Spinal Cord Injury 3

1. PHYSIOTHERAPY MANAGEMENT FOR SPINAL CORD INJURY

2. EARLY MEDICAL AND REHABILITATION MANAGEMENT IN THE ACUTE STAGE Emergency Care Fracture Stabilization Immobilization 2 #1 #2 #3

3. Emergency Care 20XX Pitch deck title 3 When an SCI is suspected, efforts should be made to avoid both active and passive movements of the spine. • If the injury caused a displaced fracture, Movement of the spine should be minimized by strapping the patient to a spinal backboard or a full-body adjustable backboard, using a supporting cervical collar, immobilizing the head. • On arrival at the emergency department, initial attention is focused on stabilizing the patient medically with a primary emphasis on ventilation and circulation. • Preventing progression of neurological impairment by restoration of vertebral alignment and early immobilization of the fracture site • High doses of methylprednisolone (anti-inflammatory) may be given early after the injury to lessen the secondary damage due to the inflammatory process. #1

5. Fracture Stabilization Pitch deck title 5 The goal of fracture/spinal injury site management is to stabilize the spinal column to prevent further damage to the cord. Reduction and immobilization of spinal injuries can be achieved via conservative or operative methods. Indications for surgical stabilization are: • Unstable fracture site • Gross malalignment • Cord compression • Deteriorating • Neurological status. #2

6. 20XX Pitch deck title 6 o In people with acute, traumatic SCI, early (within 24 hours) surgical decompression is recommended. o Closed reduction is indicated for patients with cervical subluxation or fracture dislocation injuries. o It is achieved with the use of traction devices. o Patients with thoracic or lumbar injuries that are managed conservatively without surgery require immobilization by positioning in a regular or rotating bed (Roto rest bed)

8. Immobilization 20XX Pitch deck title 8 Following reduction of the fracture site, through either conservative or surgical means, the spine is immobilized for a period of time through the use of spinal orthoses and recumbent positioning. #3 i. Cervical Orthoses: • This spinal orthosis consist of a halo ring with four steel screws that attach directly to the outer skull. • The halo is attached to a body jacket or vest by four vertical steel posts. • A halo is extremely effective at limiting cervical motion in all planes.

9. 20XX Pitch deck title 9 • The most common complication of a halo orthosis is loosening of the pin site. • This can create instability at the injury site in the vertebral column or be a sign of infection. • Skin breakdown may also occur under the vest portion of the halo.

10. 20XX 10 Minerva is another type of cervical orthosis (CO) that also effectively limits motion in all planes Like the halo, because it provides excellent cervical stability. The Minerva allows for early mobility and rehabilitation after SCI. The sterno–occipital–mandibular immobilizer (SOMI) is another type of CO. Generally these are constructed of semirigid foam and plastic and consist of two halves, which are held together with hook-and-loop closures. Common types of collars include Philadelphia collar, Miami J collar, Aspen collar, and foam soft collar. They do not effectively immobilize the spine. However, they may be used as transitional support following removal of a more rigid device (e.g., halo).

11. 20XX 11 ii. Thoracolumbosacral Orthoses: A thoracolumbosacral orthosis (TLSO) is commonly used to immobilize the spine in patients with thoracic or lumbar injuries. • A TLSO is made by an orthotist who takes a cast of the patient’s trunk and makes the molded body jacket from the impression.

12. • Body jackets are typically bivalved and connected by hook-and-loop closures, which allows for removal during bathing and skin inspection. • An extension is necessary with high thoracic injuries and low lumbar injuries in order to provide effective immobilization of the spine in these areas. A Jewett orthosis is a prefabricated device made of a metal frame and pads. he Jewett orthosis is not as effective for immobilizing the spine as a body jacket.

14. THE ACUTE STAGE RECOVERY PHYSICAL THERAPY MANAGEMENT 14

15. # Respiratory Management Respiratory care will vary according to the level of injury and individual respiratory status. Primary goals of management include improved ventilation, increased effectiveness of cough, and prevention of chest tightness and ineffective substitute breathing patterns. Individuals with cervical injuries at and above C5 often require ventilatory support using an intermittent positive pressure ventilator (IPPV). o Deep-Breathing Exercises: Diaphragmatic breathing should be encouraged. To facilitate diaphragmatic movement and increase VC.

16. o Glossopharyngeal Breathing: Glossopharyngeal breathing may be appropriate for patients with high-level cervical lesions who are dependent on a mechanical ventilation. Glossopharyngeal breathing utilizes the lips, pharyngeal muscles, and the tongue to inhale air. The patient is instructed to take in small amounts of air, using a “gulping” pattern, thus utilizing available facial and pharyngeal muscles. The patient repeats this 6 to 10 times. By using this technique, enough air is gradually inspired. Exhalation occurs due to the elastic recoil of the lungs.

17. o Respiratory Muscle Strengthening: Inspiratory muscles can be trained using relatively inexpensive handheld devices. There are generally two types of handheld inspiratory muscle training devices: resistive or threshold trainers. Breathing through these devices increases the resistive or threshold inspiratory load on the muscles.

18. o Coughing: Patients who are not able to produce a functional cough should be taught to perform a self-assisted cough. Those who cannot perform a self-assisted cough may benefit from a manually assisted cough to help remove secretions. To assist with coughing and movement of secretions, manual contacts are placed over the epigastric area. The therapist pushes quickly in an inward and upward direction as the patient attempts to cough.

19. # Abdominal Binder: An abdominal binder may improve respiratory mechanics by compensating for nonfunctioning abdominal muscles. The binder compresses abdominal contents to increase intra-abdominal pressure, and elevate the diaphragm into a more optimal position for breathing. In addition, abdominal binders may provide the secondary benefits of maintaining intrathoracic pressure and decreasing postural hypotension. # Manual Stretching: Mobility and compliance of the thoracic wall can be facilitated by manual stretching chest wall muscles in supine. This is done by placing one hand around the side of the chest wall with the fingertips on the transverse processes and the other hand on top of the chest with the heel on the edge of the sternum. The hands are moved in a wringing motion. Pressure should be distributed across the surface of the hands.

20. # Skin Care: • Positioning: to prevent development of joint contractures and secondary pulmonary complications. • Specific positioning of the UEs and LEs to prevent contractures by using pillows, foam, and positioning devices. • patients should be repositioned at least every 2 hours. • The wheelchair and seating system should also assist in promoting optimal positioning for reducing pressure and shear forces on susceptible areas. The pelvis should be positioned in a neutral position or slightly tilted anteriorly and be symmetrical. (Cushions: foam, gel, air, and flexible matrix) • Patients should perform a pressure relief (push-up maneuver) every 15 minutes when in the wheelchair. • Routine Skin inspection using a long-handled mirror.

21. # Early Strengthening and Range of Motion: Range of motion exercises should be completed daily except in those areas that are contraindicated or require selective stretching. • In this early stage of recovery, ROM or strengthening exercises that are too intense may place increased pressure and stress on vertebral sites that may be unstable and are still healing. • The pelvis should remain in a neutral position when ROM is performed on the LEs. • When the injury is in the lumbar spine, straight leg raises more than approximately 60 degrees and hip flexion beyond 90 degrees (during combined hip and knee flexion) should be avoided. • With tetraplegia, motion of the head and neck is contraindicated pending orthopedic clearance. Extreme caution should be used when stretching the shoulders. • Generally, shoulder flexion and abduction beyond 90 degrees is contraindicated until orthopedic clearance is received indicating the spine is fully healed and stable.

22. Patients with SCIs do not require full ROM in all joints. Some joints benefit from allowing tightness to develop in certain muscles to enhance function. For example, with tetraplegia, tightness of the lower trunk musculature may improve sitting posture by increasing trunk stability; tightness in the long finger flexors will provide an improved tenodesis grasp. Conversely, some muscles require a fully lengthened range. After the acute phase, the hamstrings will require stretching to achieve a straight leg raise of approximately 100 degrees. This ROM is required for many functional activities such as long sitting and LE dressing. • Care should be taken not to overstretch the hamstring muscles because some tightness in this muscle group provides passive pelvic stabilization in sitting. his process of under-stretching some muscles and full stretching of others to improve function is referred to as selective stretching

23. Positioning of the wrist, hands, and fingers • Tenodesis grasp: the wrist is actively extended, the tendons of the fingers are shortened causing the fingers to passively flex and grasp. When the wrist is flexed, the tension on the tendons is released and the hand opens providing release. • intrinsic-plus splint can be used to position the wrist (20 degrees of extension), metacarpal phalangeal joints (80 to 90 degrees of flexion), interphalangeal joints (full extension or slight flexion), and the thumb (natural opposition) to maintain the joints in optimal intrinsic-plus position. This position helps reduce edema, preserve tenodesis function, and prevent contractures.

24. ACTIVE REHABILITATION PHYSICAL THERAPY MANAGEMENT 24

25. The Goalof physical rehabilitation is for the patient to become as independent as possible and to achieve the functional mobility necessary for everyday living, work, and recreation. Independent mobility can be achieved in a way that (1) Either use new movement strategies to compensate for neuromuscular impairments. (2) Use the neuromuscular system to accomplish the task with a movement pattern similar to that before the injury. Compensation refers to use of an alternative or new movement strategy, or technology to compensate for neuromuscular deficits to accomplish a daily task. Recovery of function refers to the restoration of the neuromuscular system so that the motor task is performed in the same manner as it was before the SCI

26. # BedMobilitySkills Bed mobility skills are necessary to promote independence in functional mobility. Bed mobility skills include rolling, transitioning supine to/from sitting on the edge of the bed, and LE management. Rolling

27. Transitioning Supine to/from Sitting There are two basic methods : (1) “walking” onto elbows from prone or side-lying (2) coming straight up from supine Prone on Elbows

28. # Sitting Balance Independent sitting balance, both in short sitting and long sitting, is an important skill for many different functional tasks such as transfers, dressing, and wheelchair mobility. Sitting balance training is initially done by assisting the patient into a balanced short or long sitting position. In short sitting the patient should initially be positioned with the feet firmly supported on the floor and the hips and knees flexed to 90 degrees. In long sitting patients should have approximately 90 to 100 degrees of straight leg raise ROM to avoid overstretching the low back muscles.

29. # Transfers There are three components to the sit-pivot transfer (e.g., bed to/from wheelchair in a seated position): 1. preparatory phase 2. lift phase 3. descent phase. During the preparatory phase, the trunk flexes forward, leans laterally, and rotates toward the trailing arm. The lift phase starts when the buttocks lift off the sitting surface and continues while the trunk is lifted halfway between the two surfaces. The descent phase denotes the period when the trunk is lowered to the other seated surface, from the halfway point until the buttocks are on the other surface.

30. Floor-to-Wheelchair Transfers There are three basic floor-to-wheelchair techniques: Backward approach, forward approach, and sideways approach

31. Forward approach sideways approach

32. # Locomotor Training Strategies • Putting on and removing orthoses • Assistive device • Sit-to-stand activities • Static standing balance • Weight shifting in standing. • Swing-through pattern • body weight supported treadmill training • partial body weight supported treadmill training • weight supported treadmill training.

33. THANK YOU Presented by: Dinu Dixon MPT (Neurology)

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