Sample presentation slides (Blue ribbons design)

Transcript Sample presentation slides (Blue ribbons design)

Beth W. Jacobs, RN, CCM, CRRN Clinical Coordinator Spinal Cord System of Care - MossRehab

List the major components of the spinal cord injury (SCI) neurological exam Discuss the correlation between SCI neurological diagnosis and level of function Describe care strategies which directly affect lifelong health maintenance Identify care resources for the spinal cord injured individual

Spinal cord injury anatomy & physiology The SCI neurological exam Functional presentation Lifetime management Recognizing and treating autonomic dysreflexia Maintaining a healthy musculoskeletal system Establishing a bladder program Preventing pressure ulcers Role of neuroplasticity in mobility

Tetraplegia Paraplegia Central nervous system

The brain and spines main means of communicating, interpreting and initiating all motor and sensory impulses to and from the body

Protects the spinal cord from injury Divided into four sections

Cervical Thoracic Lumbar Sacral

Largest nerve in the body Protected by a vertebral bony structure Extends from the base of the brain down to the lumbar spine through the spinal canal as upper

motor neurons

At L1 exits the spinal canal as nerve roots resembling a horses tail as

lower motor neurons

Nerve roots exit to and enter from the body throughout the spinal cord

Comprised of bundles of electrical nerves called tracts

Ascending tracts carry sensory messages to the brain Descending tracts carry motor messages to the body

Sensory tracts

Spinothalamic Anterior part of cord Pain, temperature,touch Spinocerebellar Posterior part of cord Position sense/proprioception, vibration

Motor tracts

Upper body movement Center of cord Lower body movement Perimeter of cord

Part of the nervous system which controls our automatic bodily functions

Heart beating Blood pressure regulation Breathing Digesting food Control of urination Control of defecation

A system of balance and counter balance to maintain homeostasis

Parasympathetic Brain stem Sacral cord Sympathetic Cervical through lumbar cord

There is a neurological change in presentation due to:

Cord compression, inflammation, loss of blood supply Vertebral body fracture, dislocation Anterior ligament injury Posterior ligament injury Disruption of vertebral arteries with ischemia Disruption of myelin sheath Can be due to a trauma vs non-traumatic event or disease based injury

What is it?

International Standard for Neurological Classification of Spinal Cord Injury Endorsed by the American Spinal Injury Association

Neurological Level Motor Score Sensory Score Complete or Incomplete (AIS or ASIA impairment scale) Zone of Partial Preservation Clinical Syndromes

10 major muscle groups

5 upper body 5 lower body

Amount of strength

0 – 5 rating NT = not testable

Upper Body

C5 Elbow Flexors C6 C7 C8 T1 (elbow bent) Wrist Extensors (wrist up) Elbow Extensors (arm out straight) Finger Flexors (bend middle finger) Finger abductors (little finger to thumb)

Lower Body

L2 Hip Flexors L3 L4 L5 S1 (knee up) Knee Extensors (kick out) Ankle Dorsiflexors (ankle up) Long Toe Extensors (toes to your nose) Ankle Plantar Flexors (step on the gas)

56 Sensory Dermatomes 28 on the right side of the body 28 on the left side of the body Type of Sensation Light touch Pinprick Level of Sensation 0 - Absent 1 - Impaired 2 – Normal NT = not testable

In absence of ability to test Abdominal Muscles

T2 T3 T4 T5 T6 Axilla Third intercostal space Nipple Line Midway btw 4 & 6 xiphisternum

T7 T8 T9 T10 T11 T12 L1 Midway btw 6 & 8 Midway btw 6 & 10 Midway btw 8 & 10 Umbilicus Midway btw 10 & 12 Inguinal ligament perineal region

The lowest intact level of motor or sensory function Must be bilateral NOTE - If the patient is 3/5 with a string of 5/5 at every level above they are diagnosed at the 3/5 level

Motor & sensation should be tested throughout Confirm Complete or Incomplete diagnosis AIS A – No motor or sensory preservation below level of injury, testing of S4-S5 anal reflex AIS B – Some sensory preservation below level of injury AIS C – Some motor preservation but weak AIS D – Some motor preservation but stronger Incomplete injuries can have unusual motor preservation &/or spotty sensation throughout Zone of partial preservation Clinical syndromes can be more clearly diagnosed

Loss or impaired movement Loss or impaired sensation Loss or impaired pain, temperature and proprioception Loss or impaired bladder & bowel function Loss or impaired sexual function

Clinical Syndromes Central Cord Brown Sequard Anterior Cord Posterior Cord Conus Medullaris Cauda Equina

Central cord More motor impairment of upper extremities vs lower 9% of traumatic SCI (TSCI) - most common Hyperextension injuries, cervical spondylosis Oldest age group Brown-sequard Same side (ipsilateral) proprioception & motor loss with opposite side (contralateral) pain & temp loss 1 – 4% of TSCI Best ambulatory prognosis – 75 – 90% are Independent at discharge

Anterior cord Anterior portion of cord affected negatively impacting on pain, temperature, touch 2.7% of TSCI 10 – 20% chance of muscle recovery Posterior cord Posterior portion of cord affected negatively impacting on proprioception, vibration <1% of TSCI – least common

Conus medullaris Lumbarsacral nerve roots within canal are affected causing bowel & bladder involvement with mixed UMN & LMN presentation (usually areflexic) Trauma & tumors typically AIS B Cauda equina Lumbarsacral nerve roots within the neural canal are affected causing pure LMN areflexic bowel & bladder impairment Trauma, tumors, stenosis, disc compression, postsurgical epidural hematoma Better prognosis since peripheral nerve roots may be able to regenerate

Recognizing and treating autonomic dysreflexia Maintaining a healthy musculoskeletal system Establishing a bladder program Preventing pressure ulcers Role of neuroplasticity in mobility

Does not occur during phase of spinal shock Injuries at T6 or above

Intact sensory afferent impulses below level of injury, ascend via spinothalamic and posterior columns Inhibitory sympathetic outflow response is blocked

Sudden elevation in blood pressure – most commonly presenting as headache Heart rate drops to compensate for severe vasoconstriction – bradycardia Inhibitory sympathetic response above level of injury is intact – diaphoresis, skin flushing of upper body Inhibitory sympathetic response below level of injury is blocked – vasoconstriction unopposed & blood pressure continues to rise

Signs & Symptoms

Pounding headache, bradycardia, profuse sweating, piloerection, cardiac arrhythmia and other abnormalities, flushing of skin, blurred vision, spots in visual fields, nasal congestion, apprehension/anxiety, (silent AD)

Blood Pressure Elevation

Adults Importance of knowing baseline BP Only 20-40 mm HG above baseline may be AD Children/Adolescents Children – 15 mm HG above Adolescent – 15-20 mm Hg above

Causes

80% is bladder related Bladder distention due to Blocked foley catheter CIC with no spontaneous void – time to cath!

UTI Kidney/bladder stones

Causes

Bowel distention Pressure ulcers Ingrown toenails Tight clothing Infections Fractures PE/DVT Sexual intimacy

Action to Take

Sit upright Loosen clothing Monitor VS Rule out bladder as cause Contact MD Determine source of stimuli & eliminate Possible antihypertensive administration

Post AD episode

Monitor for 2 hours to assure no re occurrence Documentation Education Recurrent episodes – frequent re-evaluations over time

Spasticity Contracture development Heterotopic ossification

Disruption of CNS communication between the spinal cord and brain Not typically seen during acute injury due to areflexic spinal shock state Seen in UMN injuries Severity can increase suddenly or over time Must rule out infectious source Benefits Can be triggered to improve function May be early sign of infection or problem

Risks

Negatively affect function Painful for incomplete injuries Impact on sleep pattern Cause pressure/friction problems Decrease joint ROM Rehab management Routine ROM exercise Weight bearing activities to stretch muscles Oral medication use

Nerve blocks Benefits are temporary Phenol Botox Intrathecal baclofen pump Advantages Administered directly into cerebral spinal fluid via the intrathecal space Reduction of typical oral medication side effects Dosing frequency and timing can be individually established and managed

Spinal cord Capillary absorption Catheter Drug Vertebra Epidural space Dural membrane Intrathecal space CSF

Screening process to qualify Disadvantages

Surgical procedure Will need to be replaced q 5-8 years Requires diligent follow up with specialist

Injury to the spinal cord increases excitabilty of neural circuits that control muscle tension. Spastic muscles resist changes of tension by contracting.

Contraction results in shortening of muscles, tendons and ligaments Can be a secondary complication of severe spasticity Prevention Routine ROM to all joints, stretching or muscles Control spasticity Therapeutic use of functional electrical stimulation Can be functionally devastating

Rehab management Aggressive therapy Serial casting, customized splinting Medication management of spasticity Motor nerve blocks with phenol, botox Surgical interventions – tendon lengthening

Pathophysiology unclear

Inflammatory process with increased blood flow Bone is mineralized and laid down in soft tissue around joints Matures in 6 – 18 months

Incidence is 16-53% in SCI

Clinically significant in 18-27% Involves joint ankylosis in 3-5%

How to diagnose?

Assess changes in ROM Observe for hot swollen joints Primary site - hips & knees but can develop in UE Elevation of alkaline phosphatase, triple phase bone scan Identification early is crucial Rehab management Active-assistive and passive ROM – treatment controversial Didronil and/or indocin Surgical excision

Micturation – Urination

Bladder fills/distends CNS Cerebral awareness of fullness Voluntary use of abdominals ANS - mixed innervation Sympathetic –T11-L2 Compliance of volume Internal sphincter control Parasympathetic – Sacral arc S2-S4 Detrusor muscle contraction External sphincter control

Physiology of kidney and bladder function intact Awareness of bladder fullness impaired Use of abdominal muscles impaired Use of complex coordinated reflexes altered to achieve complete emptying Detrusor Sphincter Dysenergia (DSD) may result

Goal is low bladder pressure with adequate bladder emptying Preservation of upper tracts Reduce possible bladder stretch injury Prevent hyperactive detrusor Program will be determined by type of bladder Complete urodynamic testing to determine presence of reflux, outlet obstruction, DSD, hydronephrosis annual urologic follow up Medications to reduce hyperactivity Anticholinergics, botox injection

Options Long term indwelling urethral catheter Suprapubic Catheter Chronic intermittent catheterization Volumes must be under 500 cc consistently Allowed reflex voiding determined by urodynamics Surgical procedures Sphincterotomy Bladder augmentation Urinary diversion Mitrofanoff procedure

35 30 25 20 15 10 5 0 2011 National Spinal Cord Injury Statistical Center (NSCISC) Annual Statistical Report At Discharge 1 year post 10 years post 25 years post

35 30 25 20 15 10 5 0 2011 NSCISC Annual Statistical Report At Discharge 1 year post 10 years post 25 years post

National Quality Forum (NQF) 2003 “hospital never events” Medicare Patient Safety Monitoring System (MPSMS) 2006-2007 Adverse Event -

“When unintended harm, injury, or loss occurs that is more likely associated with an individual’s interaction with the healthcare system than with disease”

HAPU incidence 4.5% Present on admission (POA) 5.8% 16.7% developed at least one additional PU Concomittent co-morbidites CHF, COPD, CVD, DM, use of corticosteroids, obesity Those with hospital acquired pressure ulcers (HAPU) significantly more likely to Have longer length of stay (LOS) – 11.6 days vs 4.9 days Be readmitted within 30 days after discharge Die while hospitalized

Medicare Payment Reform Demonstration (MPRD) 2010 Standardize all post-acute data collection Continuity and Record Evaluation (CARE) tool Identify new Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PIA) outcome measures Affordable Care Act 2010

Acute rehab quality indicators Catheter acquired urinary tract infections (CAUTI) Hospital acquired pressure ulcers (HAPU) Considered a never event Monitoring/reporting began October 1, 2012 Not reporting? - 2% reduction in MC payment 2014 Once data established – they are considering - hospitals in the bottom 25% of quality outcome reporting will receive a 99% reimbursement payment

Prevalence 34% acute hospitalization 15% one-year post 20% five-year post 23% ten-year post 24% 15 year post 29% 20 year post Incidence 73% assessing 4,065 SCI individuals Consortium for Spinal Cord Medicine Clinical Practice Guidelines , Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury 2000

Autonomic nervous system disruption - Level of injury increases risk T6 and above Altered body temperature control Reflex sweating is lost Altered collagen biosynthesis Catabolic state Decrease tensile strength Lower O2 tension over sacrum Overall decreased blood supply

Mechanical issues Microvessels and capillaries close at lower levels of pressure Capillary refill may be altered First sign is typically skin color changes Loss of muscle mass over bony prominences Additional risk factors Demographics, physical,psychosocial Age, yrs post injury, cognitive, education, social supports, cultural beliefs Smoking Diabetes CVD

Second leading cause of death Infective & parasitic diseases usually (88.6%)related to septicemia Pressure ulcers Urinary tract infections Respiratory infections Disease of the skin is the second most common cause of rehospitalization (30.1%) *2011 NSCISC Annual Statistical Report

Education Treatment must include a rehabilitation focus –

impact of functional limitations on skin Lifetime rehabilitation management Ongoing equipment determination and procurement Understanding DME insurance coverage limitations in-home support surfaces Importance of customized wheelchair procurement wheelchair clinic Customized seating systems - use of pressure mapping

#1BM Alt LAL 30 degrees attends/underpad/drawsheet #1BM Powered-air 30 degrees attends/underpad/drawsheet #1BM Standard LAL 30 degrees attends/underpad/drawsheet

#2LS Powered-air 60 degrees attends/underpad/drawsheet #2LS Alt LAL 60 degrees attends/underpad/drawsheet #2LS Standard LAL 60 degrees attends/underpad/drawsheet

#3EM Standard LAL 60 degrees attends/underpad/drawsheet #3EM Powered-air 60 degrees attends/underpad/drawsheet #3EM Alt LAL 60 degrees attends/underpad/drawsheet

Neuroplasticity The central nervous systems ability to reorganize itself by forming new neural connections

An old dog CAN learn new tricks!

neurons can rearrange & create new pathways for communication sensory information is interpreted and transmitted via new electrical connections & inefficient connections are deleted “synaptic pruning” Increased neuronal activity improves the synaptic transmission Perceived importance Repetitive activities

Impact for rehab across the continuum

Activity-based therapy is the foundation for the rehabilitation of walking Recovery is task dependent The re-education of walking is an effective rehabilitative strategy Re-education – not compensation promotes recovery

Reo Go

Armeo

G-eo

Lokomat

Complete injuries (AIS A)

80 – 90% remain complete

Incomplete injuries (AIS B,C,D)

50 - 66% of patient’s motor return at 1 yr post injury was achieved within first 2 months recovery continues but slows between 3 –6 months continued recovery can occur up to 2 yrs post Outcomes Following Traumatic Spinal Cord Injury, Consortium for Spinal Cord Medicine 1999

AIS B

50% ambulatory

AIS C

75% community ambulators

AIS D

100% ambulators Younger patients with better prognosis 50-60 age with poorer prognosis Outcomes Following Traumatic Spinal Cord Injury, Consortium for Spinal Cord Medicine 1999

90 80 70 60 50 40 30 20 10 0 % Wheelchair use > 40 hrs/wk Walk 150 ft Walk 1 street block Walk up 1 flight of stairs 1 year post 10 years post 25 years post *2011 NSCISC Annual Statistical Report

Exoskeleton that allows for overground training Has only been used as orthotic device to this point Individuals with motor complete injuries Overground training may be more task-specific May allow for increased practice for training

“In the middle of every difficulty lies an opportunity”

Albert Einstein

Beth W. Jacobs, RN, CCM, CRRN [email protected]

Acute Management of Autonomic Dysreflexia. Consortium for Spinal Cord Medicine 2001.

Bladder Management for Adults with Spinal Cord Injury. Consortium for Spinal Cord Medicine 2006.

Dunlop, Sarah. Activity-dependent plasticity: implications for recovery after spinal cord injury. Trends in Neurosciences, vol. 31 No. 8, 2008.

Lyder, et al: Hospital-Acquired Pressure Ulcers: Results from the National Medicare Patient Safety Monitoring System Study. Journal of the American Geriatric Society 60:1603-160,8 2012.

Lynskey, et al. Activity-dependent plasticity in spinal cord injury. Journal of Rehabilitation Research & Development. 2008.

McKinley, William, et al. Functional Outcomes per Level of Spinal Cord Injury. http://emedicine.medscape.com/article/322604 , August 2011.

McKinley, William, et al. Incidence and Outcomes of Spinal Cord Injury Clinical Syndromes. Journal of Spinal Cord Medicine 2007; 30(3): 215–224.

Medicare Patient Safety Monitoring System Database – online – http://www.ahrq.gov/downloads/pub/advances/vol2/Hunt.pdf National Quality Forum. Serious Reportable Events in Healthcare: A Consensus Report. Washington, DC: National Quality Forum, 2002.

National Spinal Cord Injury Statistical Center, UAB, Annual Statistical Report, 2011.

Outcomes Following Traumatic Spinal Cord Injury, Consortium for Spinal Cord Medicine 1999.

Pressure ulcer Prevention and Treatment Following Spinal Cord Injury: Consortium for Spinal Cord Medicine. 2008