Spinal Cord Injury- Physical Therapy Management

SPINAL CORD INJURY: REHABILITATION

Vipinnath E. Nalupurakkal MPT (Neuro) Consultant Neurophysiotherapist

Objectives  In this session we will discuss: 2. The Aims and 3. Goals of SCI Rehab. 4. Levels of injury and their expected functional outcomes 5. The various PT measures to achieve the goals

Aims  Prevent the progression of complications.  Promote recovery

Goals Characteristics:  Patient-focused  Appropriate and objective  With the co-operation of interdisciplinary team, led by the patient

Goals  ROM  Strength of all intact and affected muscles  Muscle tone  Pain  Upright sitting and standing without complications  Pressure sores

Goals contd…  Bladder and bowel  Transfers  Ambulation  Use of assistive devices  FES

Functional Expectations Levels of injury and outcomes

C1-C3 (Tetraplegia) Cervical paraspinal, sternocleidomastoid, neck accessory muscles, partial innervation of diaphragm

C1 – 3 Levels

Expected Functional Outcomes

Equipment

Respiratory

• Ventilator dependent • Inability to clear secretions

• 2 ventilators (bedside, portable) • Suction equipment • Generator/battery backup

Bowel

Total assist

• Padded reclining shower/commode chair (if roll-in shower available)

Bladder

Total assist

Bed Mobility

Total assist

• Full electric hospital bed • side rails

Transfers

Total assist

• Transfer board • Power or mechanical lift with sling

Pressure relief

Total assist; may be independent with equipment

• 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

Eating

Total assist

Dressing

Total assist

Grooming

Total assist

Bathing

Total assist

• Handheld shower • Shampoo tray • Padded reclining shower/commode chair (if roll-in shower available)

W/C propulsion

Manual: Total assist Power: Independent with equipment

• Power recline and/or tilt W/C with head, chin, or breath control • Manual recliner W/C • Vent tray

Standing/ Ambulation

Standing: Total assist Ambulation: Not indicated

Communication

Total assist to independent, depending on work station setup and equipment availability

• Mouth stick, high-tech computer access, environmental control unit • Adaptive devices everywhere as indicated

Transportation

Total assist

• Attendant-operated van (e.g. lift, tie-downs) or accessible public transportation

Homemaking

Total assist

Assist Required

• 24-hour attendant care to include homemaking • Able to instruct in all aspects of care

C4 Further innervation of diaphragm & paraspinal muscles

C4 Level

Expected Functional Outcomes

Equipment

Respiratory

May be able to breathe without a ventilator

If not ventilator free then same equipment as for C1-3

Bowel

Total assist

• Padded reclining shower/commode chair (if roll-in shower available)

Bladder

Total assist

Bed Mobility

Total assist

• Full electric hospital bed with Trendelenburg feature • side rails

Transfers

Total assist

• Transfer board • Power or mechanical lift with sling

Pressure relief

Total assist; may be independent with equipment

• 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

Eating

Total assist

Dressing

Total assist

Grooming

Total assist

Bathing

Total assist

• Handheld shower • Shampoo tray • Padded reclining shower/commode chair (if roll-in shower available)

W/C propulsion

Manual: Total assist Power: Independent

• Power recline and/or tilt W/C with head, chin, or breath control • Manual recliner W/C • Vent tray

Standing/ Ambulation

Standing: Total assist Ambulation: Not indicated

• Tilt table • Hydraulic standing table

Communication

Total assist to independent, depending on work station setup and equipment availability

• Mouth stick, high-tech computer access, environmental control unit

Transportation

Total assist

• Attendant-operated van (e.g. lift, tie-downs) or accessible public transportation

Homemaking

Total assist

Assist Required

• 24-hour attendant care to include homemaking • Able to instruct in all aspects of care

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

C5 Level

Expected Functional Outcomes

Equipment

Respiratory

May require assist to clear secretions

Bowel

Total assist

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

Bladder

Total assist

• Adaptive devices may be indicated (electric leg bag emptier)

Bed Mobility

Some assist

• Full electric hospital bed with Trendelenburg feature • side rails

Transfers

Total assist

• Transfer board • Power or mechanical lift with sling

Pressure relief

Independent with equipment

• 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

Eating

Assist for setup, then independent with equipment

• Long opponens splint • Adaptive devices as indicated

Dressing

Lower extremity: Total assist Upper extremity: Some assist

• Long opponens splint • Adaptive devices as indicated

Grooming

Some to total assist

• Long opponens splint • Adaptive devices as indicated

Bathing

Total assist

• Handheld shower • Padded tub transfer bench or shower/commode chair

W/C propulsion

Manual: Independent to some assist indoors on noncarpet, level surface; some to total assist outdoors Power: Independent

• Power recline and/or tilt W/C with arm drive control • Manual lightweight rigid or folding W/C with handrim projections

Standing/ Ambulation

Standing: Total assist Ambulation: Not indicated

• Hydraulic standing frame

Communication

Independent to some assist after setup • Long opponens splint • Adaptive devices as indicated for page and equipment availability turning, writing, button pushing

Transportation

Independent with highly specialized equipment; some assist with accessible public transportation; total assist for attendant-operated vehicle

Homemaking

Total assist

Assist Required

• Personal care: 10 hours/day • Homecare: 6 hours/day • Able to instruct in all aspects of care

• Highly specialized modified van with lift

C6 Wrist extensors

C6 Level

Expected Functional Outcomes

Equipment

Respiratory

May require assist to clear secretions

Bowel

Some to total assist

• Padded shower/commode chair or transfer tub bench with commode cutout • Adaptive devices as indicated

Bladder

Some to total assist with equipment; may be independent with leg bag emptying

• Adaptive devices may be indicated

Bed Mobility

Some assist

• Full electric hospital bed • side rails

Transfers

Level: some assist to independent Uneven: some to total assist

• Transfer board • mechanical lift

Pressure relief

Independent with equipment and/or adapted techniques

• Power recline and/or tilt W/C • W/C pressure-relief cushion • Postural support devices • Pressure-relief mattress or overlay may be indicated

Eating

Assist for setup (cutting), then independent

• Adaptive devices as indicated (e.g. u-cuff, tenodesis splint, adapted utensils, plate guard)

Dressing

Lower extremity: some to total assist Upper extremity: independent

• Adaptive devices as indicated (e.g. button hook, loops on zippers, Velcro on shoes)

Grooming

Some assist to independent with equipment

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

Bathing

Lower body: some to total assist Upper body: independent

• Handheld shower • Padded tub transfer bench or shower/commode chair • Adaptive devices as indicated

W/C propulsion

Manual: Independent indoors; some to total assist outdoors Power: Independent

• May require standard upright power or recline • Manual lightweight rigid or folding W/C with modified rims

Standing/ Ambulation

Standing: Total assist Ambulation: Not indicated

• Hydraulic standing frame

Communication

Independent

• Adaptive devices as indicated for page turning, writing, button pushing

Transportation

Independent driving from W/C

• Modified van with lift and tie-downs • Sensitized hand controls

Homemaking

Some assist with light meal prep; total assist for other homemaking

• Adaptive devices as indicated

Assist Required

• Personal care: 6 hours/day • Homecare: 4 hours/day

C7-8

Triceps (elbow extensors), finger flexors

C7 – 8 Levels

Expected Functional Outcomes

Equipment

Respiratory

May require assist to clear secretions

Bowel

Some to total assist

• Padded shower/commode chair or transfer tub bench with commode cutout • Adaptive devices as indicated

Bladder

Independent to some assist

• Adaptive devices may be indicated

Bed Mobility

Independent to some assist

• Full electric hospital bed or full to king standard bed

Transfers

Level: independent Uneven: independent to some assist

• May need transfer board

Pressure relief

Independent

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

Eating

Independent

• Adaptive devices as indicated

Dressing

Lower extremity: independent to some assist Upper extremity: independent

• Adaptive devices as indicated

Grooming

Independent

• Adaptive devices as indicated

Bathing

Lower body: independent to some assist Upper body: independent

• Handheld shower • Padded tub transfer bench or shower/commode chair • Adaptive devices as indicated

W/C propulsion

Manual: Independent indoors and level outdoor terrain; some assist uneven terrain

• Manual lightweight rigid or folding W/C with modified rims

Standing/ Ambulation

Standing: Independent to some assist Ambulation: Not indicated

• Hydraulic or standard standing frame

Communication

Independent

• Adaptive devices as indicated

Transportation

Independent car if independent with transfer and W/C loading/ unloading; independent driving modified van from captain’s seat

• Modified vehicle

Homemaking

Independent light meal prep and light housecleaning; some to total assist for complex meal prep and heavy housekeeping

• Adaptive devices as indicated

Assist Required

• Homecare: 2 hours/day • Personal care: 6 hours/day

T1-9 (Paraplegia) Extrinsic & Intrinsic finger flexors, Intercostals, para and sacrospinalis

T1 – 9 Levels

Expected Functional Outcomes

Equipment

Bowel

Independent

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

Bladder

Independent

Bed Mobility

Independent

• Full to king standard bed

Transfers

Independent

• May need transfer board

Pressure relief

Independent

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

Eating

Independent

Dressing

Independent

Grooming

Independent

Respiratory

Bathing

Independent

• Handheld shower • Padded tub transfer bench or shower/commode chair

W/C propulsion

Independent

• Manual lightweight rigid or folding W/C

Standing/ Ambulation

Standing: Independent Ambulation: Typically not functional

• Standard standing frame

Communicati on

Independent

Transportatio n

Independent in car, including W/C loading/unloading

• Hand controls

Homemaking

Independent complex meal prep and light housecleaning; some to total assist for heavy housekeeping

• Adaptive devices as indicated

Assist Required

• Personal care: 6 hours/day • Homecare: 2 hours/day

T10-12 Lower abdominals and intercostals

T10-12 Levels

Expected Functional Outcomes

Equipment

Bowel

Independent

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

Bladder

Independent

Bed Mobility

Independent

• Full to king standard bed

Transfers

Independent

• May need transfer board

Pressure relief

Independent

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

Eating

Independent

Dressing

Independent

Grooming

Independent

Respiratory

Bathing

Independent

• Handheld shower • Padded tub transfer bench or shower/commode chair

W/C propulsion

Independent

• Manual lightweight rigid or folding W/C

Standing/ Ambulation

Standing: Independent Ambulation: functional

• Standard standing frame, bilateral KAFO, crutches or walker

Communicati on

Independent

Transportatio Independent in car, including n W/C loading/unloading

• Hand controls

Homemaking

Independent complex meal prep and light housecleaning; some to total assist for heavy housekeeping

• Adaptive devices as indicated

Assist Required

• Personal care: 6 hours/day • Homecare: 2 hours/day

level

Expected Functional Outcomes

Equipment

L1,2,3 Levels Gracilis, Iliopsoas, QL

House hold ambulation Wheelchair skills

B/L KAFO, Crutches Wheelchair

L4,5 ED, LB muscles, QF, TA

Functional ambulation Wheelchair skills

B/L KAFO, Crutches Wheelchair

SCI Mechanism video

Range of Motion  Active ROM exercises  Passive Stretching  Ankle boots and night splints CONTRAINDICATIONS  Tetraplegia: stretching shoulder muscles  Paraplegia: SLR above 60º; Hip flexion beyond 90º

Exceptions  Tightness of finger flexors will help in grasping through Tenodesis.  Lengthened hamstrings and tight low back muscles help in sitting and standing.

Strengthening  B/L exercises for UL  Bad ragaz tech, PRE using manual/mech resistance  Strengthening crutch muscles  Functional strengthening: under water walking, static bicycling etc.

Muscle tone  ES of paralysed muscles  Facilitation and inhibition techniques  Emphasis on weight bearing activities  PNF (Bad Ragaz)

Pain  Traumatic: TENS (Richardson 1980)  Nerve root: TENS  SC Dysesthesias: Pharmacological  MSK: “Treat the cause”- tightness of muscles and other ST, muscular imbalance.

Orientation to upright position  Tilt table  Abdominal binders & stockings can be used

Pressure sores  Turning and positioning for prevention  Physiotherapy modalities U/S, High Intensity Electric Stimulation, Prophylactic Heat, IRR, Cryotherapy and Kneading  In combination with Medical care

Bowel and Bladder Retraining Innervation of bladder and bowel: s2,3,4 Two types  Spastic (Automatic)  Flaccid (Autonomous)

Automatic or Reflex Emptying  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 abdomen- Crede maneuver

Bladder Training Programs  Primary goal- catheter free and control bladder function.  Most frequently uses intermittent catheterization.  Purpose: est. reflex bladder emptying at regular and predictable intervals.

Intermittent Catheterization  Fluids are restricted to 2000 ml/day. At 150180ml/hr. Intake stopped late in the day.  Initially cath pt for every 4h. Prior to cath, pt. Attempts to void in combination with 1 or more manual stim. Techniques.  Cath is inserted, residual volume recorded.  Voided and residual urine vol. is recorded  As bladder becomes more effective, residual volumes will decrease and time intervals will increase

Autonomous bladder retraining  Pattern of incontinence is est. Residual volume is measured, to assure it is in safe limits.  Once incontinence patterns are est. 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 diet high in fiber  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

Sexual rehabilitation  Males: Erectile dysfunction: use of silicon ring Infertility: Vibratory stimulation (Pryor, 1995)  Females: Can they conceive?

Yes  Potential for conception remains unimpaired  Conception is possible with close medical supervision  PT: post-partum care

Mat Programs  Sequence followed:    

Achieve stability Controlled mobility Skill Functional use of skill

Specific Mat Activities  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 L Lordosis so it’s not tolerated well by some.  Functional link:with hip hyperextension during gait necessary for postural alignment.  W/c stand  Rising from the floor with KAFO’s

Supine on Elbows  Assists with bed mobility.  Prepares for long sit position.  Without abdominals, pt. 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 Bicep and shoulder flexors. Good prep for w/c propulsion.  Pt supine, PT grasps pt. supinated forearms just above the wrist. Pt. Pulls up to sitting then lowers back to mat.

Sitting  Practice long and short sit for ADL  Required to have ~110º hamstring length for dressing  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 pt. 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, pt 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  Preamb:  balance in║bars recovery from the beginning of jackknife position  Turning “TRAIN AS YOU WALK”

Orthosis Types  KAFO- T9-T12. Ankles are in 5-10 DF to assist the hip hyperextension. COG post to hip, ant to ankles.  RGO ( reciprocal gait orthosis) T2-L1. Two KAFO’S 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

BWS (body weight support)  Theory of spinal central pattern generators (CPGs)  Generate basic motor patterns. Higher centers activate the appropriate set of CPGs and can modify. Spinal CPGs are also influenced by sensory input that responds to environmental demands.  Hence there is experimentation at present looking at Spinal Cord Motor Output in Humans

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.

References     

Umphred, 4th Ed Stokes, Physical Mgmt in Neurorehab. Sullivan, Physical Rehab, 5th Ed Somers, SCI func Rehab. Edelle Carmen Field-Fote “SC Control of Movement: Implications for Locomotor Rehabilitation Following SCI” PT: May 2000, pp.477-483.  A. Behrman, S. Harkema” Locomotor Training After Human Spinal Cord Injury: A Series Of Case Studies.” PT July 2000. Pp. 688-700.