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1、创伤性脊髓损伤物理治疗 Still waters run deep.流静水深流静水深,人静心深人静心深 Where there is life,there is hope。有生命必有希望。有生命必有希望Traumatic Spinal Cord Injury(SCI)Majority of traumatic SCI occurs in young adult malesTraumatic spinal cord injury is a non-progressive pathologyMotor and sensory function on both right and left side
2、s is determined by the level of injuryA patient with C6 level injury has intact motor and sensory function bilaterally at and above the C6 level MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury2MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury3Traumatic Spinal Cord Injury Based on the Interna
3、tional Standards for Neurological Classification of Spinal Cord Injury(published by the American Spinal Injury Association,ASIA),patients can be grouped in five categories depending on the severity of impairment from A to EA is complete spinal cord injury with no motor or sensory function below the
4、levelE is normal even though patient may have initially exhibited symptoms of spinal cord injury,but is now normal MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury4AComplete No motor or sensory function is preserved in the sacral segments S4-5BIncompleteSensory but no motor function is preserved
5、 below the neurological level and includes S4-5CIncompleteMotor function is preserved below the neurological level,and more than half of key muscles below the neurological level have a muscle grade less than 3(fair)DIncompleteMotor function is preserved below the neurological level,and at least half
6、 of key muscles below the neurological level have a muscle grade of 3(fair)or moreENormalMotor and sensory function is normalASIA Impairment Scale MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury5Traumatic Spinal Cord Injury DefinitionsParaplegia is defined as an impairment or loss of motor and/
7、or sensory function of all or part of the trunk and both lower extremitiesTetraplegia is defined as an impairment or loss of motor and/or sensory function in both upper extremities in addition to trunk and both lower extremities;respiration is often affected MODULE C4/CSDLM/2013/NR Traumatic Spinal
8、Cord Injury6Spinal Cord AnatomySpine has 8 cervical,12 thoracic,5 lumbar,5 sacral,and 1 coccygeal spinal nerves(levels)Spinal cord ends around L1 vertebral levelThe cervical spinal levels control sensory and motor function of head/neck and upper extremities and the diaphragm(phrenic nerve,C3-5)The t
9、horacic spinal levels control chest and abdominal muscles and sensory function of the trunk The lumbar spinal levels control motor and sensory function of the lower extremitiesThe sacral spinal levels control the sensory function of the back of lower extremity and buttocks,bowel and bladder control,
10、and sexual functionMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury7Symptoms of Spinal Cord InjuryMotor impairmentParalysis or weakness of affected muscles(following the myotomes)Sensory impairment Loss or impaired sensation of affected areas(following the dermatomes)MODULE C4/CSDLM/2013/NR Trau
11、matic Spinal Cord Injury8DermatomesMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury9Symptoms of Spinal Cord InjuryAutonomic dysreflexiaOften occurs in patients with high level spinal cord injury(lesion level above T5)Caused by distended bladder,distended rectum,blocked catheter,or other stimuli
12、about the sacral innervated areaPatient shows flushed face,pounding headache,very high blood pressure,sweating above the level of injury,piloerection,slow pulse,and nasal obstruction(nasal voice)Autonomic dysreflexia is a medical emergencyMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjuryPiloerect
13、ion or goosebumps on a human arm http:/en.wikipedia.org/wiki/Goose_bumps 10Symptoms of Spinal Cord InjuryAutonomic dysreflexia is managed in the following wayDont let the patient lie downPosition the patient in sittingCheck the catheter or tube for blockageCheck the feet positions for twisted ankles
14、 or pinched toesEmpty leg bag for urine if it is fullObtain immediate medical helpMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury11Symptoms of Spinal Cord InjurySpasticityMost common in patients with cervical and thoracic level injuriesOccurs below the level of lesion after the spinal shock per
15、iodPoor venous return below the level of lesion that may result in orthostatic hypotensionBradycardiaImpaired body temperature controlUnable to regulate body temperature in response to environmental changes(stay under sun)Impaired ability to sweat below the level of lesionImpaired respiratory functi
16、onDecreased tidal volume and vital capacityImpaired coughMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury12Symptoms of Spinal Cord InjuryBladder and bowel dysfunction for those patients with S2-4 involvementIf not managed properly,patient will have urinary tract infections and ultimately kidney
17、failureMust drink sufficient fluid and eat a high fiber dietMost patients can be trained to manage their bladder and bowel problems,including a schedule to void(every 4 hours)and to move bowel(once a day or once every other day)Sexual dysfunctionMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury13
18、Symptoms of Spinal Cord InjurySecondary complicationsPressure soresDeep vein thrombosisPain ContractureHeterotopic ossificationOsteoporosisMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury14PrognosisAfter stabilizing the spinal(vertebral column)injury,the patient should begin a comprehensive reha
19、bilitation programLife expectancy is related to the severity of impairmentIndividuals with spinal cord injury classified between the*ASIA A to C levels and those with tetraplegia have shorter life expectanciesRef:American Spinal Cord Injury Association(ASIA)Classificationhttp:/www.asia-spinalinjury.
20、org/elearning/ISNCSCI_Exam_Sheet_r4.pdf MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury15MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury16Medical ManagementEmergency careKeep the neck and trunk stabilized(use a cervical collar and back board)during transportation Surgery to stabilize fract
21、ureOften involves immobilization after the surgery(Halo device for cervical spine and body cast/jacket for thoracic or lumbar spine)Drugs To manage spasticity and painTo manage infectionsMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury17Physical Therapists ConcernsPatients with traumatic spinal
22、cord injury often develop pneumonia,urinary tract infection,and pressure soresPhysical therapists must teach patientsWays to achieve a productive coughProper bladder management programDaily skin inspection MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury18物理治疗检查评估确保脊髓损伤的位置是固定好的病人可能存在其他损伤部位确保病人在医
23、学上是稳定的关注生命体征 评估患者末梢循环情况，特备注意足部（桡动脉与足上动脉对比）评估呼吸功能（肺活量）吸气时相关肌肉-膈肌(膈神经,C3-5),肋间外肌和辅助呼吸肌(T1-11),腹肌呼气时相关肌肉-腹肌,肋间内肌,膈肌辅助呼吸肌对呼吸的影响-分别检查坐位、卧位下的情况判断患者是否有呼吸机依赖MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury19物理治疗检查评估评估是否能够产生有效的咳嗽咳嗽需要声门和呼吸肌的协调运动评估 会话情况(发声情况)评估 言语功能患者可能在事故后存在脑外损伤，所以其言语功能可能受到损害 评估 感觉功能基于感觉评
24、估结果遵循ASIA量表MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury20物理治疗检查评估评估 肌力基于肌力评估结果使用MMT检查10块关键肌C5-屈肘肌屈肘肌L2-屈屈髋髋肌肌C6-伸腕肌伸腕肌L3-伸膝肌伸膝肌C7-伸肘肌伸肘肌L4-踝背伸肌踝背伸肌C8-中指屈指肌中指屈指肌L5-伸趾肌伸趾肌T1-小指展肌小指展肌S1-踝跖屈肌踝跖屈肌MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury21物理治疗检查评估评估 肌张力检查损伤节段以下的痉挛情况颈髓或高位胸髓损伤患者常有痉挛评估 运动
25、范围踝关节必须能背屈达一半以确保可以站立腘绳肌必须有足够长度才能确保能穿裤子(伸膝起码达110度)髋关节后伸必须达到10度才能确保步行必须要有全范围的肩关节后伸、外旋、内收，肘关节伸，前臂旋后，腕关节的背伸来确保能坐起MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury22物理治疗检查评估肌腱的检查查看指屈肌腱是否紧张短缩当病人伸腕时，手指会有自动的屈曲(功能性抓握)MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury23有效长度的指屈肌腱才能允许患者有功能性抓握MODULE C4/CSDL
26、M/2013/NR Traumatic Spinal Cord Injury24物理治疗检查评估评估 皮肤完整性是否发红局部温度升高、肿胀开放性伤口对于长期坐在轮椅上患者必须检查：双侧坐骨结节骶骨尾骨对皮肤易产生压疮部位要尤为关注（下一张幻灯片）MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury25仰卧位仰卧位俯卧位俯卧位侧卧位侧卧位枕骨粗隆处 耳廓(头转向侧)耳廓肩胛肩峰部(肩前面)肩峰(侧面)脊椎凸处髂前上棘髋关节大转子肘部男性生殖器区域腓骨小头骶骨膝盖两膝间尾骨足尖外踝足后跟内外踝间容易产生压疮部位MODULE C4/CSDLM/20
27、13/NR Traumatic Spinal Cord Injury26物理治疗检查评估直肠和膀胱功能患者能否自己管理大小便或者自己通过辅助用品来清洁？功能性技能翻身坐起床-轮椅转移站立步行-取决于损伤程度MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury27物理治疗检查评估评估患者出院计划和家庭生活辅助用品使用FIM量表或其他合适量表*Ref:http:/www.rehabmeasures.org/lists/rehabmeasures/dispform.aspx?id=889 MODULE C4/CSDLM/2013/NR Trauma
28、tic Spinal Cord Injury28MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury29创伤性脊髓损伤患者一般管理规则持续监测生命体征和循环情况来防止体位性低血压强化损伤平面以上的肌肉力量教会患者头部/躯干和上肢对于功能性活动的关系患者积极寻找新的方式来达到完成功能性活动的目的患者有体温自我调节障碍-当病人训练时保持治疗区域舒适MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury30物理治疗师干预的目标患者功能上独立高位颈段损伤患者应当教会其直接照顾者腰段和低胸段损伤的患者以
29、独自转移为目标慢性脊髓损伤患者，不管损伤平面在哪，都应选择轮椅来作为移动的主要工具来节省体力患者应知道所有技能来预防压疮的发生与发展MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury31物理治疗师的干预呼吸功能管理皮肤护理早期肌力训练和关节活动度训练床上运动转移坐起及坐位时活动站立及站立时活动步行MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury32呼吸功能管理如果可以，安静状态下使用腹式呼吸模式深呼吸训练吞咽呼吸 使用声门来吞咽一口空气到肺里面，以此增加吸气量。对于呼吸机依赖的患者可能
30、有用 胸壁活动在坐位下考虑腹肌的支持(举例,用一根绳索)来改善静脉回流和增加血容量体位引流，叩诊，振动排痰，吸痰人工辅助咳嗽治疗师或者患者把手放在上腹部咳嗽随着手向上向内的压力同时快速进行MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury33Assisted CoughMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury34呼吸功能管理高位颈段损伤患者(C3 及以上)将依赖呼吸机进行呼吸C3-5 损伤患者可能要在夜间睡眠时使用呼吸机 MODULE C4/CSDLM/2013/NR Trau
31、matic Spinal Cord Injury35皮肤护理患者（或护工）应该检查有压疮倾向的皮肤区域，至少一天一次高位颈段损伤患者应当两小时翻身一次轮椅应该有恰当的压力缓冲垫骨盆应该放置在中立对称的位置上在轮椅上患者应该每15分钟缓解下受压部位的压力(独自或者依靠帮助)撑起侧倾前倾MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury36侧倾Side Lean撑起Push Up前倾Forward LeanMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury37Skin CareIf the
32、patient develops an ulcer,the patient should be referred to a wound care specialist to facilitate healing and to prevent infectionPatient should not put pressure on the ulcer until it is healed-for example,a patient with a right greater trochanter ulcer cannot lie on the right side until the wound i
33、s healedMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury38Early Strengthening and Range of Motion ExercisesStrengthen all innervated musclesWatch for substitutionFor example,patient may use shoulder external rotators to substitute for elbow extensorsDo not stretchFinger flexors to protect tenode
34、sisLower trunk muscles so that patient can lean on ligaments for sittingStretch Hamstrings-to assure a straight leg raise to 100 degrees Hip flexors to assure patient has 10 degrees of hip extensionAnkle plantar flexors to assure patient has 10 degrees of dorsiflexionMODULE C4/CSDLM/2013/NR Traumati
35、c Spinal Cord Injury39Sitting Patient usually experiences postural hypotension in sitting or standingInitially,bring the patient to sitting slowlyUse an abdominal binder and elastic(pressure)stockings to assist venous returnGradually elevate the head and upper trunk in bedMay also use a tilt-in-plac
36、e wheelchair with elevating leg rests or a tilt tableBiomechanical principles for mat activitiesHead-hips relationshipUnweight the body part first before moving itUse momentum MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury40SittingBe aware that the patient is using very small muscles(in upper
37、extremities)to move a heavy load(the whole body)Protect patients shoulders and wrists from Day 1 of physical therapy-patients with chronic spinal cord injury often experience shoulder problemsFor scooting sideways or up and down in bed(or on mat),patients need to clear buttocks from the supporting s
38、urface in order to move -hence,patients with short arms and a long trunk will need push-up blocks for mat activitiesPatient need to learn the new center of mass for functional movementsMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury41Sitting After the patient can tolerate sitting in the upright
39、 position,the patient can begin mat activities that may includeRolling from supine to proneProne positionProne on elbowsProne to supineSupine to long sittingScooting side to side in long sittingScooting up and down in long sittingMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury42Long sitting,lea
40、n on upper extremities,shoulders in extension and external rotation,and elbows extended MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury43Moving sideways in long sittingMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury44Sitting Balance TrainingPatient learns to use trunk ligamentsPatient in l
41、ong sitting on matLift one arm firstLift both arms Catch a ball with both armsPatient sits on a bench with feet flat on the floor and thenLift one armLift both armsTry to catch a ballMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury45Transfer Mat to WheelchairTetraplegiaUsually needs a sliding bo
42、ardParaplegiaOften may do without a sliding boardPark wheelchair at 45 degree angle to the mat and lock the wheelsRemove arm rest and leg rest next to matUse momentum to assist transferPush down on supporting surface with both arms and at the same time twist head and trunk away from wheelchairPatien
43、t with lower extremity spasticity can bear weight on legs to ease weight on upper extremitiesMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury46Patient with paraplegia transferring from mat to wheelchair at the same heightMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury47Patient with parapleg
44、ia transferring from mat to wheelchair to a higher surface MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury48Patient assisted sliding board transfer:#1-therapist assists the patient;#2-patient place left hand on sliding boardMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury49StandingStanding
45、program is good for the skeletal system and the cardiovascular systemCheck patients blood pressure in sitting firstPatient may need abdominal binder and elastic stockingsStart in parallel barsPatient may need lower extremity orthotics and/or spinal orthoticPatient first presses down on parallel bars
46、,lifts one arm,and then lifts both armsMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury50WalkingMust determine if walking is a reasonable goalFor patients with a spinal cord injury,walking consumes a tremendous amount of energyPatients have strong upper extremity muscles,no contractures,and stro
47、ng motivation are candidates for walking trainingMost patients are not going to be community ambulators Potential gait patternsSwing toSwing throughFour pointTwo pointMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury51WalkingPatients with a T12 above level will need bilateral knee and ankle ortho
48、ses(e.g.Craig Scott orthoses)to walk using a swing through or swing to gaitPatients with a T12 or below level will need bilateral knee and ankle orthoses and can walk with a reciprocal gait pattern(four point or two point)Patients with an L4-5 level or below will need ankle foot lorthoses to walk re
49、ciprocally and are best candidates for reciprocal gait trainingRef:UustalH.andBaergaEOrthoticsinPhysical Medicine and Rehabilitation Board Review CuccurulloS,Editor.NewYork:DemosMedicalPublishing;2004MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury52Wheelchair Patients with a high cervical level
50、 injury may have difficulty sitting upright,due to postural hypotension,and will need a wheelchair with a reclining backrestMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury53Wheelchair Wheelchair should be fitted for each patient.It is not one size fits all patients.Patient should have a proper