SCI. Demographics and IncidenceDemographics and Incidence Approx. 11,000 new cases of SCI occur in U.S.A. annually 37.1 Years old: Average age Male: 78.3%;

SCI

Demographics and Incidence• Approx. 11,000 new cases of SCI occur in

U.S.A. annually

• 37.1 Years old: Average age

• Male: 78.3%; Female: 21.7%

• Whites> African Americans> Hispanics> Asians

Etiological Categories1. Traumatic Injuries

- MVA: 40.4%- Falls: 27.9%- Violence: 15.0%- Sports: 8.0%

2. Non-traumatic

Damage (39% of all SCI)

- Vascular Dysfunction (AVM)

- Thrombosis- Embolus- Hemorrhage

Functional Categories1. Tetraplegia (56%)

- Cervical- Paralysis of all 4 extremities and trunk

including respiratory muscles

2. Paraplegia (43%)- Thoracic- Lumbar- Sacral- Paralysis of all/ part of trunk and (B) LE

Etiological Categories1. Incomplete Tetraplegia (39.5%)

- Most Common

2. Complete Paraplegia (22.1%)

3. Incomplete Paraplegia (21.7%)

4. Complete Tetraplegia (16.3%)

Neuroanatomical Organization and Structure

Designation of Lesion Level• American Spinal Injury Association (ASIA)

• International Standards for Neurological Classification of SCI

• standardized examination method to determine the extent of motor and sensory function loss after a SCI

Designation of Lesion Level

• Neurological Level- Most caudal level of the spinal cord with normal

motor and sensory function on both left and right sides of the body

• Motor Level- Most caudal level of the spinal cord with normal

motor function bilaterally• Sensory Level

- Most caudal level of the spinal cord with normal sensory function bilaterally


• Motor Level- testing the strength of a key muscle at myotomes

adjacent to the suspected level of impairment

- Using the ordinal scale:0 – Paralyzed1 - Trace2 – Poor3 – Fair4 – Good5 - Normal


• Motor Level- testing the strength of a key muscle at myotomes

adjacent to the suspected level of impairment

- Using the ordinal scale:0 – Paralyzed1 - Trace2 – Poor3 – Fair4 – Good5 - Normal


• Motor Level

• C5 – Elbow Flexors• C6 – Wrist Extensors• C7 – Elbow Extensors• C8 – Finger Flexors• T1 – Finger Abductors

• L2 – Hip Flexors• L3 – Knee Extensors• L4 – Ankle Dorsiflexors• L5 – Long Toe

Extensors• S1 – Ankle

Plantarflexors


• Motor Level

- Key muscle is defined as having intact innervation if it has a manual muscle test score of at least (3/5) and next most rostral key muscle exhibits 5/5 strength on MMT.

- For myotomes that are not clinically testable, (C1-C4, T2-L1, S2-S5), motor level is defined as the same as sensory level


• Sensory Level- testing the patient’s sensitivity to light touch and

pinprick on (B) sides of the body at key dermatomes

- Scoring of Sensation:0 – Absent1 - Impaired2 – Normal

• Complete Injury – (-) sensory or motor function in the lower sacral

segments (S4 and S5)

• Incomplete Injury – (+) motor, (+) sensory function below the

neurological level, (+) motor and (+) sensory at S4 and S5

• Zone of Partial Preservations- (+) motor, (+) sensory function below the

neurological level, (-) motor and (-) sensory at S4 and S5

ASIA Impairment ScaleA Complete: No motor or sensory function is preserved in the sacral segments

S4 to S5

B Incomplete: Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4 to S5

C Incomplete: Motor 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

D Incomplete: Motor function is preserved below the neurological level, and at least half of key muscles below the neurological level have a muscle grade of 3 or more

E Normal: Motor and sensory function is normal

Clinical Syndromes

• 1/5 of all SCI fell under an injury pattern similar to clinical SCI syndromes

• Brown-Sequard Syndrome• Anterior Cord Syndrome• Central Cord Syndrome • Cauda Equina Injuries

Brown Sequard Syndromes• Hemisection of spinal cord

• Typically caused by penetration wounds (gunshot/ wound)

• Partial lesions (Brown Sequard Plus Syndromes) are more common

• Assymetrical clinical features

• Typically achieve good functional gains during inpatient rehabilitation

Brown Sequard Syndromes

• Ipsilateral:• Paralysis: Damage to the lateral corticospinal tract• Loss of proprioception, light touch, vibratory sense

d/t damage to the dorsal column

• Contralateral: • Loss of pain and temperature sensation: Damage

to the spinothalamaic tracts (several segments below the level of injury)

Anterior Cord Syndromes

• Flexion injuries of the cervical region with resultant damage to the ant. Portion of the cord or its vascular supply from the anterior spinal artery

• Fracture, dislocation or cervical disk protrusion

• Loss of motor function (corticospinal tract damage)

• Loss of sense of pain and temperature (spinothalamic tract damage)

• Often require longer length of stay during in-patient rehabilitation

Central Cord Syndromes• Most Common SCI syndrome

• Hyperextension injuries to the cervical region

• Congenital/ Degenerative narrowing of the spinal canal

• Damage to the central aspects of the cord

• UE neurological deficits > LE neurological deficits

• Recover the ability to ambulate

Cauda Equina Injuries• Lesions are frequently anatomically incomplete

• Areflexic bowel and bladder and saddle anesthesia

• Lower extremity paresis and paralysis is variable

• Considered peripheral nerve (Lower Motor Neuron Injury)

NEUROLOGICAL COMPLICATIONS AND ASSOCIATED CONDITIONS

Spinal Shock• Period of Areflexia after SCI

• Characterisitics:• Absence of all reflex activity

• Impairment of autonomic regulation (hypotension)

• Loss of control of sweating and piloerection

• Loss of bulbocavernosus reflex, cremasteric reflex, babinski response and delayed plantar response

Spinal Shock• Evolves over time

• Initial period of areflexia: 24 hours

• Gradual return of reflexes 1 – 3 days after injury

• Period of increasing hyperreflexia 1-4 weeks

• Final hyperreflexia 1-6 months

Motor and Sensory Impairments• Complete (paralysis) or partial (paresis) loss of

muscle function below the level of lesion

• Impaired / Absent sensation below the level of lesion

Autonomic Dysreflexia• Life Threatening pathological autonomic reflex

• Typically occurs in lesions above T6 (sympathetic splanchnic outflow)

• More common in chronic stage of recovery (3-6 months after injury)

• Produces an acute onset of autonomic activity from noxious stimuli below the level of lesion

Autonomic Dysreflexia• Initiating Stimuli:• M.C. cause: Bladder and Bowel distention/

Irritation• Pressure sores• Noxious cutaneous stimuli below level of lesion• Kidney malfunction• Electrical stimulation below level of lesion• Sexual activity• Labor• Skeletal fracture

Autonomic DysreflexiaInitiating Stimuli Signs and Symptoms

Bladder distention/ Irritation Hypertensiom (rise in systolic BP 20-30 mm Hg)

Bowel distention/ Irritation Bradycardia

Noxious stimuli below level of lesion

Severe Headache

GI Irritation Feeling of anxiety

Sexual activity Constricted Pupils

Labor Blurred Vision

Skeletal fracture below level of injury

Flushing and piloerection above level of lesion

Electrical stimulation below level of lesion

Dry, pale skin below level of lesion (due to vasoconstriction)

Nasal Congestion

Autonomic Dysreflexia• Intervention:• Medical emergency• If lying flat, Pt. should be brought to upright

position, loose clothing, restrictive device• Check for stimuli

• Pharmacological intervention (Nifedipine, nitrates, captopril)

Spastic Hypertonia• Velocity dependent increase in resistance to passive

stretch• Typically emerges below level of lesion after period

of spinal shock evolves• Patients with minimal to moderate involvement

may learn to trigger their spasticity at appropriate times to assisst in functional activities

Spastic Hypertonia

• Management:• A recent systematic review found that stretch had no

clinically important impact on spasticity in people with neurological conditions

• Medications:• Baclofen• Tizanidine• Diazepam• Dantrolene sodium

Spastic Hypertonia

• Management:• Surgical approach:

• Myotomy• Tenotomy• Dorsal Rhizotomy – cutting of dorsal nerve roots to

disrupt stretch reflex arc

Cardiovascular Impairment

• Loss of sympathetic connection between brainstem and heart, while parasympathetic input remains intact

• Bradycardia and dilation of peripheral vasculature below level of lesion

• Orthostatic hypotension• Deconditioning

Cardiovascular Impairment

• Management:• Slow progression to vertical position• Use of compressive stockings and abdominal binder• Epedhrine to increase BP• Low-dose diuretics to relieve persistent edema

Impaired Temperature Control

• Loss of internal thermoregulatory response

• Initially after injury, hypothermia may occur then hyperthermia

Pulmonary Impairment

• In people with high cervical injuries, pulmonary problem are the leading cause of death

• Below T10 = normal/ near normal ventilatory and respiratory function

Pulmonary ImpairmentLevel of Injury Respiratory Muscles Management

C1 – C2 SCM, Upper Trapezius, Cervical Extensors Artificial Ventilator/ Phrenic Nerve stimulator, Airway clearance assisstance

C3 – C4 Partial diaphragm, Scalenes, Levator Scapulae

Acute: Mechanical Ventilation, Part-time ventilation, Airway clearance assisstance

C5 – C8 Diaphragm, Pectoralis major and minor, Serratus anterior, rhomboids, latissimus dorsi

Weak cough management

T1 – T5 Some intercostals, Erector Spinae

T6 – 10 Intercostals and abdominals

Impaired Temperature Control

• Paradoxical Breathing• d/t paralysis/ paresis of scalenes and intercostal muscles• flattening of upper chest wall, decreased chest wall

expansion, dominant epigastric rise during inspiration

Bladder Dysfunction

• UTI – one of the major cause of morbidity and mortality in SCI• 50% develop SCI

• Spinal control of micturition: S2-S4

• Lesions above conus medullaris/ sacral segments• Spastic/ Hyperreflexic bladder (UMN bladder)

• Lesions on sacral segments/ conus medullaris• Flaccid/ Areflexic bladder (LMN bladder)

Bladder Dysfunction

• Spastic Bladder• Contracts and reflexively empties in response to a

certain level of filling pressure• Reflex arc intact• Hyperrelfexive detrusor• Dyssynergia between detrusor and sphincters

Bladder Dysfunction

• Bladder management:• Primary goal: prevent/ minimize urinary tract

complications• Intermittent catherization• External/ Condom catheter• Suprapubic Tapping• Valsalva Maneuver

Bowel Dysfunction

• 98% report problems with bowel care

• Lesions above S2: spastic/ reflex bowel• Reflex defecation

• Lesions at S2/ below S2• Flaccid/ areflexive bowel

Bowel Dysfunction

• Bowel management:• Reflexic bowel• Suppositories/ Digital stimulation• Valsalva Maneuver• Abdominal Massage

• Areflexic Bowel• Manual Excavation• Gentle Valsalve• Diet changes

Sexual Dysfunction

• Male Response• Erectile capacity: • UMN > LMN• Incomplete lesions > Complete lesions

• Ability to ejaculate• LMN > UMN• Incomplete lesions > Complete lesions

Sexual Dysfunction

• Female Response• Components of sexual arousal (Vaginal

lubrication, engorgement of labia, clitoral erection):• UMN > LMN (through reflexogenic stimulation

but psychogenic response will be lost)

• Fertility not affected• Menstrual cycle interrupted for 4 – 5 months

following injury• Normal menses return, conception unimpaired

Secondary Medical Complications

• Most common secondary complications:

• Pressure sores ( 15%)• Pneumonia (4%)• DVT (2.5%)


• Pressure sores:• Complete > Incomplete SCI• Most common sites:• Sacrum• Heels • Ischium


• DVT• Most likely to occur during acute stage of recovery• Local swelling, erythema and heat

• Interventions:• Early mobilization• Compression stockings and boots• Pneumatic compression sleeves• IVC Filter• Prophylactic anti-drug therapy: Heparin


• Pain• Nociceptive pain• Shoulder pain• Musculoskeletal pain

• Neuropathic pain• can occur below, at, or above the level of

lesion• Allodynia/ Hyperalgesia• If above lesion: nerve impingement/

compression


• Contractures• Heteretropic (Ectopic) Ossification

• Osteogenesis in soft tissues, usually near joints, below the level of lesion

• Etiology: unknown• Most often occurs at hip and knee joint• Early symptoms: swelling, joint and muscle pain, decreased

ROM, erythema, local warmth near a joint

• Management: NSAIDS, Pulse low-intensity electromagnetic field, Bisphosphonates, surgical excision


• Osteoporosis and skeletal fractures• Most common in the LE

EARLY MEDICAL AND REHABILITATION MANAGEMENT IN THE ACUTE STAGE

Emergency Care

• Stabilization of the patient

• Goal: stabilize the spinal column to prevent further damage to the cord

• High doses of methylprednisolone

PT Examination

• Motor and sensory function:• Using the ISNCSCI

• Respiratory• Chest expansion (N = 2.5 to 3 in.)• Vital capacity• Coughing:

• Functional cough: loud and forceful, 1-2 coughs/ exhalation

• Weak functional cough: soft, 1 cough/ exhalation• Non-functional cough: not a true cough, clearing of a

throat and no expulsive force

PT Examination

• Integument:• Braden scale• SCIPUS and SCIPUS- Acute

• PROM• Early mobility skills

PT Intervention

• Respiratory management:• Intermittent positive pressure ventilator (IPPV)• Invasive mechanical ventilation

• Deep breathing exercises:• PT apply light pressure during both inspiration and expiration

with manual contact just below the sternum• To facilitate expiration: manual contacts are made over the

thorax with hands spread wide• Glossopharyngeal breathing

• Gulping of air 6 – 10 times

PT Intervention

• Respiratory management:• Air shift maneuver

• Closing of glottis after maximum inhalation, relaxing the diaphragm, and allowing air to shift from lower to upper thorax

• Respiratory muscle strengthening• Handheld inspiratory muscle training devices

• Coughing• Self-assisted cough/ Manual assissted

• Abdominal Binder• Compensation for abdominal muscles

• Manual stretching

PT Intervention

• Skin care• Prevention• Bed positioning every 2 hours • Wheelchair pressure relief maneuvers every 15 minutes

• Early stregthening and ROM• If the lesion is on the lumbar spine, SLR > 60 deg. Or hip

flexion > 90 degrees is avoided• Tetraplegia: shoulder flexion and abduction > 90 deg. Is

avoided

Active Rehabilitation

• Goal: for the patient to become as independent as possible and to achieve the functional mobility necessary for living, work and recreation

Active Rehabilitation: PT EXAM

• Aerobic capacity/ Endurance• 6 Minute Arm Test

• Arousal, attention and cognition• MMSE

• Environmental or work barriers• Gait, locomotion and balance• Wheelchair Skills Test• Modified Functional Reach test• Berg Balance Scale• RLA-OGA• Walking Index for Spinal Cord Injury (WISCI)

Active Rehabilitation: Functional Expectations

Documents

SCI. Demographics and IncidenceDemographics and Incidence Approx. 11,000 new cases of SCI occur in U.S.A. annually 37.1 Years old: Average age Male: 78.3%;