Embed Size (px)
Citation preview
Pulmonary Rehabilitation in Acute Spinal Cord Injury
Jatuporn Jatutawanit
Physical therapist,
Physical therapy unit,
Prince of songkla university
Causes of spinal cord injury
Traumatic injury•Motor vehicle crash
•Falls
•Acts of violence•Sport injury
Non-traumatic
injury•Cancer
•Infections
•Disc herniation
•Osteoporosis
•Spinal cord vascular
disease•Vertebral injury
Spinal cord injury
Spinal cord injury (SCI) results in
physiologic changes that affect many organ
systems
Pulmonary physiologic changes due to spinal
cord injury (SCI) are related to the extent of neurological impairment
Classification of SCI
The American Spinal Injury Association
(ASIA) Impairment Scale is used to classify
the degree of impairment that is based on
strength in key muscles and on a sensory exam
International_Stds_Diagram_Worksheet.pdf
Classification of SCI
Grading scales for spinal cord injury:
American Spinal Injury Association Scale (ASIA)
ANo motor or sensory function is preserved below the neurologic
level through the sacral segments (Complete motor SCI )
BSensory but not motor function is preserved below the neurologic
level and extends through the sacral segments
C
Motor function is preserved below the neurologic level and the
majority of key muscles below the neurologic level have a muscle
grade less than 3
D
Motor function is preserved below the neurologic level and the
majority of key muscles below the neurologic level have a muscle
grade of at least 3
E Motor and sensory functions are normal (no cord injury)
Classification of SCI
Normal breathing
Motion of diaphragm and ribs
alternate volume of thoracic cavity, a space bounded
by ribs, sternum, vertebral column and diaphragm
Inspiration
-Space in thoracic cavity increase
-Intra-thoracic pressure falls-Air move into the lungs
Expiration
-Space in thoracic cavity decrease
-Intra-thoracic pressure rises-Air move out of the lungs
Inspiration phase
Major muscle Diaphragm m.(C3-C5)
Accessory muscles
◦ external intercostals(T1-T11)
◦ clavicular portions of pectoralis major m.(C5-C6)
◦ scaleni m.(C3-C8)
◦ sternocleidomastoids m.(C2-C3 and CN.XI)
◦ trapezius m.(C2-C4 and CN.XI)
Trapzius & sternocleidomastoid m. COMPENSATORY muscle in SCI for respiration depend on high level injury
Expiration phase
Normally, expiration is passive
In forced exhalation: exercise or coughing
◦ Abdominal wall muscle (T6-L1)
◦ Internal intercostals muscle (T1-T11)
MECHANICS OF RESPIRATION
Normal respiration
https://thoracickey.com/spinal-cord-injury/
Normal coughing
Coughing is an explosive expiration that
provides a normal protective mechanism for
clearing tracheobronchial trees of secretion and
foreign material
Coughing involve coordinated action of the
glottis and muscle of both inspiration and expiration
https://clinicalgate.com/airway-clearance-therapy/
Cough mechanism
Ability to breathe deeply and cough forcefully is
impaired to varying degrees depending on the
level and completeness of SCI
Respiratory complications are a major
cause of death in the early stages of spinal injury
Respiratory function Impairment in SCI
Respiratory impairment depends upon
◦ Level of the injury: Quadriplegia or Paraplegia
◦ Severity of injury: complete or incomplete
◦ Additional trauma sustained at time of injury: rib
fracture, chest trauma
◦ Premorbid respiratory status: asthma, COPD
Respiratory function Impairment in SCI
Respiratory complications
Most common:
◦ Respiratory failure
◦ Pneumonia
◦ Atelectasis
PULMONARY PHYSIOLOGIC CHANGES
Pulmonary physiologic changes following
spinal cord injury include:
◦ Impairment of respiratory muscle performance
◦ Changes in lung and chest wall compliance
◦ Changes in respiratory control
◦ Airflow limitation and bronchial hyperresponsiveness
Impairment of respiratory muscle performance
Respiratory m. below level of complete SCI
non-function or weakness in both inspiratory &
expiratory m.
◦ ↓vital capacity
◦ ↓tidal volume
◦ ↓peak cough flow
Changes in lung and chest wall compliance
Especially in tetraplegia
Changes in respiratory control
In quadriplegia, central control of respiration is
effected abnormally small increase in ventitory drive hypercapnia
Airflow limitation and bronchial hyperresponsiveness
Loss of postganglion sympathetic innervations in C-spine injury
Parasympathetic hyperactivity
-Dec. airway diameter & patency
(bronchoconstriction)-Dec. mucocilialy activity
- Inc. production of secretion
Progressive cycle of respiratory dysfunction after SCI
Respiratory Assessments
Respiratory rate at rest
Breathing pattern
Chest mobility
Cough
Breath sound
Strength of respiratory muscle
◦ Muscle test >> diaphragm, intercostals, abdominal, accessory muscles
◦ Static pressure >> MIP, MEP
Chest Physical Therapy
Objectives
◦ Prevent lung complications: atelectasis, pneumonia
◦ Increase ventilation
◦ Respiratory muscle training
By
◦ Improve bronchial hygiene
◦ Improving/ maintainance of chest mobility
◦ Strengthening of respiratory muscle
◦ Education of patients and care giver
Chest Physical Therapy
Positioning (Postural Drainage)
Percussion & Vibration
Assist cough technique
Hyperinflation technique
Mechanical insufflation-exsufflation (MI-E)
Inspiratory muscle training (IMT)
◦ Flow incentive spirometer
◦ Volume incentive spirometer
◦ Threshold IMT
https://www.pinterest.com/pin/763641680535547790/
Positioning
(Postural
Drainage)
http://keckmedicine.adam.com/content.aspx?productId=117&pid=60&gid=000051
https://clinicalgate.com/airway-clearance-techniques/
Percussion &
Vibration
http://www.myshepherdconnection.org/respiratory/assist-cough
http://bcrt.ca/assisted-cough/
Assist cough
technique
www.healthlinkbc.ca/healthtopics/content.asp?hwid=ug2709
http://downloads.lww.com/wolterskluwer_vitalstream_com/sample-content/9780781788786_Craven/samples/mod09/topic5b/text.html
Self-Assist cough technique
http://slideplayer.com/slide/6065224/
Hyperinflation
technique
Mechanical insufflation-exsufflation (MI-E)
https://www.vitalitymedical.com/respironics-cough-assist.html https://www.youtube.com/watch?v=rOvR8ZKxI_M
http://www.firstphysioclinic.com/%E0%B8%95%E0%B8%AD%E0%B8%99%E0%B8%97%E0%B8%B5%E0%B9%88126-passive-chest-mobilization/
Rib torsion
Contra-indications / precautions for manual techniques
Osteoporosis
# ribs / rib pathology
Thoracic / cardiac surgery
Pain
Haemoptysis
Bronchospasm
Disordered coagulation
Metastatic deposits
Loss of skin integrity (surgery, burns, wounds)
Subcutaneous emphysema
https://www.amazon.co.uk/Triflow-Incentive-Exerciser-Deep-Breathing/dp/B00JFRH3KE
https://www.healthproductsforyou.com/p-hudson-rci-air-eze-incentive-deep-breathing-exerciser.html
Flow incentive
spirometer
www.henleysmed.com
https://www.pinterest.com/pin/98094098109289257/
Volume incentive
spirometer
https://rider.in.th/article/384-power-breathe.html
https://www.peanjaruan.com/products/threshold-inspiratory-muscle-trainer-imt/
Thredshold
inspiratorymuscle training
thailand.digitaljournals.org
Abdominal support
http://www.sciencedirect.com/science/article/pii/S0003999312004339
https://quadcapable.com/Quadriplegic,awareness,tetraplegia,spinalcordinjury,therapy,treatments,help/daughter/
Range of Motion Exercise
Divide to
◦ Passive ROM
◦ Active-assisted ROM
◦ Active ROM
Objectives
◦ Stimulate circulation
◦ Maintain ROM
◦ Prevent muscle shortening
◦ Strengthening muscle (Active-assisted & Active ROM)
http://www.dinf.ne.jp/doc/english/global/david/dwe002/dwe00244.html
http://acceleratedinc.net/index.php/industry-news/21-joint-movement-active-v-passive-range-of-motion
Range of Motion Exercise
https://www.google.co.th/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact
=8&ved=0ahUKEwjl4I3l_ZfXAhXGKo8KHeEGCT8QjRwIBw&url=https%3A%2F%2Fakuf
isio.blogspot.com%2F2015%2F05%2F&psig=AOvVaw2uvx_FiJ2RmzFEehvMotwM&ust=1509440373578760
Range of Motion Exercise
Cautions
◦ Extreme ROM in spinal shock phase
◦ First 6 weeks post-injury:
SLR < 60º
Combined flexion of hip and knee > 90º
Combined flexion of wrist and fingers
◦ DVT (INR target 2-3)
Bed positioning
Objectives
◦ Ventilation perfusion
◦ Correct alignment of posture
◦ Prevent pressure sore and contracture
◦ Inhibit onset of spasticity
Bed positioning
Supine position
Foot drop and hip Ext. rotation
Bed positioning
Side-lying position
Bed mobilities
Full support
Keep normal alignment
Log rolling
http://accessphysiotherapy.mhmedical.com/content.aspx?bookid=1472§ionid=86198760
Ambulation
Up to doctor allow
Orthosis
Slow upright due to postural hypotension
Abdominal bandage, elastic bandage, stocking
Questions?
