Key Assessment information for SCI

Database

a. Spinal fracturesb. Spinal level lesionc. Spinal stabilityd. Assosiated injurye. Spinal shock- transient suppression and gradual return of reflex activity caudal to the

SCI(Dinno et al 2004)Subjective

a. Pre-morbid moskuloskeletal problemb. PMH : relevant respiratory factors

Objectivea. Respiratory status (including FCV and cough)b. Passive range of movement of all jointc. Active movementd. Muscle strengh e. Tone : Modified Ashworth Scale(Bahannon & Smith 1987)f. Sensory espicially pin prick sensationg. Joint rangeh. Other injury

Treatment consideration in the acute phase, key intervention are :

1. Prophylactic chest careEspesially for T6 and above, including assisted coughing, repiratory muscle training and positioning programme

2. Maintenance of muscle lenght and joint range of motion. This is include of maintaining position in order to manage spasticity, hypertone and prevent loss of range and the dvelopment of shoulder pain. Some muscle are prone to contracture because of habitual positions adopted , muscle imbalance and weakness.

3. Active assisted and passive movement.Limbs are normally taken through range twice a day (No evidance – base rules for SCI are currently available ). Time orf treatment depend of the level spacticity, active strengh available and pain.

4. Teaching subtitution movement where active movement is lost, e.g. elbow extension using shoulder lateral rotation and gravity to assist. Splinting the hands of the patients with C6 complete lesion, in order to effective tendoesis grip.

5. Progressive mobilization up againt gravity Using a tilt table is commonly used after flat bed rest. Patients will be hypotensive due to loss of venous tone and muscle pump. An Abdominal binder and compression stockings are worn to assist in venous return. Pharmacological management wil assist in the control of low blood pressure and complication of autonomic dysreflexia.

Treatment consideration in the acute phase of the paraplegiaImpairments :

- Respiratory compromise, - Weakness in affected muscle of trunk and lower limbs- Alterd tone – flaccid (cauda equina) or spasticity- Altered/loss sensation sense , cutaneus hypersensitivity- Autonomic dysreflexia T6 and above- Muscle Imbalance leading to contracture

Activity Limitations- Pain- Distupted postural/balance system- Loss/impairmed functional gait- Compromised ability to caugh- Loss of funtional bowel and bladder control- Distrupted temperature control systems- Pressure are consideration

Key aims & strategies - Respiratory muscle training- Strengthen/ maintain inervated muscle- Passive and active assisted movement- Teach compensatory activities- Prevent contractures- Gait re- education with orthotic- Progressive standing programme: tilt table, with abdo binder and pressure stockings- Anasthetic skin prone to demage- Adress psycological issues- Education

Physioterapy management (derived from paddison and Middleton, 2004) of the rehabilitation phase1. Establishment of a standing programme : progressing from the tilt table to a standing frame.2. Balance re education : proggresion from bilateral arm support to unilateral arm support to

no arm support, e.g. reaching in the different direction3. Basic level transfer techniques : from bed to whelchair ; progressing to varied level transfers,

e.g. chair to floor, car transfer.4. Learning Wheelchair mobility skills5. Postural amd wheelchair seating assesment

To facilitate an optimum pushing position and minimize upper limb joint pain.6. General bed mobility and mat activities7. Orthotics and gait training. During rehabilitation, the patient may be assesed for walking

with orthoses dependign of the fracture.

Key factors for consideration in Spinal Cord Injury ManagementA. Spinal stability

1. Spinal Stability account of structural and ligamentous of demage2. Surgical or conservatif management(bed rest/traction/bracing)

B. Orthothic Bracing1. For conservative management or as an adjunct to the surgical fixation2. The halo brace jacket for stability to the upper and lower cervical spine; thoraco-lumbal

for vary ektensivelyC. Spinal Shock

1. Transient suppression and gradual return of reflex activity caudal to the SCID. Pain Management

1. May affect accuracy of assessment, respiratory effort and ability to participate in treatment

2. Source of pain : neurodynamic, central dysaesthesia, mechanical instability, fracture pain, muscle spasm pain, viseral pain, nerve root entrapment and syringomyelia(cyst formation within the spinal cord)

E. Autonomic dysreflexia1. A sympathetic nervous system dysfunction producing hyperekstension, bradicardia and

headaches with pilo erection and capillary dilatation and sweating, above the level of the lesion with the lesion T6 or above.

2. Can result from any noxious stimulus such as bladder or rectal distension.F. Heterotropic ossification

1. Calcification in denervated or UMN disordered muscle may result from loss of range in joint and impaired functional activities such as sitting.

2. May be confused in early stage with DVT, when it presents as swelling, alterating in skin colour and increased heat, usually in relation to joint.

Question :

1. Relief the pain??