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1、Physical Therapy for Adults with Traumatic Spinal Cord InjuryAcknowledgement:International educators for the China Self-Directed Learning Modules MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury1Traumatic Spinal Cord Injury(SCI)Majority of traumatic SCI occurs in young adult males Traumatic spin
2、al cord injury is a non-progressive pathology Motor and sensory function on both right and left sides is determined by the level of injury A 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 Injury2M
3、ODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury3Traumatic Spinal Cord Injury Based on the International 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 o
4、f impairment from A to E A is complete spinal cord injury with no motor or sensory function below the level E 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 Injury4ASIA Impairment Scale MODULE
5、C4/CSDLM/2013/NR Traumatic Spinal Cord Injury5Traumatic Spinal Cord Injury Definitions Paraplegia is defined as an impairment or loss of motor and/or sensory function of all or part of the trunk and both lower extremities Tetraplegia is defined as an impairment or loss of motor and/or sensory functi
6、on in both upper extremities in addition to trunk and both lower extremities;respiration is often affected MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury6Spinal Cord Anatomy Spine has 8 cervical,12 thoracic,5 lumbar,5 sacral,and 1 coccygeal spinal nerves(levels)Spinal cord ends around L1 verte
7、bral level The cervical spinal levels control sensory and motor function of head/neck and upper extremities and the diaphragm(phrenic nerve,C3-5)The thoracic spinal levels control chest and abdominal muscles and sensory function of the trunk The lumbar spinal levels control motor and sensory functio
8、n of the lower extremities The sacral spinal levels control the sensory function of the back of lower extremity and buttocks,bowel and bladder control,and sexual functionMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury7Symptoms of Spinal Cord Injury Motor impairment Paralysis or weakness of affe
9、cted muscles(following the myotomes)Sensory impairment Loss or impaired sensation of affected areas(following the dermatomes)MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury8DermatomesMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury9Symptoms of Spinal Cord Injury Autonomic dysreflexia Often
10、occurs in patients with high level spinal cord injury(lesion level above T5)Caused by distended bladder,distended rectum,blocked catheter,or other stimuli about the sacral innervated area Patient shows flushed face,pounding headache,very high blood pressure,sweating above the level of injury,piloere
11、ction,slow pulse,and nasal obstruction(nasal voice)Autonomic dysreflexia is a medical emergencyMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjuryPiloerection or goosebumps on a human arm http:/en.wikipedia.org/wiki/Goose_bumps 10Symptoms of Spinal Cord Injury Autonomic dysreflexia is managed in th
12、e following way Dont let the patient lie down Position the patient in sitting Check the catheter or tube for blockage Check the feet positions for twisted ankles or pinched toes Empty leg bag for urine if it is full Obtain immediate medical helpMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury11S
13、ymptoms of Spinal Cord Injury Spasticity Most common in patients with cervical and thoracic level injuries Occurs below the level of lesion after the spinal shock period Poor venous return below the level of lesion that may result in orthostatic hypotension Bradycardia Impaired body temperature cont
14、rol Unable to regulate body temperature in response to environmental changes(stay under sun)Impaired ability to sweat below the level of lesion Impaired respiratory function Decreased tidal volume and vital capacity Impaired coughMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury12Symptoms of Spin
15、al Cord Injury Bladder and bowel dysfunction for those patients with S2-4 involvement If not managed properly,patient will have urinary tract infections and ultimately kidney failure Must drink sufficient fluid and eat a high fiber diet Most patients can be trained to manage their bladder and bowel
16、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 Injury13Symptoms of Spinal Cord Injury Secondary complications Pressure sores Deep vein thrombosis Pain Contracture Heterotopic oss
17、ification OsteoporosisMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury14Prognosis After stabilizing the spinal(vertebral column)injury,the patient should begin a comprehensive rehabilitation program Life expectancy is related to the severity of impairment Individuals with spinal cord injury clas
18、sified between the*ASIA A to C levels and those with tetraplegia have shorter life expectancies Ref:American Spinal Cord Injury Association(ASIA)Classificationhttp:/www.asia-spinalinjury.org/elearning/ISNCSCI_Exam_Sheet_r4.pdf MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury15MODULE C4/CSDLM/201
19、3/NR Traumatic Spinal Cord Injury16Medical Management Emergency care Keep the neck and trunk stabilized(use a cervical collar and back board)during transportation Surgery to stabilize fracture Often involves immobilization after the surgery(Halo device for cervical spine and body cast/jacket for tho
20、racic or lumbar spine)Drugs To manage spasticity and pain To manage infectionsMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury17Physical Therapists Concerns Patients with traumatic spinal cord injury often develop pneumonia,urinary tract infection,and pressure sores Physical therapists must teac
21、h patients Ways to achieve a productive cough Proper bladder management program Daily 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
22、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
23、MMT检查10块关键肌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/CSDLM/2013/NR Traumatic Spinal Cord Injury24