Post on 10-Apr-2015
description
SPINAL CORD INJURY: REHABILITATION
Vipinnath E. NalupurakkalMPT (Neuro)
Consultant Neurophysiotherapist
Objectives
In this session we will discuss:1. The Aims and 2. Goals of SCI Rehab.3. Levels of injury and their expected
functional outcomes4. 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 assistPower: 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 assistAmbulation: 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 assistPower: Independent
• Power recline and/or tilt W/C with head, chin, or breath control• Manual recliner W/C• Vent tray
Standing/ Ambulation
Standing: Total assistAmbulation: 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 assistUpper 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 outdoorsPower: 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 assistAmbulation: Not indicated
• Hydraulic standing frame
Communication Independent to some assist after setup and equipment availability
• Long opponens splint• Adaptive devices as indicated for page turning, writing, button pushing
Transportation Independent with highly specialized equipment; some assist with accessible public transportation; total assist for attendant-operated vehicle
• Highly specialized modified van with lift
Homemaking Total assist
Assist Required • Personal care: 10 hours/day• Homecare: 6 hours/day• Able to instruct in all aspects of care
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 independentUneven: 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 assistUpper 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 assistUpper 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 outdoorsPower: Independent
• May require standard upright power or recline• Manual lightweight rigid or folding W/C with modified rims
Standing/ Ambulation
Standing: Total assistAmbulation: 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: independentUneven: 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 assistUpper extremity: independent
• Adaptive devices as indicated
Grooming Independent • Adaptive devices as indicated
Bathing Lower body: independent to some assistUpper 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 assistAmbulation: 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
Respiratory
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
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
Communication
Independent
Transportation
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
Respiratory
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
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
Communication
Independent
Transportation
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
level Expected Functional Outcomes
Equipment
L1,2,3 LevelsGracilis, Iliopsoas,QL
House hold ambulationWheelchair skills
B/L KAFO, Crutches
Wheelchair
L4,5ED, LB muscles, QF, TA
Functional ambulationWheelchair 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 150-180ml/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 dayFollow a diet high in fiberDrink at least 8 glasses of water/dayDrink a warm liquid 30 mins before
initiating the programPerform in an upright positionConsider 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.