Neuromuscular Rehabilitation

By. Dr. H . El Sharkawy

Rehabilitation of Spinal cord injury

Dr. H . Elsharkawy

General OverviewGeneral OverviewSpinal Cord Injury is damage to the

spinal cord that results in a loss of function such as mobility or feeling. Frequent causes of damage are trauma and disease.

Spinal Cord is the major bundle of nerves that carry impulses to/from the brain to the rest of the body.

Spinal Cord is surrounded by rings of bone-vertebra. They function to protect the spinal cord.

PrognosisPrognosis Patients with a complete cord injury have a less than

5% chance of recovery. If complete paralysis persists at 72 hours after injury, recovery is essentially zero.

The prognosis is much better for the incomplete cord syndromes.

If some sensory function is preserved, the chance that the patient will eventually be able walk is greater than 50%.

Ultimately, 90% of patients with SCI return to their homes and regain independence.

In the early 1900s, the mortality rate 1 year after injury in patients with complete lesions approached 100%. Much of the improvement since then can be attributed to the introduction of antibiotics to treat pneumonia and urinary tract infection.

Currently, the 5-year survival rate for patients with a traumatic quadriplegia exceeds 90%. The hospital mortality rate for isolated acute SCI is low.

Scale of Motor Strength in Scale of Motor Strength in SCISCIThe American Spinal Injury Association:

◦ 0 - No contraction or movement ◦ 1 - Minimal movement ◦ 2 - Active movement, but not against gravity ◦ 3 - Active movement against gravity ◦ 4 - Active movement against resistance ◦ 5 - Active movement against full resistance

Assessment of sensory function helps to identify the different pathways for light touch, proprioception, vibration, and pain. Use a pinprick to evaluate pain sensation.

Types of Spinal Cord Types of Spinal Cord ParalysisParalysisDepending on the location and the

extent of the injury different forms of paralysis can occur.

Monoplegia- paralysis of one limbDiplegia- paralysis of both upper or

lower limbsParaplegia- paralysis of both lower limbsHemiplegia- paralysis of upper limb,

torso and lower leg on one side of the body

Quadraplegia- paralysis of all four limbs

Spinal Cord Paralysis LevelsSpinal Cord Paralysis LevelsC1-C3 All daily functions must be totally assisted Breathing is dependant on a ventilator Motorised wheelchair controlled by sip and puff or chin

movements is requiredC4 Same as C1-C3 except breathing can be done without a

ventilatorC5 Good head, neck, shoulder movements, as well as elbow flexion Electric wheelchair, or manual for short distancesC6 Wrist extension movements are good Assistance needed for dressing, and transitions from bed to

chair and car may also need assistanceC7-C8 All hand movements Ability to dress, eat, drive, do transfers, and do upper body

washes

Spinal Cord Paralysis LevelsSpinal Cord Paralysis Levels

T1-T4 (paraplegia)Normal communication skillsHelp may only be needed for heavy household

work or loading wheelchair into carT5-T9Manual wheelchair for everyday living Independent for personal careT10-L1Partial paralysis of lower bodyL2-S5Some knee, hip and foot movements with

possible slow difficult walking with assistance or aids

Only heavy home maintenance and hard cleaning will need assistance

Complete and IncompleteComplete and Incomplete

Spinal Cord Syndromes can be classified into either complete or incomplete categories

Complete – characterized as complete loss of motor and sensory function below the level of the traumatic lesion

Incomplete – characterized by variable neurological findings with partial loss of sensory and/or motor function below the lesion

Spinal ShockSpinal ShockAn immediate loss of reflex function,

called areflexia, below the level of injury

Signs: ◦ Slow heart rate◦ Low blood pressure◦ Flaccid paralysis of skeletal muscles◦ Loss of somatic sensations◦ Urinary bladder dysfunction

Spinal shock may begin within an hour after injury and last from several minutes to several months, after which reflex activity gradually returns

Central Cord SyndromeCentral Cord SyndromeUsually involves a cervical lesionMay result from cervical hyperextension

causing ischemic injury to the central part of the cord

Motor weakness is more present in the upper limbs then the lower limbs

Patient is more likely to lose pain and temperature sensation than proprioception

Patient may complain of a burning feeling in the upper limbs

More commonly seen in older patients with cervical arthritis or narrowing of the spinal cord

Brown-Sequard SyndromeBrown-Sequard Syndrome

Results from an injury to only half of the spinal cord and is most noticed in the cervical region

Often caused by spinal cord tumours, trauma, or inflammation

Motor loss is evident on the same side as the injury to the spinal cord

Sensory loss is evident on the opposite side of the injury location (pain and temperature loss)

Bowel and bladder functions are usually normal

Person is normally able to walk although some bracing or stability devices may be required

Anterior Spinal Cord Anterior Spinal Cord SyndromeSyndromeUsually results from compression of

the artery that runs along the front of the spinal cord

Compression of SC may be from bone fragments or a large disc herniation

Patients with anterior spinal cord syndrome have a variable amount of motor function below the level of injury

Sensation to pain and temperature are lost while sensitivity to vibration and proprioception are preserved

Pre-hospital CarePre-hospital CareMost pre-hospital care providers recognize

the need to stabilize and immobilize the spine on the basis of mechanism of injury, pain in the vertebral column or neurological symptoms.

Patients are usually transported to the hospital with a cervical hard collar on a hard backboard.◦ Commercial devices are available to secure the

patient to the board.◦ The patient should be secured so that in the

event of vomiting, the backboard may be rapidly rotated 90 degrees while the patient remains fully immobilized in neutral position. Spinal immobilization protocols should be standard in all pre-hospital care systems.

Kinesiologist’s RoleKinesiologist’s Role

Perform Subjective and Objective Assessment

Analyse the situation and determine your diagnosis

Plan how you will treat the condition. Includes consultation with or referral to other areas of the medical community

What can a Kinesiologist What can a Kinesiologist DoDo

Evaluate a person's ability and level of functioning in his or her home, at work, and while engaging in leisure activities and hobbies.

Determine how motivated a person is to participate in activities that he or she participated in prior to the injury.

Identify any changes in roles a person may experience as a result of SCI.

Provide individualized therapy to retrain people to perform daily living skills using adaptive techniques.

Facilitate coping skills that could help a person overcome the effects of SCI.

Implement exercises and routines that strengthen muscles that may have been affected that are necessary in daily activities, such as dressing, eating, and taking care of a home.

Determine the type of assistive devices that could help a person become more independent with daily living skills.

Basic Life ChangesBasic Life Changes

The Kinesiologist will need to determine through conversation with the client, as well as subjective and objective assessment:

EatingDressingBowel/Bladder functionWeight Management- nutrition and fitnessRespiratory IssuesPainPsychosocial IssuesSex and Pregnancy Independence

Equipment / AccessibilityEquipment / Accessibility

Kinesiologist should plan with client ways to improve personal mobility:

HomesVehiclesPublic AccessTypes of wheelchairs,

mobility devices, splinting and seating available

Psychosocial IssuesPsychosocial IssuesThese topics should be covered with

the client, but will most likely be referred to another professional for:

Aging Education/EmploymentFamily/RelationshipsPsychosocial AdjustmentsRehabilitationSexSubstance Abuse

Treatment FieldsTreatment Fields

Occupational TherapyPhysiotherapyPhysicians Social WorkersTherapeutic RecreationRehabilitationPsychologists Vocational CounsellorsNutrition AssistanceTelemedicine-employing

a SCI caregiver

Transfers of Para & quadriplegic Transfers of Para & quadriplegic PT.PT.depends upon the level & degree depends upon the level & degree of lesionof lesion

Hydrotherapy

paraplegia

• Commonly used in cases of spina bifida and spinal cord injury.

• Combines flexion of one hip with extension of the opposite hip.

• The flexion power of one hip is utilized to extend the opposite hip.

Walker Walker ParaplegiaParaplegia(adult)(adult)

Partners to ConsultPartners to ConsultNeurosurgeryNeurologyUrologyOrthopedicsPlastic SurgeryNeuropsychologyInternal MedicineGynecology

Driver EducationRehabilitation

EngineeringChaplaincyPulmonary

MedicineGeneral SurgeryPsychiatrySpeech

Pathology

Treatment FocusTreatment FocusThe treatment team must specialize in

treating SCIThe focus should be on family and

patient participation where the clients personal abilities are maximized towards independence

Client should be a principal contributor to treatment decisions and goal making

Treatment should be on a regular scheduled basis for at least three hours per day

Tilting Table Tilting Table

Stationary bicycleStationary bicycle

Thank you