SPINAL CORD INJURY

MUTHUUKARUPPAN M.

Introduction:
Spinal Cord Injury is damage to the spinal cord that results in a loss of function such as mobility or feeling. Spinal cord injury can be grossly divided into traumatic and non-traumatic spinal cord injuries. Traumatic spinal cord injuries are due to motor vehicle accident, fall or gun shot wound. Non-traumatic injuries occur due to circulatory abnormalities, infectious disorders, degenerative bone disease and congenital malformations.

TRACTS OF SPINAL CORD

DORSAL COLUMN PATHWAY

SPINOCEREBELLAR PATHWAY

SPINOTHALAMIC TRACT

CORTICOSPINAL TRACT

Classification:
Tetraplegia complete (sensory/motor) paralysis of all 4 extremities and trunk, and the respiratory muscles. Paraplegia complete paralysis of trunk and both lower extremities Complete & incomplete lesions: Complete total absence of sensory & motor function in S4 & S5(Anal sensation & voluntary external anal sphincter contraction) Incomplete partial preservation of sensory or motor functions below the level of lesion and/or motor function at S4 & S5. Zones of partial preservation

Spinal Shock
Occurs within 30-60 mins after trauma Flaccid paralysis and absence of all spinal cord reflex activity below the level of the spinal cord lesion Last from few hours, few weeks to months. Recovery from spinal shock would assist in identifying the extent of lesion.

Clinical Syndromes:
Central cord syndrome Anterior cord syndrome Posterior cord syndrome Brown-sequard syndrome Cauda equina syndrome Conus medullaris syndrome

Central Cord Syndrome

Occurs from cervical hyperextension injuries causing ischemic injury to the central part of the cord Congenital or degenerative narrowing of the spinal canal. Compressive forces cause hemorrhage & edema to the central regions of the cord. Severe neurological involvement of the upper extremities than lower extremities. Patient is more likely to lose pain and temperature sensation than proprioception Preservation of sacral tracts normal sexual, bladder & bowel.

Brown-Sequard Syndrome
Results from an injury to only half of the spinal cord Gunshot, stab & spinal cord tumours Motor loss is evident on the same side (ipsilateral) as the injury. Motor signs & dorsal sensory functions are lost on the ipsilateral side Sensory loss is evident on the opposite side (contralateral) of the injury location (pain and temperature loss) Pain & temperature is lost several dermatomes below the level of injury in the contralateral side.

Anterior Cord Syndrome

Flexion injuries with resultant damage to the anterior portion of the cord and or its vascular supply from anterior spinal artery. Loss of motor function, loss of pain & temperature below the level of lesion. Vibration and proprioception are preserved

Posterior cord syndrome

Rare syndrome with deficits in posterior column function Preservation of motor function, light touch, pain & temperature Loss of proprioception, vibration & kinesthesia.

Sacral Sparing
Evident by perianal sensation, rectal motor function and great toe flexor activity Preservation of sacral function be the only sign of incomplete cord lesion If no sacral sparing is identified then it is considered complete cord lesion

Cauda equina syndrome

Spinal cord tapers distally to form conus medullaris at 1st lumbar vertebra. Cauda equina lesions are frequently incomplete owing to the great number of nerve roots involved. Cauda equina lesions are peripheral nerve injuries and have potential to regenerate as elsewhere in the body.

Clinical Presentations:
Direct Impairments: Motor and sensory impairments as per the lesion and the level is exhibited Tone abnormalities Autonomic dysreflexia Postural hypotension Respiratory impairment Impaired temperature control Bladder & bowel dysfunction Sexual dysfunction

Clinical Presentations:
Indirect impairments: Respiratory complications Pressure sores Deep vein thrombosis Contractures Heterotrophic ossification

Autonomic dysreflexia:
Pathologic autonomic reflex present in lesions above T6 level. Acute autonomic activity (hypertension, bradycardia, headache, profuse sweating, increased spasticity, restlessness, vasodilatation above the level of lesion, vasconstriction below the level of lesion, constricted pupils, nasal congestion, piloerection & blurred vision) to noxious stimuli below the level of lesion. Lack of inhibition from higher centres Bladder distention, tight clothing, restricting catheter or abdominal binders are often the stimuli. Medical assistance is always sought at once.

Postural or Orthostatic hypotension

Reduction in BP when assuming vertical position Loss of sympathetic vasoconstriction, leading to peripheral pooling of venous and lymphatic return. Decreased cerebral blood flow, decreased venous return to heart Slow raise of vertical position needs to be obtained from acute stage and taken to vertical position Compression garments to lower limbs, abdominal binder helps in minimizing the effects

Impaired temperature control

Hypothalamus cannot control cutaneous blood flow or sweating after spinal cord injury. Vasodilatation does not occur in response to heat & vasoconstriction neither does not occur in response to cold. Excessive compensatory diaphoresis is observed above the lesion, spotty areas of sweating are observed below the level.

Respiratory Impairment:
C1-C3 lesions require ventilator support or phrenic nerve stimulator Diaphragm & external intercostals provide significant support in inspiratory volume Abdominals & internal intercostals important for expiratory efficiency Effective expiration is reduced leading to increased expiratory reserve volume, does not assist in removing secretions, susceptible to secretions, atelectasis and pulmonary infections. Premorbid respiratory problems adds to all the exisiting symptoms.

Spasticity:
Intact reflex arcs below the level of lesion characterizes spasticity, hperactive stretch reflexes and clonus. Spasticity is increased by internal and external stimuli. Patients with minimal to moderate involvement trigger spasticity to assist in functional activities. Drugs to reduce spasticity is provided along with other invasive procedures (intrathecal baclofen, rhizotomy, neurectomy, tenotomy & tendon lengthening).

Bladder dysfunction:
During spinal shock the bladder would be flaccid. Micturation centre conus medullaris S2,S3&S4. Lesion above conus medullaris (above T12) Spastic or reflex or automatic bladder Lesion at conus medullaris (at or below T12) Flaccid or nonreflex or autonomous bladder Spastic reflex emptying Flaccid pressure techniques

Sexual dysfunction:
Male response: Erectile capacity reflexogenic and not psychogenic Ejaculations are reduced Orgasms reduced Female response: Vaginal lubrication, engorgement of labia & clitoral erection are reflexogenic Mensturation returns to normal after 3 months of injury. Fertility & pregnancy is not impaired

Medical Management:
Emergency care Fracture stabilization immobilization

Goals of Physiotherapy:
Maintaining or improving ROM Strengthening of all intact and affected muscles Modulating muscle tone Reducing pain Training transfers & ambulation Maintaining bladder & bowel functions Training use of assistive devices Prevention of pressure sore and maintain muscle length Maintaining respiratory functions

Range of Motion
Active ROM exercises Passive Stretching Ankle boots and night splints CONTRAINDICATIONS: Tetraplegia: Stretching shoulder muscles Paraplegia: SLR above 60; Hip flexion beyond 90 EXCEPTIONS: Tightness of finger flexors will help in grasping through Tenodesis. Lengthened hamstrings and tight low back muscles help in sitting and standing.

Motor Functions:
Strengthening: Bilateral exercises for UL Bad ragaz technique, PRE using manual/mechanical resistance Strengthening crutch muscles Functional strengthening: under water walking, static bicycling etc. Tone: ES of paralyzed muscles Facilitation and inhibition techniques Emphasis on weight bearing activities PNF

Orientation to upright position:

Tilt table Abdominal binders & stockings can be used Pressure Sores: Turning and positioning for prevention Physiotherapy modalities Ultrasound, LASER, Ionotophoresis with medical management

Bowel and Bladder Retraining

Innervation of bladder and bowel: s2,3,4 Two types Spastic (Automatic) Flaccid (Autonomous) Automatic or Reflex Bladder: Lesions above the conus medullaris Reflex arc is intact Empty by giving different stimuli- stroking the inner thigh, pressure over the lower abd., kneading or tapping the supra pubic region, and hair pulling

Autonomous or Non Reflexive Emptying:

Lower motor neuron disorders. No reflex action of the detrusor. Empty by increasing abdominal pressure, using Valsalva, or manually compressing the lower abdomenCrede maneuver

Bladder Training Program

Primary goal- catheter free and control bladder function. Most frequently uses intermittent catheterization. Purpose: establish reflex bladder emptying at regular and predictable intervals.

Intermittent Catheterization
Fluids are restricted to 2000 ml/day. At 150-180ml/hr. Intake stopped late in the day. Initially catheterize patient for every 4h. Prior to catheterization, patient attempts to void in combination with 1 or more manual stimulation techniques. Catheter is inserted, residual volume recorded. As bladder becomes more effective, residual volumes will decrease and time intervals will increase

Autonomous bladder retraining

Pattern of incontinence is established Residual volume is measured, to assure it is in safe limits. Once incontinence patterns are established a comparison is made with intake patterns. Next an intake and voiding schedule is made Eventually, the bladder becomes trained to empty at regular, predictable intervals. As incontinence decreases, schedules are readjusted to increase intervals bet. voiding

Bowel Retraining:
Reflexive and Autonomous as in the Bladder. Reflex defecation: digital stimulation of the anal sphincter with a gloved hand or an orthotic digital stimulator. Autonomous: relies on straining heavy musculature and manual evacuation of the rectum.

Guidelines for bowel program

Perform at same time each day Follow a high fiber diet Drink at least 8 glasses of water/day Drink a warm liquid 30 mins before initiating the program Perform in an upright position Consider premorbid bowel schedule

C1-C3 Lesion
Cervical paraspinal, sternocleidomastoid, neck accessory muscles, partial innervation of diaphragm

C1 3 Levels Respiratory

Expected Functional Outcomes Ventilator dependent Inability to clear secretions Total assist

Equipment 2 ventilators (bedside, portable) Suction equipment Generator/battery backup Padded reclining shower/commode chair (if roll-in shower available)

Bowel

Bladder

Total assist

Bed Mobility
Transfers

Total assist
Total assist

Full electric hospital bed side rails

Transfer board Power or mechanical lift with hoist Power recline and/or tilt W/C W/C pressure-relief cushion Postural support and head control devices as indicated Hand splints may be indicated Specialty bed or pressure-relief mattress may be indicated

Pressure relief

Total assist; may be independent with equipment

Eating Dressing

Total assist Total assist

Grooming

Total assist

C4 lesion
Diaphragm & Paraspinal muscles

C4 Level Respiratory Bowel

Expected Functional Outcomes May be able to breathe without a ventilator Total assist

Equipment If not ventilator free then same equipment as for C1-3 Padded reclining shower/commode chair (if rollin shower available)

Bladder Bed Mobility

Total assist Total assist Full electric hospital bed with Trendelenburg feature side rails Transfer board Power or mechanical lift with sling Power recline and/or tilt W/C W/C pressure-relief cushion Specialty bed or pressure-relief mattress may be indicated

Transfers

Total assist

Pressure relief Total assist; may be independent with equipment Eating Dressing Grooming Total assist Total assist Total assist

C5 Lesion
Biceps (elbow flexors), deltoids, rhomboids, partial innervation of serratus anterior (shoulder flexion, extension, & abduction)

C5 Level Respiratory

Expected Functional Outcomes May require assist to clear secretions

Equipment

Bowel
Bladder Bed Mobility Transfers Pressure relief

Total assist
Total assist Some assist Total assist Independent with equipment

Padded shower/commode chair or transfer tub bench with commode cutout

Adaptive devices may be indicated Full electric hospital bed Side rails Transfer board Power or mechanical lift with hoist Power recline and/or tilt W/C W/C pressure-relief cushion Specialty bed or pressure-relief mattress may be indicated Long opponens splint Adaptive devices as indicated Long opponens splint Adaptive devices as indicated Long opponens splint Adaptive devices as indicated

Eating Dressing

Assist for setup, then independent with equipment Lower extremity: Total assist Upper extremity: Some assist Some to total assist

Grooming

C6 Lesion
Wrist extensors

C6 Level
Respiratory Bowel

Expected Functional Outcomes

May require assist to clear secretions Some to total assist

Equipment

Padded shower/commode chair or transfer tub bench with commode cutout Adaptive devices as indicated Adaptive devices may be indicated Full electric hospital bed side rails Transfer board mechanical lift Power recline and/or tilt W/C W/C pressure-relief cushion Pressure-relief mattress or overlay may be indicated Adaptive devices as indicated (e.g. u-cuff, tenodesis splint, adapted utensils, plate guard) Adaptive devices as indicated (e.g. button hook, loops on zippers, Velcro on shoes)

Bladder Bed Mobility Transfers Pressure relief

Some to total assist with equipment Some assist Level: some assist to independent Independent with equipment and/or adapted techniques

Eating

Assist for setup (cutting), then independent Lower extremity: some to total assist Upper extremity: independent

Dressing

Grooming

Some assist to independent with equipment

Adaptive devices as indicated (e.g. u-cuff, adapted handles)

C7-8 Lesion
Triceps (elbow extensors), finger flexors

C7 8 Levels
Respiratory Bowel

Expected Functional Outcomes Equipment

May require assist to clear secretions Some to total assist Padded shower/commode chair or transfer tub bench with commode cutout Adaptive devices as indicated

Bladder Bed Mobility

Independent to some assist Independent to some assist

Adaptive devices may be indicated Full electric hospital bed or full to king standard bed May need transfer board

Transfers

Level: independent Uneven: independent to some assist Independent

Pressure relief

W/C pressure-relief cushion Postural support devices as indicated Pressure-relief mattress or overlay may be indicated

Eating Dressing

Independent Lower extremity: independent to some assist Upper extremity: independent

Adaptive devices as indicated Adaptive devices as indicated

Grooming

Independent

Adaptive devices as indicated

T1-9 LESION
Extrinsic & Intrinsic finger flexors, Intercostals, para and sacrospinalis

T1 9 Levels Respiratory Bowel

Expected Functional Outcomes

Equipment

Independent

Elevated padded toilet seat or tub bench with commode cutout Adaptive devices as indicated

Bladder

Independent
Full to king standard bed May need transfer board W/C pressure-relief cushion Postural support devices as indicated Pressure-relief mattress or overlay may be indicated

Bed Mobility Independent Transfers Pressure relief Independent Independent

Eating Dressing

Independent Independent

Grooming

Independent

T10-12 LESION
Lower abdominals and intercostals

T10-12 Levels
Respiratory Bowel

Expected Functional Outcomes

Independent

Equipment

Elevated padded toilet seat or tub bench with commode cutout Adaptive devices as indicated

Bladder Bed Mobility Transfers Pressure relief

Independent Independent Independent Independent Full to king standard bed May need transfer board W/C pressure-relief cushion Postural support devices as indicated Pressure-relief mattress or overlay may be indicated

Eating Dressing Grooming

Independent Independent Independent

Bathing

Independent

Handheld shower Padded tub transfer bench or shower/commode chair Manual lightweight rigid or folding W/C Standard standing frame, bilateral KAFO, crutches or walker Hand controls Adaptive devices as indicated

W/C propulsion Standing/ Ambulation Communication Transportation Homemaking

Independent Standing: Independent Ambulation: functional Independent Independent in car, including W/C loading/unloading Independent complex meal prep and light housecleaning; some to total assist for heavy housekeeping Personal care: 6 hours/day Homecare: 2 hours/day

Assist Required

Level

Expected Functional Outcomes

House hold ambulation Wheelchair skills

Equipment

L1,2,3 Levels Gracilis, Iliopsoas, QL L4,5 ED, LB muscles, QF, TA

B/L KAFO, Crutches Wheelchair

Functional ambulation Wheelchair skills

B/L KAFO, Crutches Wheelchair

Mat Programs
Sequence followed: Achieve stability Controlled mobility Skill Functional use of skill Rolling: Improves bed mobility Prepares for positional changes in bed LE dressing Start teaching from supine With asymmetry, start towards affected side

Prone on Elbows
Indications: Enhance bed mobility Preparation for quadruped and sitting Facilitates head and neck control Facilitates glenohumeral and scapular m cocontraction Scapula strengthening can be done here

Prone on hands
Used with paraplegics. Requires an excessive Lumbar Lordosis so not tolerated well by some. Functional link: with hip hyperextension during gait necessary for postural alignment. W/C stand Rising from the floor with KAFOs

Supine on Elbows
Assists with bed mobility. Prepares for long sit position. Without abdominals, patient Must wedge the hands beneath the hips or hook thumbs on into pants pockets or belt loops. Pt uses the biceps or wrist extensors to pull up partially into the position then shifts repeatedly from side to side until elbows are under the shoulders.

Pull Ups
Strengthening to the Biceps and shoulder flexors. Good prep for w/c propulsion. Patient supine, PT grasps patient supinated forearms just above the wrist. Patient Pulls up to sitting then lowers back to mat.

Sitting
Practice long and short sit for ADL In sitting, the higher the lesion, the > the curve in long sit. The head is maintained forward for balance.

Quadruped
Paraplegics: important for pregait, Allows WB through the hips. Have patient Start prone on elbows, progressing WB on hands, one at a time, then forcefully flex head, neck and upper trunk while pushing into the mat. This assists with elevating the pelvis, patient continues to walk back until hips are over knees.

Kneeling
Functional patterns of trunk control and pelvic control are developed here. Important pregait activity. Can be done with mat crutches. Start in quadruped: transitions by walking back with hands, sitting on heels. Stall bars are good to facilitate. PT guards pelvis

Wheel chair Transfers

Removable/ flip up armrests Breaks Sliding boards for assistance

Ambulation
Preambulation balance in parallel bars, recovery from the beginning of jackknife position Turning

Orthosis Types
KAFO- T9-T12. Ankles are in 5-10 DF to assist the hip hyperextension. COG posterior to hip, anterior to ankles. RGO (reciprocal gait orthosis) T2-L1. Two KAFOS joined at the pelvis by a pelvic band. Help transmit forces between LE and provide reciprocal movement. R hip ext facilitates L hip flexion AFO- for L3 and below

FES
Functional Electric Stim has been applied to various nerves in the lower extremities to facilitate a more normal gait. Theory is that FES applies the appropriate sensory input necessary to normalize reflex output of the spinal cord. Therefore the disruption caused by the SCI is removed. Can be used in conjunction with BWS.

ANY QUESTIONS???