standardizes the
way in which severity of injury is determined
Neurological Level – most caudal level of spinal
cord w/ normal motor & sensory function bilaterally
Motor Level – most caudal level of spinal cord w/
normal motor function bilaterally
Sensory Level – most caudal level of spinal cord w/
normal sensory function bilaterally
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ISNCSCI Scoring
Motor
Most caudal segment with normal motor function (B)
Uses the same scale as MMT
Cannot test one muscle and assume this represents
an entire myotome
Sensation
Defined in the same way in terms of sensory function
Usually tested with light touch and pin prick
0 = absent,1 = impaired, 2 = normal
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ASIA Impairment Scale
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SCI Classification
Tetraplegia/Quadriplegia
Complete paralysis of all 4 extremities & trunk
Upper Motor Lesion
• C1 – C8 (Trunk, Limbs)
Paraplegia
Complete paralysis of all or part of trunk & both LEs
Upper Motor Lesion
• T 1 – T12, L1
Lower Motor Lesion
• Below L1
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Clinical Syndromes
Brown-Sequard Syndrome (incomplete)
• Hemisection of spinal cord
• Usually secondary to penetration wound – GSW, stab
• Ipsilateral sensory loss of sensation, reflexes, vibration
and position sense (lateral and dorsal columns)
• Contralateral sensory loss of pain and temperature
sense (spinothalamic tract)
Cauda Equina Injury
• Lesion is below L1 vertebra
• Peripheral injury (lower motor neuron injury)
• Flaccidity, absent reflexes
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Clinical Syndromes
Anterior cord syndrome
Injury site: anterior spinal cord or ant. spinal artery
Usually related to flexion injuries, compression from fracture,
dislocation or cervical disc protrusion)
Characterized by loss of motor function (corticospinal tract) & pain
and temp (spinothalamic tract)
Central cord syndrome
Injury site: center of the spinal cord
Most commonly occurs because of hyperextension; congenital or
degenerative narrowing of spinal canal
Most common with hyperextension of cx region
Posterior cord syndrome
Injury site: posterior spinal cord or posterior spinal artery
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Clinical Syndromes
Posterior cord syndrome
Injury site: posterior spinal cord or posterior spinal
artery
Characterized by preserved motor function, sense of
pain and temperature and light touch; loss of
proprioception and epicritic sensations (ie: 2 point
discrimination) below the level of the lesion
Sacral Sparing
refers to incomplete lesion; clinical signs include
perianal sensation and external anal sphincter
contraction
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Clinical Manifestations
Spinal Shock
Motor and Sensory Impairments
Autonomic Dysreflexia
Postural hypotension
Impaired temperature control
Respiratory Impairment
Spasticity
Bowel and Bladder dysfunction (Micturition; Crede
maneuver)
Sexual Dysfunction
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Acute Medical Care
Stabilize respiratory status
C1 to C4 lesions effect the phrenic nerve &
diaphragm
Patient placed on respiratory ventilator
Minimize spinal shock and edema that results from
the injury
Steroids
Control of hydration and nutrition to avoid over
hydration and further cord necrosis
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Acute Medical Care
Catheterization bladder
Spinal stabilization
Surgery to realign vertebra & spinal
cord
Insertion of halo to head & spine
Rigid to semi-rigid cervical collar
Thoracolumbarsacral Orthoses
(TLSO)
Immobilize patient in bed
• Stryker Frame, air support beds
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TLSO
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Spinal Cord Injury Disorders
Respiratory Impairment
Impairment is directly related to:
• Lesion level
• Residual respiratory muscle function
• Additional trauma at time of injury
• Premorbid respiratory status
Will be dependent on artificial ventilation or phrenic
nerve stimulation with C1 – C3 injury
Low respiratory endurance (C4 to T12)
Higher level lesions may result in difficulty with
coughing
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Spinal Cord Injury Disorders
Complete to partial motor and sensory dysfunction below the level
of the lesion
Autonomic Dysreflexia (Hyperreflexia)
Deep Vein Thrombosis
Inactivity & diminished muscle contraction effect circulation
Sympathetic Pain, Phantom Pain
Dyesthesia
Heterotrophic bone formation in soft tissue
Orthostatic Hypotension (aka Postural Hypotension)
• ↓ in BP when assuming an erect or vertical position
• Caused by loss of sympathetic vasoconstriction and lack of muscle
tone
• Example: supine to sitting, sit to stand
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Spinal Cord Injury Disorders
Pressure Sores/Decubitis Ulcer
2 ˚↓ sensation, difficulty w/ positional changes
Motor Impairment
Spasticity
• Varies in range, mild to severe
• Influence by internal and external stimuli
• Can be managed via drug therapy, injections, surgery
Flaccidity
Muscle weakness
• Muscle atrophy
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Spinal Cord Injury Disorders
Bladder and Bowel Dysfunction
UTIs are a common early complication
Lesions above conus medullaris typically develop a
reflexive/spastic bladder & bowel (automatic bladder
& bowel)
Conus Medullaris and Cauda Equina lesions typically
develop a nonreflex/flaccid bladder & bowel
(autonomic bladder & bowel)
Calcium Absorption (renal calculi)
Osteoporosis
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Spinal Cord Injury Disorders
Contractures
Autonomic Nervous System Disturbances
Loss of thermal regulation
• Vasodilation does not occur in response to heat
• Vasoconstriction does not occur in response to cold
• Absence of sweating
• Often associated with compensatory excessive sweating above the level
of the lesion- diaphoresis
Flushing, headaches
Sexual Dysfunction
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Spinal Cord Lesion
Level &
Functional Outcomes
Refer to O’Sullivan, Table 23.6, page 961
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C1 to C3
Muscles preserved: Face and
Neck Muscles
Respiration: Ventilator dependent
Bed Mobility: Dependent
Transfers: Dependent
Self Care: Dependent (Groom,
Dress, Bath, Feed) - Full time
attendant
Wheelchair: Power, microswitch
or sip-and-puff controls
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C4
Muscles preserved: All of above
Diaphragm, Trapezius
Endurance: Low
Bed Mobility: Dependent
Transfers: Dependent
Self Care: Dependent
Wheelchair: Powered;
head/chin/mouth control or
sip-and-puff control
Attendant Care
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C5
Movement preserved: All of the above
Scapula elevation, adduction
Shoulder abduction, ER, flexion (limited)
Elbow flexion & supination
Endurance: Low
Bed Mobility: Dependent
Transfers: Dependent → Assistance
Self Care: Dependent
Wheelchair: Powered with joystick or adapted UE
controls or manual with hand rim projections
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Hand Rim Projections
Joystick
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C6
Muscles preserved: All of the above
Scapular abduction & upward rotation
Shoulder flexion, extension, IR and adduction
Forearm pronation
Wrist extension (Tenodesis grasp)
Endurance: Low
Bed Mobility: Assistance (Rolling, Sit, Mobility)
Transfers: Assistance→Independent (Slide board)
Self Care: Assistance
Wheelchair: Powered or manual with projections or
friction surface hand rims
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C7
Movement preserved: All of the above
Elbow extension
Wrist flexion
Fingers extension
Endurance: Low
Bed Mobility: Independent
Transfers: Assistance → Independent (Slide board)
Self Care: Assistance → Independent
Wheelchair: Manual with friction surface hand rims
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C7
Continued
Ambulation: Spinal Orthoses,
Long leg braces, Pelvic Band
Drag to gait
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C8 to T1
Movement preserved: All of the above
Full UE innervations including fine coordination &
strong grasp
Endurance: Low
Bed Mobility: Independent
Transfers: Independent
Self Care: Assistance/Independent
Wheelchair: Independent with manual chair
Ambulation: Spinal Orthoses, Long leg braces,
Pelvic Band, Drag to gait
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T4 toT6
Movement preserved: All of the above
Improved trunk control
Pectoral girdle stabilization
Endurance: Increased
Bed Mobility: Independent
Transfers: Independent
Self Care: Independent
Wheelchair: Independent, improved skills
Ambulation: Minimal distances with assist; bilateral
knee-ankle-foot orthoses with spinal attachment
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T9 to T12
Movement preserved: All of the above
Thoracic Extensors, Lower Abdominal Muscles
(Flexion); Improved trunk control
Endurance: Increased
Bed Mobility: Independent
Transfers: Independent
Self Care: Independent
Wheelchair: Independent, used to conserve energy
Ambulation: Functional with bilateral long leg
braces; walker or crutches; swing thru, 4 point, 2
point gait
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L2 to L4
Muscles preserved: All of the above
Hip flexion and adduction
Knee extension (quadriceps)
Endurance: Increased
Bed Mobility: Independent
Transfers: Independent
Self Care: Independent
Wheelchair: Independent, used to conserve energy
Ambulation: Functional with bilateral KAFO and
crutches; 4 point, 2 point gait
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L4 to L5
Muscles preserved: All of the above
Stronger hip flexion
Stronger knee extension, weak knee flexion
Improved trunk control
Endurance: Increased
Bed Mobility: Independent
Transfers: Independent
Self Care: Independent
Wheelchair: Independent; used to conserve energy
Ambulation: (B) AFO w/ crutch or cane, 2 pt. gait
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PT Examination
Respiratory Examination
Integumentary examination
Sensation
Tone and DTR
MMT
ROM
Functional Status
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SCI – Outcome Measures
Functional Independence Measure (FIM)
Wheelchair Skills Test
(O’Sullivan, pg 966)
Examining walking ability:
SCI Functional Ambulation Inventory SCI-FAI
(O’Sullivan, pg 967)
Walking Index for Spinal Cord Injury (WISCI)
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Physical Therapy Intervention
Respiratory Management
Diaphragmatic breathing
Glossopharyngeal breathing
Assisted coughing
Abdominal support
Stretching pectorals and chest wall muscles
Postural draining
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Physical Therapy Intervention
ROM
Spinal motion is normal in the acute phase
depending on the level of injury
ROM in supine & prone (if cleared by MD)
Less than full ROM of joints is often beneficial
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Physical Therapy Interventions
Positioning
Splints for wrist, hands & fingers
Ankle boots or splints
Once cleared, tolerance to prone position is
important
Therapeutic Exercise
Passive, Active Assistive, Active, Strengthening &
Functional exercises
Must be aware of contraindications in acute phase
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Physical Therapy Interventions
Orientation to vertical position
Mat/Bed Exercises
Achievement of stability within a posture
⇓
Controlled mobility
⇓
Skill in functional use
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Physical Therapy Interventions
Mat/Bed exercises
Often individual components of a functional skill
Sequenced from easiest to most difficult
Complete mastery of one skill is not always required
to move on to the next skill
Degree of independence and rate of progression
depends on level of spinal lesion and the individual
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Physical Therapy Interventions
Mat Programs Progression
Rolling (Prone, Supine, Sidelying)
Prone on elbows
Prone on hands (paraplegia)
Supine on elbows
Pull ups (tetraplegia)
Sitting (long sitting & sitting at edge of bed)
Quadruped
Kneeling
Transfers
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Physical Therapy Interventions
Rolling
Easiest to begin supine to prone
If applicable, easier to roll
towards weaker side
Should always encourage
independence, however
adaptive devices may be used if
unable to perform activity
independently
• Bed rails, ropes, canvas
“ladders”, trapeze
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Physical Therapy Interventions
Rolling assists with bed mobility, pressure relief
and dressing
Rolling techniques
Flexion of head & neck w/ rotation for supine→prone
Extension of head & neck w/rotation for
prone→supine
Pendular motion with outstretched UEs
Crossing the ankles
Place pillows under the patient’s pelvis
PNF patterns – UE D1 Flexion, D2 Extension
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Physical Therapy Interventions
Prone on elbows
Assists with improved bed mobility & preps for
quadruped and sitting later
Facilitates head, neck and shoulder girdle strength
May need assistance from therapist initially
Caution with thoracic and lumbar injuries!
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Physical Therapy Interventions
Prone on elbows activities
Weightbearing improves shoulder stability
Weightshifting – lateral 1st, progressing to anterior
and posterior movements
Rhythmic stabilization
Manually applied approximation
Unilateral weightbearing on one elbow
Strengthening the serratus anterior & other scapular
muscles
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Physical Therapy Interventions
Prone-on-Hands
Promotes extension of the hips and low back
• Assists with standing and ambulation
Can use bolster, wedge, pillows to assist with
tolerance and independence with position
Activities may include weight shifting, approximation,
scapular depression and prone push ups
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Physical Therapy Interventions
Supine-on-Elbows
Assists with bed mobility and preparing for long
sitting, strengthens shoulder extensors and scapular
adductors
Assuming the position can be accomplished by:
1. Using abdominals if sufficient strength
2. Wedging hands under hips, hooking thumbs into
belt loops and pull up while lateral weight shifting
3. Can be done from sidelying, lower elbow
positioned first and then roll supine extending the
opposite arm and landing on the elbow
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Physical Therapy Interventions
Supine-on-Elbows activities:
Lateral weight shifting
Side-to-side movement assists with aligning the trunk
and LEs necessary for positional changes
Be cautious of shoulder pain, ↑ pressure placed on
the anterior shoulder joint capsule in this position
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Physical Therapy Interventions
Pull-Ups
Strengthens the biceps & shoulder flexors necessary
for wheelchair propulsion
Patient is supine while therapist is squatting over the
patient, therapist grabs the patient’s supinated
forearms just above the wrists, patient pulls to sitting
and then lowers back to the mat
May also use a trapeze bar
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Physical Therapy Interventions
Sitting
Long and short sitting are essential for daily activities
(dressing, transfers, WC mobility)
Good sitting balance (static and dynamic) is
necessary to progress to standing
Sitting posture varies depending on level of lesion
What does sitting look like for these patients?
• Patient with triceps and abdominal muscles initially find
stability through shoulder hyperextension and ER,
elbows and wrists extended and fingers flexed
• W/o tricep function, patients lock the elbows
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Physical Therapy Interventions
How to get to a sitting position
Start in supine-on-elbows, shift weight from side-toside, with sufficient momentum the patient tosses
one arm behind and bears weight on the hand,
repeats with opposite arm; pt. then “walks” the arms
forward
2. Start in prone-on-elbows, pt. creeps sideward using
elbows and forearms, trunk in flexion allows the
forearm to hook under knees and pulls them forward;
pt. tosses the opposite UE behind followed by the 2nd
UE; patient then “walks” arms forward
1.
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Physical Therapy Interventions
Sitting activities
Initially, focus on maintaining the position; mirror may
provide helpful visual feedback
Manual approximation at the shoulder
Decrease UE support
PNF
Challenge limits of stability – balloon tapping, ball
throwing, reaching for cones
Sitting push ups
Movement within the sitting posture
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Physical Therapy Interventions
Quadruped
Important for progression to ambulation
Initially position is assumed from the prone-on-
elbows position
Quadruped activities
• Maintaining the position
• Manual approximation
• Weight shifting in all directions
• Rocking
• Decreasing UE support
• Movement within the position
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Physical Therapy Interventions
Kneeling Position
Promotes trunk and pelvic control, good for upright
balance and progression to ambulation
Easiest to assume position from quadruped
• Patient can initially find UE support using a wall ladder,
therapists shoulders and eventually mat crutches
Kneeling activities
• Maintain the position
• Decrease UE support
• Weight shifting
• Hip Hiking
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Physical Therapy Interventions
Transfers
Initiated with achievement of adequate sitting balance
Mat/bed to wheelchair
Progression: WC to toilet, shower chair, car, floor, stairs
Lateral scoot transfer w/ or w/o slide board
3 important components of transfer:
• Momentum
• Muscle substitution
• Head-hips relationship
Helpful exercise to improve transfers: push-ups
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Physical Therapy Interventions
Wheelchair Mobilization/Prescription
Manual or Powered, Tilt-in-space, Standing frame,
Sport chairs
Fitting the wheelchair
Wheelchair skills
Setting and releasing locks
Removing foot and arm rests
Forward, backward, turns, surfaces, wheelies for
curbs
Pressure relief techniques (discussed later in lecture)
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Physical Therapy Interventions
Standing Progression
Compression: (corset) trunk and lower extremities
Tilt Table
• **Monitor Blood Pressure**
• Start at 15 degrees
Purpose of Tilt Table
• Aids circulation & skin integrity
• Assists bowel and bladder function
• Weight bearing, diminishes bone demineralization
• May improve sleep
• Psychological benefits to be upright
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Physical Therapy Interventions
Donning and doffing braces on mat/bed
Sit to Stand Activities
Practiced in parallel bars initially
Progress from pulling up on bars to using arm rests
on wheelchair to push to standing
In upright position, patient pushes down on hands
and tilts pelvis forward
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Physical Therapy Interventions
Standing in Parallel Bars (braces)
Balance Exercises
• Maintaining static balance in hips extended position
• Trunk flexion, trunk extension (with MD clearance)
• Weight shifting
• Eyes closed
• Releasing 1 hand support from the bar
• Placing hands in front of and behind the body
• Push up
• Push up and drag or swing body forward (beginning gait
training)
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Wheelchair that transitions
to standing position
Standing Frame
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Physical Therapy Interventions
Gait Training
Be realistic with the patient
Consider orthotic devices, assistive devices,
adequate ROM, strength & CV endurance
Consider incomplete vs. complete SCI
Other limiting factors: spasticity, loss of PPC, pain
Is the patient motivated?
Start in parallel bars
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Physical Therapy Interventions
Gait training: Parallel Bar Activities
Achieve adequate level of standing balance first
Turning around
Jack knifing
Practice various gait patterns: swing to, swing
through, 2 point, 4 point
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Physical Therapy Interventions
Progressing ambulation outside the parallel bars
Choosing an AD
• Forearm crutches, walker, cane(s)
Standing from wheelchair with AD
Balancing with AD (crutches, walker w/incomplete)
Practice different gait patterns, progress timing &
speed
Travel activities
• Sideways, backward, turning, negotiating doorways/
elevators
• Practice with variable surfaces, indoors & outdoors
• Stairs, curbs
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Ambulation after SCI: Videos
http://www.youtube.com/watch?v=AQDCFMYGuGQ
http://www.youtube.com/watch?v=Ff3QUler05A
T3 injury with RGOs
http://www.youtube.com/watch?v=jJvxYQklHfs
http://www.youtube.com/watch?v=r3F_a_jqDmw
http://www.youtube.com/watch?v=BhWZajGXtPk
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Physical Therapy Interventions
Fall & Recovery training
Locomotor Training
Means of intensely practicing the distinct and specific
task of walking (O’Sullivan, pg. 983)
Provides the sensory experience of walking
Body weight support treadmill training
Means of progression:
• Decrease body weight supported percentage
• Treadmill speed
• Amount of manual assistance
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Body Weight Support Systems
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Ambulation after SCI: Videos
http://www.youtube.com/watch?v=AWj9O-oMFyo
http://www.youtube.com/user/ryanclausing?blend=
24&ob=5#p/u/0/E5s9uetONYw
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Physical Therapy Interventions
Reinforcement of Bowel and Bladder Program
Education regarding skin inspection
Gradually the patient becomes more responsible for
regular inspection
Involves both visual inspection and palpation daily
• Use of a long handled mirror, wall mirrors
Pressure relief
• 10-15 seconds of relief for every 10 minutes of sitting
• Techniques: WC push ups, hook & lean forward or
sideways
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Areas Susceptible to Pressure
Supine
Sidelying
Prone
Occiput
Ears
Scapulae
Shoulders
Vertebrae
Iliac Crest
Elbows
Male genital region
Sacrum
Patella
Coccyx
Dorsum of feet
•
•
•
•
•
•
•
Heels
O’Sullivan, pg. 957 Table 23.5
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Ears
Shoulders
Greater Trochanter
Head of Fibula
Knees
Lateral Malleolus
Medial Malleolus
Physical Therapy Interventions
Reinforcement of Self Care Activities
Grooming, Bathing, Dressing, Feeding,
Recreation, Sports
Energy Conservation
Cardiovascular training
Aquatic Exercises
Patient and Family Education
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Assess for Understanding:
What is the effect of Autonomic Dysreflexia
(Hyperreflexia) and how does the therapist handle
the situation?
What are the symptoms of Autonomic Nervous
System Disturbances/ increased sympathetic
activity?
Upper motor neuron spinal lesions are located
between which spinal segments?
Lower motor neuron spinal lesions are located
between which spinal segments?
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References
Physical Rehabilitation, 5th ed., Susan B. O’Sullivan and
Thomas J. Schmitz, 2007; F.A. Davis, Company. Chapter
23
PTA Exam The Complete Study Guide, Scott M. Giles,
2011; Scorebuilders.
PTA Examination Review and Study Guide, Karen Ryan
and Becky McKnight, 2010; International Educational
Resources.
Functional Significance of Spinal Cord Lesion Level, C.
Long MD E. Lawton PT, MA, Archives of Physical Medicine
and Rehabilitation, September, 1955.
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Peripheral Nerve System
Disorders
PTA 150: Fundamentals of Treatment II
Day 12
Lesson Objectives
Define peripheral nerve
Discussing major functions of peripheral nerves
List and describe the major peripheral
neuropathies and their pathogenesis
Discuss entrapment syndromes specifically
naming each, identifying the structural
considerations that are involved
Discuss the fundamental rehabilitation of LMN
lesions
Peripheral Nerve Defined
Nerves outside the Central Nervous System
Connects CNS to limbs and organs
Provide motor and sensory function
Cranial nerves and spinal nerves
31 pairs of spinal nerves
Terminology
Neuropathies
Myopathy
Polyneuropathy
Mononeuropathy
Radiculopathy
Causalgia
Entrapment syndrome
Major Pathologies
Bell’s palsy – swelling/inflammation of facial nerve
(CN VII)
Usually caused by a viral infection
S&S: facial droop, weakened taste, sound sensitivity,
weak facial expressions
Trigeminal neuralgia - compression of trigeminal
nerve (CN V)
AKA tic douloureux
S&S: episodes of intense pain (like electric shock) in
the face
Major Pathologies
Poliomyelitis
Viral infection
S&S: flu like symptoms, loss of reflex, muscle
ache/spasm, flaccid limbs
Post-polio syndrome
New onset of weakness and severe fatigue occurring
years after recovery from acute poliomyelitis
S&S: severe long lasting fatigue that does not go
away with rest, new onset of weakness in muscles
thought to be strong, new loss of functional abilities
Major Pathologies
Guillian-Barre Syndrome
Associated with autoimmune attack; often occurs
after recovery from an infectious disease
Demyelinating LMN motor: cranial and peripheral
nerves
S&S: weakness, tingling, loss of sensation, difficulty
breathing; progresses from lower extremities to
upper extremities and from distal to proximal; may
result in quadriplegia and respiratory failure
Major Pathologies
Myasthenia gravis
Grave muscular weakness
Autoimmune disorder in which there is a production
of antibodies that combine with acetylcholine
receptors at motor end plates; destroys the receptor
sites
S&S: fluctuating weakness, usually affects eye
movements first, more noticeable in proximal
muscles, dysphagia, gagging, muscle function better
after rest, fatigue, double vision
Major Pathologies
Complex regional pain syndrome - vasomotor
dysfunction to chronic sensory stimulus
S&S: severe pain, swelling, changes in the skin, loss
of motion
AKA reflex sympathetic dystrophy
Diabetic neuropathy/Peripheral Nerve Neuropathy
- occurs with advanced diabetes mellitus, occurring
in limbs
Capillary fragility with diminished distal circulation
Hypoesthesia of the feet and hands
Radicular pathology
Foraminal stenosis - intervertebral foramen is
narrowed by something such as osteophytes (bone
spurs)
Structural
Functional
• Postural
• Activity dependent – overhead work – computer use
Entrapment syndromes
Thoracic outlet syndrome
Compression of the subclavian artery and vein,
brachial plexus
Neurovascular compression
Cervical rib
Postural and overuse of anterior chest wall muscles
Cubital tunnel syndrome
Entrapment of the ulnar nerve at the elbow
Entrapment syndromes
Pronator teres entrapment
AKA Pronator syndrome
Median nerve compression at the pronator teres
muscle
Carpal tunnel syndrome (CTS)
Entrapment median nerve at the wrist
Usually caused by repetitive motions of the wrist
S&S: numbness, tingling, pain, clumsiness with hand
activity, weak grip, swelling
Entrapment syndromes
Piriformis syndrome
Entrapment of the sciatic nerve through or under the
piriformis muscle
Tarsal Tunnel Syndrome
Tibial nerve entrapment at the medial aspect of the
ankle
“Burning” pain and paresthesias behind the medial
malleolus that radiate to the plantar surface of foot
Rehabilitation
P.R.I.C.E
Protection from nerve compression
Padding, positioning, splinting
Resolve acute inflammation in area of nerve
compression
Cool to warm
Gentle massage for swelling (instruct patient)
Gentle compression wrapping
Rehabilitation
Control repetitive motions and continuous
pressures
Normalize poor ergonomics and biomechanics of
work, ADL and recreation
Normalize posture and utilize assistive supporting
devices as necessary
Rehabilitation
Restore normal ROM and strength
Take care not to overstretch nerve as this will
increase symptoms
Passive ROM to active resistive strengthening
Maintain stability
Support co-contraction and coordinated patterning
EMG biofeedback
Electrical stimulation for muscle re-education
Rehabilitation
Normalize soft tissue mobility and resolve
binding/entrapping scars
Be very careful not to aggravate nerve
Conditions that are long standing often require
longer periods of rehab
Ergonomic and biomechanics training
Rehabilitation
Postural training
Strategies for postural awareness
• Alignment - static using supportive devices
• Alignment – dynamic; stabilization within movement
Proper alignment enhances proprioception, balance
and economy of energy
Rehabilitation
Sensory considerations
Monitor skin for pressure and irritation in patients
with hypoesthesia
Pad and protect skin from pressure
Frequent changes in position
Aerobics training for enhanced skin circulation
Rehabilitation
Sensory integration
Desensitization
• TENS
• Increase sensory input of varying types and intensities
Recognize normal by comparative contralateral
awareness
Recognize appropriate response and level
• Comparison to norms
• Comparison to functional ability
Summary
Define peripheral nerve
Discussing major functions of peripheral nerves
List and describe the major peripheral
neuropathies and their pathogenesis
Discuss entrapment syndromes specifically
naming each, identifying the structural
considerations that are involved
Discuss the fundamental rehabilitation of LMN
lesions
Questions
References
Physical Rehabilitation, 5th ed., Susan B. O’Sullivan
and Thomas J. Schmitz, 2007; F.A. Davis,
Company. Chapter 13