1. Shayla Haynes
2. Demographics
   1. Etiology
      1. 2 Etiological Categories:
         1. 1. Traumatic Injuries
            1. – MVA (45.6%) – Falls (19.6%) – Acts of violence (17.8%) – Recreational sports injuries (10.7%) – Other etiologies (6.3%)
         2. 2. Nontraumatic Damage (~30%)
            1. – From disease or pathological influence: – Vascular malfunctions (arteriovenous malformations [AVM], thrombosis, embolus, hemorrhage) – Vertebral subluxations (secondary to RA or DJD) – Infections (syphilis or transverse myelitis, spinal neoplasms, syringomyelia, abscess of spinal cord) – Neurological diseases (MS & ALS)
   2. Distribution by National Spinal Cord injury Database (NSCID) Variables
      1. – 81% = men; men > women; higher than 4:1 – 51.6% = ages 16 – 30 – whites = 66.6% – African-Americans = 21% – Hispanics = 9.7% – others = 3.5% – cervical lesions = 51% – thoracic lesions = 34.6% – lumbosacral lesions = 10.8% – REHAB HOSP DISCHARGE: *neurologically incomplete paraplegia = 18.6% *neurologically incomplete tetraplegia = 29.4% *neurologically complete paraplegia = 26.3% *neurologically complete tetraplegia = 20.7% – @ TIME OF DISCHARGE *return to private residence/homes = 88.3% *discharge to nursing homes = 5.1% – Avg hosp stay= 15 days – Avg rehab unit stay = 40 days – Life expectancy factors: age @ injury & level & extent of neurological injury – relatively low incidence disability affecting predominantly young pop & assoc w/lengthy & costly care
3. Classification of SCIs
   1. 2 Broad Functional Categories:
      1. 1. Tetraplegia
         1. – Complete paralysis of all 4 extremities & trunk, including respiratory muscles – Results from lesions of cervical cord
      2. 2. Paraplegia
         1. – Complete paralysis of all or part of trunk & both LEs – Resulting from lesions of thoracic or lumbar spinal cord or cauda equina
   2. Designation of Lesion Level
      1. 3 LEVELS:
         1. Neurological Level
            1. The most caudal level of spinal cord w/normal (B) motor & sensory function
         2. Motor Level
            1. The most caudal segment of spinal cord w/normal (B) motor function
            2. scoring: MMT ; myotomes
            3. – The key muscle defined as having intact innervation if it has a MMT score of 3/5 & the next most rostral key muscle exhibits 5/5 – For myotomes that are not clinically testable (C1-C4; T2-L1; S2-S5) the motor level is defined as the same as the sensory level
         3. Sensory Level
            1. The most caudal segment of spinal cord w/normal (B) sensory function
            2. scoring: 0=absent, 1=impaired, 2=normal (light touch & pin prick)
   3. Complete Injuries, Incomplete, & Zone of of Partial Preservation
      1. Complete Injury
         1. – No sensory or motor function and the lowest sacral segments (S4 & S5) – sensory & motor function at S4 & S5 = determined by anal sensation & voluntary external anal's painter contraction
      2. Incompletel Injury
         1. Having a motor &/or sensory function below the neurological level, including sensory &/or motor function at S4 & S5
      3. Zones of Partial Preservation:
         1. – This is where an individual has motor &/or sensory function below the neurologic level, but does not have function at S4 & S5. – The areas of intact motor &/or sensory function below the neurological level = zones of partial preservation
   4. ASIA Impairment Scale
   5. Clinical Syndromes
      1. 1. Brown-Sequard Syndrome
         1. – Occurs from hemisection of spinal cord caused by penetration wounds – Clinical features = asymmetrical
         2. Ipsilateral to Lesion:
            1. – Loss of sensation in dermatome segment corresponding to level of lesion – Due to lateral column damage = decreased reflexes, lack of superficial reflexes, clonus, & +Babinski sign – Due to dorsal column damage = loss of proprioception, kinesthesia & vibratory sense
         3. Contralateral to Lesion:
            1. Damage to the spinothalamic tracts = loss of sense of pain & temperature which begins several dermatome segments below the level of injury b/c lateral spinothalamic tracts ascend 2 -4 segments on the same side b4 crossing
      2. 2. Anterior Cord Syndrome
         1. FLEXION INJURIES
         2. – Frequently related to flexion injuries of cervical region==> damage to the anterior portion of cord &/or its vascular supply from anterior spinal artery – Compression of anterior cord from fx, dislocation, or cervical disc protrusion – Characterized by: loss of motor function (corticospinal tract damage) & loss of sense of pain & temperature (spinothalamic tract damage) below level of lesion – (proprioception, kinesthesia & vibratory sense = preserved b/c they're mediated by posterior columns with a separate vascular supply from posterior spinal arteries)
      3. 3. Central Cord Syndrome
         1. HYPEREXTENSION INJURIES
         2. – Occurs from hyperextension injuries to cervical region – Associated with congenital/degenerative narrowing of spinal cord – Compressive forces==> hemorrhage & edema producing damage to most central aspect of cord – characterized by: more severe neurological involvement of UEs (cervical tracts = more centrally located) than LEs (lumbar & sacral tracks = more peripherally located) – Severity Varies: sensory impairments < motor deficits – Pts=typically recoverability to ambulate with some remaining distal UE weakness – + Surgical intervention – (Preservation = sacral tracks, normal sexual, bowel & bladder fnx)
      4. 4. Posterior Cord Syndrome
         1. – Rare==> deficits of function served by posterior columns – Characterized by: loss of proprioception & epicritic sensations (2-pt discrim, graphesthesia, sterognosis) below level of lesion – Wide-based steppage gait – In past = seen w/Tabes Dorsalis (cond. found w/late-stage syphilis)
      5. 5. Sacral Sparing
         1. – An incomplete lesion where the most centrally located sacral tracks are spared – Varying levels of innervation from sacral segments remain intact – Clinical signs: perianal sensation & external anal spanker contraction= often the 1st signs that a cervical lesion is incomplete
      6. 6. Cauda Equina Injuries
         1. These lesions are peripheral nerve (LMN) injuries
         2. Thus they have the same potential to regenerate as peripheral nerves elsewhere in body BUT full return of innervation isn't common b/c:
            1. 1. There is a large distance between lesion & point of innervation 2. Axonal regeneration may not occur along the original distribution of nerve 3. Axonal regeneration may be blocked by glial-collagen scarring 4. The end organ may no longer be functioning once reinnervation occurs 5. The rate of regeneration slows & finally stops after about 1 yr
4. Mechanisms of Injury Table 23.2 p. 942
   1. – Most frequently occurs from indirect forces produced by movement of the head & trunk & must often from direct injury to a vertebra – Highest frequency of injury: btwn C5 & C7; T12-L2
   2. Flexion Force
   3. Compression Force
   4. Hyperextension Force
   5. Flexion-Rotation Force
   6. Shearing Force
   7. Distraction Force
5. Clinical Manifestations
   1. Spinal Shock
      1. – Occurs immediately after SCI = pd of areflexia – Believed to result from very abrupt w/d of connections btwn higher centers & spinal cord
      2. Characterized by:
         1. – Absence of all reflex activity – loss of Bulbocanvernosus Reflex – loss of Cremasteric Reflex – delayed plantar response – plasticity – loss of sensation & motor function All below the level of lesion, lasting several days to several weeks
      3. 1st Indicator that spinal Shock is Resolving=Presence of a Pos Bulbocavernosus Reflex
         1. Digital Rectal Exam: reflex is elicited by pressure applied to glans penis/glans clitoris or by intermittently tugging on indwelling catheter. If pos, a reflex contraction of anal sphincter around examining digit will be evident
   2. Motor & Sensory Impairments
      1. – Complete or partial loss of muscle function below level of lesion – Impaired or absent sensation below level of lesion – Clinical presentation depends on specific features of lesion: neurological level, the completeness of lesion, & symmetry of lesion (transverse or oblique
   3. Autonomic Dysreflexia
      1. – Pathological autonomic reflex that typically occurs in lesions above T6 (above sympathetic splanchnic outflow) but as been reported at T7 & T8 – The episodes gradually subside over time & relatively uncommon but not rare, 3 years following injury – Seen in patients with both complete & incomplete lesions – Produces an acute onset of autonomic activity from noxious stimuli below level of lesion that reach the lower spinal cord (lower thoracic & sacral) & initiate a mass reflex response resulting in elevated BP – The vasomotor center is the region to readjust peripheral resistance but w/ SCI, impulses from the vasomotor center can't pass the site of lesion to counteract the HTN by vasodilation (HTN can persist if not treated promptly and death may result)
      2. Initiating Stimuli
         1. MOst common Cause= Bladder Distention (Urinary Retention)
         2. Other Precipitating Simuli:
            1. Rectal distention, pressure sores, urinary stones, bladder infections, noxious cutaneous stimuli, kidney malfunction, urethral or bladder irritation, & environmental temperature changes; reported following passive stretching at hip
      3. Sxs
         1. Include: HTN, bradycardia, headache, profuse sweating, increase spasticity, restlessness, vasoconstriction below level of lesion, vasodilation above level of lesion, constricted pupils, nasal congestion, piloerection (goose bumps), & blurred vision
      4. Intervention
         1. – Treated as medical emergency – if lying flat bring to sitting position to lower BP – due to bladder distention, drainage system should be examined immediately – release clamps catheter – drainage tubes should be checked for internal or external blockage or twisting check patient's body for irritating stimuli – if symptoms don't subside immediately contact medical/nursing (A) – bladder irrigation (a higher – level block may exist) – removal & replacement with the a catheter – examination for bowel impaction – drug therapy (antihypertensives)
   4. Postural Hypotension
      1. – Is a decrease in BP that occurs when assuming any wrapped/vertical position (i.e. lying to setting; sitting to standing) – caused by loss of sympathetic vasoconstriction control – tend to occur more frequently with lesions of the cervical & upper thoracic regions
      2. Sx:
         1. – Reduced cerebral blood flow & decreased venous return to heart==> lightheadedness, dizziness, or fainting – edema (pitting) of legs, ankles & feet 2°
      3. Minimize Effects:
         1. – Cardiovascular system should be allowed to adapt gradually by a slow progression to vertical position: elevation of head of bed & progress to a reclining w/c w/ elevating leg rests & use of tilt table – use of compressive stockings & and abdominal binder – pharmacological therapy – the cardiovascular system over time, gradually reestablishes sufficient vasomotor tone to allow assumption of vertical position
   5. Impaired Temperature Control
      1. – Damage to spinal cord = inability of hypothalamus to control cutaneous blood flow or level of sweating which results in loss of internal thermal regulatory responses – can't shiver, vasodilation doesn't occur in response to heat nor does vasoconstriction in response to cold – absence of thermal regulatory sweating which eliminates normal evaporative cooling effects of perspiration and warm environments which is often associated with excessive compensatory diaphoresis (perspiration) above the level of lesion – these changes = body temperature being significantly influenced by external environment – more frequent problem with cervical lesions – tetraplegia Pts. typically experience LT impairment of body temp regulation
   6. Respiratory Impairment
      1. – With high spinal cord lesions between C1 & C3, phrenic nerve innervation & spontaneous respiration are significantly impaired or lost, resulting in the requirements of an artificial ventilator or phrenic nerve stimulator to sustain life – lumbar lesions = full innervation of both primary (diaphragm) & secondary (neck, intercostal & abdominal) respiratory muscles – all patients with tetraplegia & those with high-level paraplegia demonstrate some compromise in respiratory function
      2. Muscles:
         1. Primary Muscles of Inspiration:
            1. Diaphragm & external intercostals
         2. Accessory muscles of REspiration assist w/elevation of ribs:
            1. SCM, Trapezii, Scaleni, Pec Minor & Serratus Anterior
         3. Primary Muscles of Expiration:
            1. Abdominals & Internal Intercostals
      3. Paralyses:
         1. Intercostals:
            1. Decrease chest wall expansion & a lowered inspiratory volume
         2. Abdominals & Internal Intercostals
            1. Significant decreases in expiratory efficiency
         3. Abdominals
            1. Loss of support (maintaining intrathoracic pressure for effective respiration; supporting abdominal viscera; assisting in maintaining position of diaphragm; pushing diaphragm upward during forced expiration), causing the diaphragm to assume an unusually low position in the chest resulting in a decrease expiratory reserve volume that subsequently decreases cough effectiveness & ability to expel secretions
         4. External Obliques
            1. Also influences expiration and with higher-level lesions further reduction in the patient's ability to cost & expel secretions occur all of which make the patient susceptible to retention of secretions atelectasis & pulmonary infections
         5. Paralysis also results in development of an altered breathing pattern characterized by flattening of the upper chest wall, decrease chest wall expansion & a dominant epigastric rise during inspiration
   7. Spasticity
      1. – Results from release of intact reflex arcs from CNS control & characterized by hypertonicity, hyperactive stretch reflexes & clonus – occurs below the level of lesion after spinal shock subsides – is a gradual increase in spasticity during the first 6 months & plateaus at 1 year after injury
      2. Tx:
         1. Drug Therapy
         2. Injected Chemical Agents:
            1. Peripheral Nerve Blocks
            2. Chemical injection is used peripherally to selectively block transmission of the motor nerve to a spastic muscle & interrupt the intact reflex arc peripherally
            3. Temp reduction in spasticity & include:
            4. Phenol Peripheral Nerve Blocks
            5. Phenol Motor Point Blocks
            6. Intrathecal Injections
            7. A central (w/in spinal canal) chemical injection is used
         3. Surgical Approaches:
            1. Myotomy
            2. Neurectomy
            3. Tenotomy
         4. Radical Neurosurgical Interventions=destructive approaches=permanent
            1. Rhizotomy
            2. Myelotomy
   8. Bladder Dysfnx Table 23.3 p. 947
      1. – UTI=among most common – during spinal shock, urinary bladder = flaccid; all muscle tone & bladder reflexes are absent
      2. Micturition
         1. – Spinal integration Center for micturiction- CONUS MEDULLARIS – primary reflex control originates from S2-S4 w/in Conus Medullaris
      3. Following Spinal Shock 1 of 2 types of Bladder Conditions will Develop:
         1. Spastic or Reflex (automatic) Bladder (UMN Lesion)
            1. – Spastic bladder contracts & reflexively empties in response to a certain level of filling pressure –Occurs w/SCI above micturition reflex center (S2-S4), gen involving T11-T12 injury or above – reflex arc is intact (intact micturition reflexes) – reflex emptying may be triggered by manual stimulation techniques
            2. Prognosis for bladder control:
            3. Bladder training is aimed at using micturition reflexes & "trigger" stimulus to establish planned reflex voiding
         2. Flaccid or Nonreflex (autonomous) Bladder (LMN Lesions)
            1. – Is flaccid b/c there's no reflex action of the detrusor muscle – Occur w/SCI @ micturition reflex center (S2-S4), gen involving T12 injury or below – Loss of micturition reflexes – Can be emptied by increasing entropy nominal pressure via Valsalva or Crede maneuver (manually compress lower abdomen)
            2. Prognosis for bladder control:
            3. Unable to establish reflex voiding, intermittent bladder Radiation may be best method for bladder mgmt
      4. Bladder Training Programs p. 946
         1. Primary Goal:
            1. allow pt. to be free of catheter & to control bladder fnx
         2. Spastic/Reflex Bladder:
            1. Intermittent Catheterization
            2. estab reflex bladder emptying @ regular, predictable intervals in response to a certain level of filling
         3. Flaccid/Nonreflex Bladder:
            1. Timed Voiding Program
            2. Find the pattern of incontinence and compare it to the patterns of intake to make a schedule so bladder gradually becomes accustomed/trained to empty at regular, predictable intervals
   9. Bowel Dysfnx Table 23.4 p. 948
      1. Spastic/Reflex Bowel
         1. Lesions above conus medullaris
      2. Flaccid/Nonreflex Bowel
         1. Lesions in conus medullaris or cauda equina
      3. Bowel Programs p. 946
         1. Spastic/Reflex Bowel Mgmt:
            1. Suppositories
            2. Digital Stimulation
         2. Flaccid/NonReflex bowel Mgmt:
            1. Straining w/available musculature
            2. Manual evacuation techniques
   10. Sexual Dysfnx
       1. Male Response
          1. Erectile Capacity
          2. Ejaculation
          3. Orgasm
       2. Female Response
          1. Menstruation
          2. Fertility and Pregnancy
   11. Indirect Impairments & Complications
       1. 3 Common 2° complications:
          1. Pneumonia (34.3%)
             1. – Week &/or paralyzed muscles of inspiration = reduced ventilation of lungs – inadequate/absent strength of coughing muscles = difficult to clear secretions – inability to clear secretions = buildup of fluid in lungs ==>atelectasis & pneumonia
          2. Pressure Ulcers (33.5%)
             1. 2 Most Influential Development FActors
             2. 1. Impaired Sensory Fnx
             3. 2. Inability to Make Approp. Positional Changes
             4. Other Factors:
             5. 1. Loss of vasomotor control ==> lowering of tissue resistance to pressure 2. Spasticity ==> shearing forces between surfaces 3. Skin Maceration form exposure to moisture (urine) 4. Trauma (adhesive tape/sheet burns) 5. Nutritional Deficiencies ==> reduce tissue resistance to pressure 6. Poor gen skin condition 7. 2° Infections
          3. DVT (15%)
             1. – Results from development of a thrombus within a vessel – most frequently occurs within the first 2 months following injury – risk heightened with age & prolonged pressure – formation of thrombus results in thrombophlebitis with characteristic clinical features of local swelling, erythema & head; which are signs similar to those of early ECTOPIC BONE FORMATION & long bone fx
             2. Most Important Contributing Factor:
             3. Loss of normal pumping mechanism provided by active contraction of LE musculature
             4. which slows blood flow==>high conc of procoagulants (thrombin) to develop in localized areas==>predisposition to thrombus formation
             5. Other Contributing Factors:
             6. – Prolonged pressure – loss of vasomotor tone & immobility – immobility leading to venous stasis, sepsis, hypercoagulability & trauma
             7. Mgmt:
             8. – Prevention – prophylactic anticoagulant drug therapy initiated following acute onset & continued for 2-3 months or up to 6 months – turning program designed to avoid pressure over large vessels – PROM exercises – elastic support stockings – positioning of LEs to facilitate venous return
       2. Contractures
       3. Heterotopic Ossification
          1. HO vs MO
             1. Heterotopic Ossification
             2. osteogenesis in soft tissues
             3. Myositis Ossificans
             4. results from injury to a muscle & characterized by bony deposits w/in muscle tissue
          2. Etiology Theories:
             1. Tissue hypoxia 2° to circulatory stasis, abnormal calcium metabolism, local pressure, & Michael trauma related to overly aggressive ROM exercises
          3. Location:
             1. – Always extra articular & extracapsular – may develop in tendons, connective tissue between muscle, aponeurotic tissue, or peripheral aspect of muscle – typically occurs adjacent to large joints: HIPS & KNEES=most common
          4. Signs & Sx
             1. Early Sx
             2. Resemble those of thrombophlebitis, including swelling, decreased ROM, erythema & local warmth near a jt
             3. Early Onset
             4. Characterized by serum alkaline phosphatase levels & negative radiographic findings
             5. Later clinical stages:
             6. Soft tissue swelling subsides & radiographic findings are positive
          5. Mgmt
             1. – Pharmacological therapy: diaphosphates-inhibit formation of calcium phosphate & prevent ectopic bone formation – Physical therapy: maintain ROM & prevent deformity – Surgery: resection of ectopic bone
       4. Pain
          1. Traumatic Pain
             1. – Related to extend & type of trauma sustained & structures involved following acute traumatic injury – subsides with healing in ~ 1 – 3 months
             2. Mgmt:
             3. – Immobilization – Analgesics – TENS
          2. Nerve Root Pain
             1. – Occurs at or near side of cord damage – Caused by acute compression or tearing of nerve roots, arise 2° to spinal instability, periradicular scar tissue & adhesion formation, or improper reduction – "Sharp, Stabbing, Burning, or Shooting" pain following dermatomal pattern – most common in cauda equina injuries
             2. Mgmt:
             3. Conservative management: – Pharmacological therapy – TENS Cervical interventions: – Nerve root sections (neurectomy) – Posterior Rhizotomies
          3. Spinal Cord Dysesthesias
             1. – Diffuse & don't follow a dermatome distribution – Occur in body parts that otherwise lacked sensation & are often described by patient as Burning, Numbness, Pins & Needles, or Tingling feelings, and occasionally involving abnormal proprioceptive sensations – "Phatom Pains" – Etiological theories: scarring and distal end of severed spinal cord
             2. Mgmt:
             3. – Is resistant to treatment – Acknowledged complaints as real & educate on legitimacy of pain – Gentle handling & careful positioning – Pharmacological mgmt: Tegretol, Dilantin – Narcotic analgesics = discouraged==>addiction
          4. Musculoskeletal Pain
             1. – May occur above the level of lesion & for equally involved shoulder joint – Causes: faulty positioning, inadequate ROM, tightening of joint capsule & surrounding soft tissue structures; muscle imbalances around join, inflammation, UE fx
             2. Mgmt:
             3. – Prevention of 2° shoulder involvement – Regular program of ROM exercise – Positioning program designed to facilitate full-motion at shoulder
          5. Osteoporosis & Renal Calculi
             1. – b/c osteoclasts > osteoblasts ==> greater susceptibility to fx and due to this resorption, there are large concentrations of calcium present in the urinary system (hypercalciuria), creating a predisposition to stone formation – Highest incidence of bone mass changes & hypercalciuria-1st 6 mos post SCI – Contributing Factors: immobility & lack of stress placed on skeletal system through dynamic WB activities
             2. Mgmt:
             3. – Dietary management: calcium-restricted foods, vigorous hydration, high-protein foods (NO dairy high in calcium) – Early & continuing WB activities – Risk of colliculus formation = reduce by prevention of UTIs Emerson careful maintenance of bladder drainage to prevent urinary stasis
6. Prognosis
   1. – Potential for recovery is directly related to extent of damage to spinal cord &/or nerve roots – Prognosis is initiated after spinal shock has subsided & is guided by whether or not the lesion is complete
   2. 3 Factors Affecting Prognosis:
      1. The degree a pathological changes imposed by the trauma
      2. The precautions taken to prevent further damage during rescue
      3. Prevention of additional compromise of neural tissue from hypoxia & hypotension during acute management
   3. For Complete Lesions:
      1. No motor improvement is expected other than that which may occur from nerve root return
   4. For Incomplete Lesions:
      1. – Good prognosis for significant recovery of motor function – Improvements begin almost immediately following cessation of spinal shock – Many have some progressive improvement of muscle returned during the first several months following injury with further recovery expected at same rate, or a slightly slower rate – Rate of recovery will decrease & plateau will be reached where there will be no more additional recovery to be expected
7. Acute Medical Mgmt Phase
   1. Emergency Care
      1. – At the accident scene once SCI is suspected, ever should be made to avoid both active & passive movement of spine – Helpful strapping patient to spinal backboard or full body adjustable backboard, use of supporting cervical collar & assistance from multiple personnel – Administration of high doses of Methylprednisolone w/in 3-8 hrs of injury for 24-48 hrs to improve motor & functional recovery – @ ER: complete neuro exam, radiographic & imaging; restoration of vertebral alignment & early mobilization of fx site; cardiac, hemodynamic & respiratory status closely monitored; insert urinary catheter; 2° injuries addressed; early reduction & fixation of unstable spinal fx
   2. Fx Stabilization
      1. Closed Reduction via Traction Devices
         1. Tongs (attached to outer skull)
         2. Halo Devices
      2. Surgical Decompression & Stabilization
         1. For patients with deteriorating neurological status, instability following closed reduction, unstable fx site, & (B) facet dislocation
      3. Operative Tx
         1. – Usually consists of an anterior or posterior arthrodesis w/plate or rod fixation – can occur as early as w/in first 24 hrs postinjury
      4. Immobilization
         1. Occurs following reduction of the fx site to allow for healing
         2. Tongs
            1. Purpose? Used When?
            2. Used primarily as a temporary mode of skeletal traction w/ replacement using a Halo device
            3. – Tongs/calipers=inserted laterally on outer table of skull. – A traction rope is attached to the skull fixation and while pt is in supine, the rope is threaded through a pulley or traction collar with weights attached distally & freely hanging w/o touching floor
         3. Halo Devices
            1. Advantages:
            2. – Assist in reducing 2° complications of prolonged bed rest – Permit earlier progression to upgrade activities – Allowed earlier involvement in a rehab program – Reduce length & cost of hospital stay
            3. – Commonly used to mobilize cervical fxs – Consists of a halo ring with 4 steel screws attached directly to the outer skull. It is attached to a body jacket/best by 4 vertical steel posts – Contraindicated with severe respiratory involvement – Left in place until radiographic findings indicate stability (~12 wks) – After removal, a cervical orthosis is applied until unrestricted movement is allowed (~4-6 wks)
         4. Turning Frames & Beds
            1. Frames are now used primarily as a temporary method of immobilization
            2. Benefits:
            3. – Allow positional changes while maintaining anatomical alignment of the spine – Turning can be accomplished without interruption of the cervical traction
            4. Cons:
            5. – Positioning is limited to prone & supine – Can't accommodate obese pts & unsuitable for unconscious pts
            6. How It Works:
            7. – Consists of an anterior & posterior frame attached to a turning based – Turning from supine position: anterior frame is placed on top of patient. Circular ring clamps in place to secure 2 frames during turning. Safety straps provide additional security – Rotation to prone position: by manually turning the 2 frames as a unit. Uppermost frame is then removed. Return to supine position.
         5. Thoracolumbosacral Orthoses (TLSO)
            1. – Used to mobilize the spine in patients with thoracic or lumbar injuries – The plastic body jacket functions to mobilize the spine & allow earlier involvement in rehab program – Body jackets are typically bivalve to allow for removal during bathing & skin inspection
   3. PT Exam
      1. Respiratory Exam
         1. Fnx of Respiratory mm.
            1. Diaphragm, Abdominals, Intercostals; & RR noted
         2. Chest Expansion
            1. – Circumferential measurements:@ level of axilla & xiphoid process; – The diff in measurements btwn max exhale & max inhale – Norm expansion= 2.5-3 in. @ xiphoid process
         3. Breathing Pattern
            1. – Manual palpation over chest & abdominal region & observation – Pay close attention to use of accessory neck muscles & alteration in breathing pattern when pt is talking/moving
         4. Cough
            1. 3 Cough Classifications
            2. Functional:
            3. strong enough to clear secretions
            4. Weak Functional:
            5. adequate force to clear upper respiratory tract secretions in small quants
            6. Nonfunctional:
            7. unable to produce any cough force
         5. Vital Capacity
            1. – Take w/handheld Spirometer – Can be used as baseline for defining respiratory muscle weakness
      2. Integument
         1. Areas Most Susceptible to Pressure in Recumbent:
            1. Supine
            2. Occiput, scapulae vertebrae, elbows, sacrum, coccyx, heels
            3. Prone:
            4. Ears, shoulders (ant), iliac crest, male genital region Patella, dorsum of feet
            5. Sidelying:
            6. Ears, shoulders (lat), greater trochanter, head of fibula, knees (medial), lateral malleolus Medial malleolus (malleoli contact)
      3. Sensation
         1. Place particular emphasis on pin prick, light touch, & proprioceptive responses
         2. **Sensory level of injury may not correspond to the motor level of injury
      4. Tone & DTR
      5. DTRs
         1. C5 – biceps C6 – ECRL C7 – triceps L3 – quadriceps S1 – gastrocnemius
      6. MMT & ROM
      7. Functional Status
         1. although done in active rehab stage, initial screen is fine but be aware of contraindications & precautions to movement necessitated by healing & potentially unstable fx sites
   4. PT Intervention
      1. Respiratory Mgmt
         1. 3 Primary Goals:
            1. Improved Ventilation
            2. Increased Effectiveness of Cough
            3. Prevention of Chest Tightness & Ineffective Substitute Breathing Patterns
         2. Treatment Activities:
            1. Deep-Breathing Exercises
            2. To facilitate Diaphragmatic movement & increase vital capacity:
            3. Inspiration
            4. apply light pressure just below sternum
            5. Expiration
            6. apply light pressure over the thorax w/hands spread wide
            7. Glossopharyngeal Breathing
            8. – Approp. for or patients with high-level cervical lesions – Pt is instructed to inspire small amounts of air repeatedly, using a sipping or gulping pattern thus utilizing available facial & neck muscles thereby allowing enough air to gradually be inspired to improve chest expansion despite paralysis of the primary muscles of respiration
            9. Airshift Maneuver
            10. – Provides patient with independent method of chest expansion – Closing glottis after maximum inhalation, relaxing diaphragm, & allowing air to shift from lower to upper thorax – Can increase chest expansion by 0.5-2 inches
            11. Strengthening Exercises
            12. Progressive resistive exercises: – Manual contact over epigastric area below xiphoid process or by use of weights
            13. Assisted Coughing
            14. &– Manual contacts over epigastric area – PT pushes quickly in an inward & upper direction as pt attempts to cough
            15. Abdominal Support
            16. – Use of abdominal corset/binder = 4 pts w/proturding abdomen allowing diaphragm to "sag" into poor pos. for fnx
            17. Benefits:
            18. – Will support abdominal contents & improve resting position of diaphragm – (2°): Maintain intrathoracic pressure & degrees postural hypotension
            19. Stretching
            20. stretch pecs & other chest wall muscles to facilitate mobility & compliance of thoracic wall
            21. Others:
            22. – Intermittent positive pressure breathing: assist in maintenance of lung compliance – Modified postural drainage & percussion techniques: to assist with mobilizing & eliminating secretions
      2. ROM & Positioning
         1. Contraindications:
            1. Paraplegia
            2. Motion of the trunk & some motions of the hip *Avoid: SLR more than 60° & hip flexion beyond 90° (during combo hip & knee flexion)
            3. Tetraplegia
            4. Motion of the head & neck pending orthopedic clearance
            5. In prone, position Pt. out of usual position of comfort, in which there is IR, ADD & Ext of shoulders, elbow flex, forearm pronation & wrist flexion
         2. ROM:
            1. exercises should be completed in prone & supine if possible
         3. – Some joint benefit from allowing tightness to develop in certain muscles to enhance function – some muscles require a fully lengthened range – Selective Stretching: process of under stretching some muscles & full stretching of others to improve function
         4. Gadgets:
            1. Positioning Splints
            2. for wrist, hands fingers to maintain alignment for fnxal activities or future dynamic splinting
            3. Ankle Boots
            4. to maintain alignment & prevent heel cord tightness & pressure sores
            5. suspends heel in space & distributes pressure evenly along lower leg
            6. Sandbags/Towel Rolls
            7. to maintain position of neutral hip rotation
      3. Selective Strengthening
         1. – During acute phase certain muscles must be strengthened very cautiously to avoid stress at fx site – Acute phase = emphasize (B) UE activities b/c these will avoid asymmetric, rotational stresses on the spine – Early involvement in functional activity should be stressed (intrinsic value + progressive strengthening benefit
         2. Forms of Strengthening Exercises in Early Phase:
            1. – (B) Manually resisted motions in straight planes – (B) UE PNF patterns – Progressive resistive exercises using cuff wts/dumbbells *Biofeedback training=useful adjunct
         3. w/Tetraplegia
            1. Emphasis should be placed on strengthening: – anterior deltoid – shoulder extensors – biceps – lower trapezius – radial wrist extensors, triceps & pectorals = important in improving functional capacity
         4. w/Paraplegia
            1. All UAE musculature should be strengthened with emphasis on the following which are req'd for transfers & ambulation: – shoulder depressors – triceps – latissimus dorsi
      4. Orientation to the Vertical Position
         1. Cleared for upright Activities when:
            1. Once radiographic findings have estab'd stability of fx site, or early fx stabilization methods are complete
         2. Techniques/Gadgets:
            1. – Gradual acclamation to upright posture to minimize postural hypotension – use of abdominal binder & elastic stockings: retarded venous pooling – In early upright positioning, elastic wraps placed over elastic stockings are often used
         3. Slowly elevating head of bed ==>Reclining or Tilt-in-Space W/C w/elevating leg rests (or just a tilt table)
8. Active Rehab Phase
   1. See Table 23.6 p. 961 for Functional Expectations for young SCI Pts.
   2. PT Exam
      1. Exams & procedures completed during acute phase will continue here at irregular intervals with more complete testing of MMT, ROM, & functional skills now more mobility is allowed
      2. What to examine:
         1. – Functional ability – Wheelchair Skills: setting & releasing will locks, removing foot rest & armrest, propelling w/c on level surfaces, performing wheelies, ascending/descending curbs etc – Seating & wheelchair to determine most appropriate seating syst & w/c for Pt.
      3. Frequently Used Standardized Outcome Measures
         1. Functional Independence Measure (FIM)
            1. – Measures functional ability in a variety of ADLs – reliable & valid
         2. The Wheelchair Skills Test
            1. – Examine a manual w/c user's skills in performing 57 representative w/c skills – Can be used as diagnostic measured to determine which w/c skills need to be addressed & document improvement
            2. Diff skills are categorized according to 3 Levels that reflect difficulty & the setting in which the skills are most often used:
            3. 1. Indoor 2. Community 3. Advanced
         3. The Walking INdex for Spinal Cord Injury (WISCI)
         4. The Spinal Cord Injury Functional Ambulation Inventory (SCI-FAI)
   3. PT Intervention
      1. – Emphasis = maximizing functional independence – Initially = basic skills; progression = skills necessary for work, home & community reentry – If patient is unable to accomplish a specific functional task independently they must be able to instruct a personal-care attendant on how to perform the task
      2. Continuing Activities
         1. – Continuation from acute phase (respiratory management, ROM & positioning) & expanded program of resistive exercise for all muscles that remain innervated – development of motor control & muscle reeducation techniques directed appropriate muscles (based on lesion level) = indicated – emphasis: regaining postural control & balance by substituting upper body control & vision (per loss proprioception) – focuses on improved cardiovascular response to exercise the use of interval training using an UE aerobic activity
      3. Skin Inspection
      4. Mat Programs
         1. General Info:
            1. – Sequence of activities typically progresses from achievement of stability with any posture & advances through control mobility to skill in functional use – early activities: bilateral & symmetrical. A progression is then made to weight shifting & movement within the posture – complete mastery of an activity is not always necessary before moving on to the next – several components of the map progression will be worked on concurrently – should be initiated as soon as patient is cleared for activity
         2. Benefits:
            1. Progression through the sequence of Matt activities develops: – improved strength & functional ROM – improves awareness of new COG – promotes postural stability – facilitates dynamic balance – assists with determining the most efficient & functional methods for accomplishing specific tasks – provides the opportunity to develop functional patterns of movement (i.e. use of innervated musculature or momentum to move body parts that lack active movement)
         3. Rolling
            1. Functional Implications & Benefits
            2. – For improved bed mobility, preparation for independent positional changes in bed (for pressure relief) & LE dressing – provides an early lesson in developing functional patterns of movement – requires the patient to learn use of head, neck & UEs, & momentum, to move trunk &/or LEs – practice on Mat but be sure patient can perform activity in their own bed & roll independently when covered by sheets & blankets – supine==>prone; movement toward weaker side
            3. Approaches/Activities
            4. Flexion of H & N w/Rot
            5. assist w/supine==>prone
            6. Ext of H & N w/Rot
            7. assist w/ prone==>supine
            8. (B), Symmetrical UE Rocking w/outstretched arms 4 pendular motion
            9. assist supine==>prone
            10. Crossing ankles and/or Flexing Hip & Knee of top LE over opp limb
            11. Rolling with use of pillows
            12. assist supine==>prone
            13. pillows under 1 side of pelvis or scapula
            14. assist prone==>supine
            15. pillows under 1 side of chest &/or pelvis
            16. Using PNF Patterns
            17. Assist rolling toward prone
            18. D1 Flexion, D2 Extension, & Reverse Chop
            19. Assist rolling toward Supine
            20. UE Lift Pattern
         4. Prone on Elbows Position
            1. Functional Implications & Benefits
            2. – Improved bed mobility & preparation for assuming the quadruped & sitting positions – facilitates head & neck control as well as proximal stability of the GH & scapular musculature via co-contraction – scapular strengthening exercises can be accomplished
            3. Approaches/Activities
            4. Weightbearing
            5. improve stability @ shoulders thru jt approx
            6. Weight Shifting
            7. Assist w/development of controlled mobility
            8. Rhythmic Stabilization
            9. increase stability of H & N & scapula
            10. Manual Approximation
            11. facilitate stabilization of proximal musculature
            12. Unilat WB
            13. Further facilitate co-contraction in the WB limb
            14. Progressions: fwd-->backward; side 2 side
            15. Strengthening Serratus Ant & other Scapular mm.
            16. Push-up: sim to cat/camel in quadruped
         5. Prone on Hands Position (w/Paraplegia)
            1. Functional Implications & Benefits
            2. – Development of the initial hyperextension of the hips & low back for patients who will required this postural alignment during ambulation & standing from a w/c or rising from the floor with crutches & (B) KAFOs – need a strong pectoralis major & deltoid mm (hands more lateral & arms ER)
            3. Approaches/Activities
            4. Lateral Weight Shift w/Wt tranfer btwn hands
            5. increase joint approximation
            6. Additional Manual Approximation
            7. facilitate tonic holding of proximal musculature further
            8. Scapular Depression & Prone Push-ups
            9. Strengthening exercises
         6. Supine on Elbows Position
            1. Functional Implications & Benefits
            2. – Assist with bed mobility & pair patient to assume a longer sitting position – important strengthening exercise for shoulder extensors & scapular adductors – may cause in pre-shoulder pain due to pressure exerted on anterior shoulder joint capsule
            3. Approaches/Activities
            4. Lateral Weight Shifting
            5. Side-to-Side Movement
            6. enhance pt's ability to align trunk w/LEs when in bed or in prep for positional changes
         7. Pull-Ups (w/Tetraplegia)
            1. Functional Implications & Benefits
            2. – to strengthen the biceps & shoulder flexors in prep for w/c propulsion
            3. Approaches/Activities
            4. – Patient position in supine – PT assumes high kneeling position with 1 LE on each side of patient's hips – PT grasps patient's supinated forearm just above risks – patient pulls to sitting & then lowers back to matt
         8. Sitting
            1. Functional Implications & Benefits
            2. – Many activities are required in sitting – good sitting balance & ability to move within this posture = critical prerequisite skills to standing – early mobility activities in both long & short sitting should emphasize adequate clearance of the buttocks for skin protection
            3. Approaches/Activities
            4. Practice Maintaining the Position
            5. Manual Approximation Force
            6. @ shoulders to promote co-contraction
            7. Variety of PNF Techniques
            8. – Alternating isometrics – rhythmic stabilization
            9. both=important in promoting early stability in this posture
            10. Balancing Activities
            11. Sitting Push-Ups
            12. important preliminary activities for transfers & ambulation
            13. Movement: sitting Push-Up in Combo w/Momentum
         9. Quadruped Position
            1. Functional Implications & Benefits
            2. – Important as a lead up activity to ambulation – first position in the mat sequence that allows WB through the hips – useful for facilitating initial control of the available musculature of the lower trunk & hips
            3. Approaches/Activities:
            4. Maintaining Position; Rhythmic Stabilizaion
            5. facilitate co-contraction
            6. Manual Approximation Application
            7. Facilitate co-contraction
            8. Weight Shifting
            9. Rocking through increments of range
            10. promote development of balance responses
            11. Alternately freeing 1 UE from a WB position
            12. Provides greater jt approximation forces on the supporting extremity & increased tonic holding of the available postural mm.
            13. Movement w/in the Quadruped Position (Creeping)
            14. – Important implications for ambulation – used to improve strength (resisted forward progression) – facilitates dynamic balance reactions – improves coordination & timing
         10. Kneeling Position
             1. Functional Implications & Benefits
             2. – Important for establishing functional patterns of trunk & pelvic control & for promoting upright balance control – important lead up activity to ambulation using crutches & (B) KAFOs
             3. Approaches/Activities:
             4. Maintaining position
             5. Balancing Activities
             6. Variety of Mat Crutch Activities:
             7. – weight shifting – alternately raising 1 crutch at a time – hip hiking – instruction and gait pattern – forward progression using crutches
         11. Transfers
             1. – Generally initiated once the patient has achieved adequate sitting balance
             2. In addition to neurological lesion level, thee are 3 important Components of Transfer Skills:
             3. Momentum
             4. facilitate movement @ a jt(s) when surround musculature is weak
             5. Muscle Substitution
             6. facilitate movement @ a jt(s) when surround musculature is weak
             7. Head-Hips Relationship
             8. head moves forward, butt moves backwards
      5. Prescriptive Wheelchair
         1. Types of W/Cs:
            1. Manual w/c:
            2. 2 Basic Frames
            3. Folding Frame
            4. – For patients who plan to transfer into a car – incorporate a below seed crossbar & generally provide a smoother ride on uneven surfaces – con: more movable parts causing it to be less energy-efficient & slightly less lateral stability
            5. Rigid Frame
            6. – More energy-efficient, usually lighter weight; adjustable seat-to-back angle – more difficult to store and car – allows placement of w/c into Emerson out of a car as components rather than as 1 large unit – generally less smooth riding on an even surfaces (some have shock absorbing springs)
            7. – Need intact triceps function to independently propel – for Pts. With C6 or C-5 level injury or lower
            8. Powered w/c
            9. – for Pts. w/ cervical injuries above C5/C6 – indicated for all patients with C4 lesions & above although patients with C-5 lesions may elect to use power w/c for community mobility – a tilt-in-space or reclining seating system provides improved postural control & it allows the user to independently perform pressure relief
            10. Powered Manual w/c Mix:
            11. PAPAW: Push rim Activated Power Assist Wheelchair
            12. – Is a manual w/c to which power assist wheels have been added – user applies force to the pushrims and the motor is activated providing assistance to the wheels – less energy, lower stroke frequency, & less shoulder ROM (when propelling) – beneficial for individuals with mid to lower level cervical injuries (C5-C6) who may not have the endurance or string to use a manual w/c all the time
         2. General W/C Prescription Guidelines:
            1. Seat Depth
            2. 1-2 in. back from popliteal space – to allow even wt distribution on thighs & prevent excessive pressure on ischial tuberosities
            3. Floor-to-Seat Height
            4. – Needs to allow adequate ( 2 in.) clearance from floor to foot pedals – can provide slightly greater than a 90° angle at the hips
            5. Back height
            6. Seat Width & Depth
            7. Pt. Should be fitted in the narrowest chair possible, but have adequate space between the lateral edges of the thighs & w/c armrests or wheels to avoid skin irritation
            8. Heel Loops/Toe Loops on Footrest; Pelvic Belt; Elevating Footrest
            9. Removable Armrests & Detachable Swing-away Leg rests
            10. Additional Features:
            11. – Enlarged release mechanisms on the foot rests – a friction surface on the hand rims – break extensions – anti-tipping devices – grade aids (which decrease backward movement of the chair while ascending inclined surfaces)
         3. Wheelchair Skills
            1. – Management of the breaks, arms & pedals = crucial for transfer activities – use of cycling gloves will protect skin & improve patients grip on hand rims – be instructed on how to perform wheelies which is required for independent curb climbing – using the wheelchair skills test & wheelchair skills training program which is designed to improve manual wheelchair user performance & safety – instruct patient and pressure relief techniques from a sitting position
      6. Ambulation After SCI
         1. Gait Training for Individs w/Complete SCI
            1. Emphasis is placed on:
            2. – Strengthening available musculature – using assistive devices & orthosis to support weaker and innervated muscles – learn it in a new, compensatory methods of walking
            3. Orthotic Prescription
            4. KAFOs
            5. – Req'd for pts w/complete thoracic lesions – ankle joint usually locked and 5° – 10° of DF to assist hip ext @ heel strike
            6. Types:
            7. Conventional (p 979)
            8. Reciprocating Gait Orthosis (RGO) p. 980
            9. – Allows for unilateral leg advancement & reciprocating gait pattern – a 2 or 4 point gait pattern can be used in combo with crutches or a reciprocating Walker
            10. AFOs
            11. appropriate for pts w/lower-level lesions (L3 & below)
            12. Gait Training Strategies p. 980-982
            13. – A swing-through type of gait pattern should be the ultimate goal for functional emulators with KAFOs – important to stress a smooth, even cadence
            14. Putting on & removing Orthoses
            15. STS Activities
            16. Trunk Balancing
            17. Push-Ups
            18. Turning Around
            19. Jack-knifing
            20. – Entails controlling the pelvic position using UE support & positioning the head & shoulders forward ahead of the pelvis – this is an unstable position, & the patient must be taught recovery to overcome and/or to prevent this from happening during ambulation
            21. Ambulation Activities in // Bars
            22. – 4 & 2 point gaits req hip flex or hip hiking – Pts. w/high lesions may learn this movement using secondary hitchhikers (internal & external obliques & latissimus dorsi)
            23. AD
            24. Forearm crutches: pts. w/paraplegia
            25. Standing from w/c w/crutches
            26. Crutch Balancing
            27. Ambulation Activities
            28. Travel Activities
            29. Elevation Activities
            30. Falling
         2. Locomotor Training for Individs w/Incomplete SCI
            1. Train Like You Walk
            2. Translates into the following practical training guidelines: – the LEs are maximally loaded for WB, minimizing or eliminating loading of the arms – the posture, trunk, pelvis & limb kinematics are coordinated & specific to the task of walking – compensatory strategies for movement (i.e. hitchhiking) are minimized or eliminated
            3. BWS Syst & TM:
            4. – Provide safety, support, task specific repetition of walking and present a means to challenge & progress abilities – affords control of the amount of lower limb loading, assists and upright posture & balance, & allows control of the speed of walking; allows for manual assistance as needed – PT must determine what elements of practice are consistent with task of walking & what elements are inconsistent with task of walking and choose the parameters accordingly – parameters: adjusting load, treadmill speed, & amount of manual assistance – intensity is required; achieving 20 – 30 minutes of total stepping time is recommended, with increasing duration of each training about – transferring skills: daily examination of walking abilities overground & on treadmill with BWS is necessary. Modifying parameters of training in both environments will challenge the use of new skills, reinforce new parameters & independence, & afford information for goal setting across environments
            5. Current Literature p. 987:
            6. – Indicates that following locomotor training that Incorporated use of a BWS system & TM in subacute & post acute rehab that persons with incomplete SCI improved in balance, gait speed, endurance, stairclimbing & Independents – persons with incomplete SCI performing LT during acute rehab has also been established
      7. FES
         1. Uses for SCI:
            1. – Cardiovascular training – breathing – UE function – ambulation – transfers & standing – bowel & bladder function
      8. Prevention, Health Promotion, Fitness & Wellness
         1. Shoulder Pain
            1. Proper postural alignment is a key factor as well as strengthening & stretching shoulder musculature
         2. Exercise
            1. 3-5x/wk @ 50-80% peak HR
            2. Endurance:
            3. –UE ergometer – wheelchair propulsion – swimming – circuit resistance training
            4. Strengthening:
            5. 8-12 reps per exercise for 2 session per wk using: – free weights or – weight machines or – elastic tubing
         3. Education