spinal cord injury- physical therapy management

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


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



• 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


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)


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


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



• 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


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

C6

Wrist extensors



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



• 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


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


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: 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


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: 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


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: 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


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.

spinal cord injury- physical therapy management

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