1、Traumatic Spinal Cord Injury (SCI) Majority of traumatic SCI occurs in young adult malesTraumatic spinal cord injury is a non-progressive pathologyMotor and sensory function on both right and left sides is determined by the level of injuryA patient with C6 level injury has intact motor and sensory f

2、unction bilaterally at and above the C6 level MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury1MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury2Traumatic Spinal Cord Injury Based on the International Standards for Neurological Classification of Spinal Cord Injury (published by the American S

3、pinal Injury Association, ASIA), patients can be grouped in five categories depending on the severity of impairment from A to EA is complete spinal cord injury with no motor or sensory function below the levelE is normal even though patient may have initially exhibited symptoms of spinal cord injury

4、, but is now normal MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury3ASIA Impairment Scale MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury4Traumatic Spinal Cord Injury DefinitionsParaplegia is defined as an impairment or loss of motor and/or sensory function of all or part of the trunk and

5、both lower extremitiesTetraplegia is defined as an impairment or loss of motor and/or sensory function in both upper extremities in addition to trunk and both lower extremities; respiration is often affected MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury5Spinal Cord AnatomySpine has 8 cervical

6、, 12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal spinal nerves (levels)Spinal cord ends around L1 vertebral levelThe 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 abdo

7、minal muscles and sensory function of the trunk The lumbar spinal levels control motor and sensory function of the lower extremitiesThe 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

8、 Traumatic Spinal Cord Injury6Symptoms of Spinal Cord InjuryMotor impairmentParalysis or weakness of affected muscles (following the myotomes)Sensory impairment Loss or impaired sensation of affected areas (following the dermatomes)MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury7DermatomesMODUL

9、E C4/CSDLM/2013/NR Traumatic Spinal Cord Injury8Symptoms of Spinal Cord InjuryAutonomic dysreflexiaOften 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 areaPati

10、ent shows flushed face, pounding headache, very high blood pressure, sweating above the level of injury, piloerection, 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

11、arm /wiki/Goose_bumps 9Symptoms of Spinal Cord InjuryAutonomic dysreflexia is managed in the following wayDont let the patient lie downPosition the patient in sittingCheck the catheter or tube for blockageCheck the feet positions for twisted ankles or pinched toesEmpty leg bag for ur

12、ine if it is fullObtain immediate medical helpMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury10Symptoms of Spinal Cord InjurySpasticityMost common in patients with cervical and thoracic level injuriesOccurs below the level of lesion after the spinal shock periodPoor venous return below the leve

13、l of lesion that may result in orthostatic hypotensionBradycardiaImpaired body temperature controlUnable to regulate body temperature in response to environmental changes (stay under sun) Impaired ability to sweat below the level of lesionImpaired respiratory functionDecreased tidal volume and vital

14、 capacityImpaired coughMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury11Symptoms of Spinal Cord InjuryBladder and bowel dysfunction for those patients with S2-4 involvementIf not managed properly, patient will have urinary tract infections and ultimately kidney failureMust drink sufficient flui

15、d and eat a high fiber dietMost patients can be trained to manage their bladder and bowel 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 Injury12Symptoms of Spinal Cord Injur

16、ySecondary complicationsPressure soresDeep vein thrombosisPain ContractureHeterotopic ossificationOsteoporosisMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury13PrognosisAfter stabilizing the spinal (vertebral column) injury, the patient should begin a comprehensive rehabilitation programLife exp

17、ectancy is related to the severity of impairmentIndividuals with spinal cord injury classified between the *ASIA A to C levels and those with tetraplegia have shorter life expectanciesRef: American Spinal Cord Injury Association (ASIA) C/elearning/ISNCSCI_Exam_Sheet

18、_r4.pdf MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury14MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury15Medical ManagementEmergency careKeep the neck and trunk stabilized (use a cervical collar and back board) during transportation Surgery to stabilize fractureOften involves immobilizati

19、on after the surgery (Halo device for cervical spine and body cast/jacket for thoracic or lumbar spine)Drugs To manage spasticity and painTo manage infectionsMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury16Physical Therapists ConcernsPatients with traumatic spinal cord injury often develop pne

20、umonia, urinary tract infection, and pressure soresPhysical therapists must teach patientsWays to achieve a productive coughProper bladder management programDaily skin inspection MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury17物理治療檢查評估確保脊髓損傷的位置是固定好的病人可能存在其他損傷部位確保病人在醫學上是穩定的關注生命體征 評估患者末梢循環情況，特備注

21、意足部（橈動脈與足上動脈對比）評估呼吸功能（肺活量）吸氣時相關肌肉 - 膈肌(膈神經, C3-5), 肋間外肌和輔助呼吸肌(T1-11), 腹肌呼氣時相關肌肉 - 腹肌, 肋間內肌, 膈肌輔助呼吸肌對呼吸的影響 - 分別檢查坐位、臥位下的情況判斷患者是否有呼吸機依賴MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury18物理治療檢查評估評估是否能夠產生有效的咳嗽咳嗽需要聲門和呼吸肌的協調運動評估 會話情況(發聲情況)評估 言語功能患者可能在事故后存在腦外損傷，所以其言語功能可能受到損害 評估 感覺功能基于感覺評估結果遵循ASIA量表MODUL

22、E C4/CSDLM/2013/NR Traumatic Spinal Cord Injury19物理治療檢查評估評估 肌力基于肌力評估結果使用MMT檢查10塊關鍵肌MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury20物理治療檢查評估評估 肌張力檢查損傷節段以下的痙攣情況頸髓或高位胸髓損傷患者常有痙攣評估 運動范圍踝關節必須能背屈達一半以確保可以站立腘繩肌必須有足夠長度才能確保能穿褲子 (伸膝起碼達110度 )髖關節后伸必須達到10度才能確保步行必須要有全范圍的肩關節后伸、外旋、內收，肘關節伸，前臂旋后，腕關節的背伸來確保能坐起MODUL

23、E C4/CSDLM/2013/NR Traumatic Spinal Cord Injury21物理治療檢查評估肌腱的檢查查看指屈肌腱是否緊張短縮當病人伸腕時，手指會有自動的屈曲(功能性抓握)MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury22有效長度的指屈肌腱才能允許患者有功能性抓握MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury23物理治療檢查評估評估 皮膚完整性是否發紅局部溫度升高、腫脹開放性傷口對于長期坐在輪椅上患者必須檢查：雙側坐骨結節骶骨尾骨對皮膚易產生壓瘡部位要尤為關

24、注（下一張幻燈片）MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury24容易產生壓瘡部位MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury25物理治療檢查評估直腸和膀胱功能患者能否自己管理大小便或者自己通過輔助用品來清潔？功能性技能翻身坐起床-輪椅轉移站立步行-取決于損傷程度MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury26物理治療檢查評估評估患者出院計劃和家庭生活輔助用品使用FIM量表或其他合適量表* Ref: rehabmea

25、/lists/rehabmeasures/dispform.aspx?id=889 MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury27MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury28創傷性脊髓損傷患者一般管理規則持續監測生命體征和循環情況來防止體位性低血壓強化損傷平面以上的肌肉力量教會患者頭部/軀干和上肢對于功能性活動的關系患者積極尋找新的方式來達到完成功能性活動的目的患者有體溫自我調節障礙-當病人訓練時保持治療區域舒適MODULE C4/CSDLM/2013

26、/NR Traumatic Spinal Cord Injury29物理治療師干預的目標患者功能上獨立高位頸段損傷患者應當教會其直接照顧者腰段和低胸段損傷的患者以獨自轉移為目標慢性脊髓損傷患者，不管損傷平面在哪，都應選擇輪椅來作為移動的主要工具來節省體力患者應知道所有技能來預防壓瘡的發生與發展MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury30物理治療師的干預呼吸功能管理皮膚護理早期肌力訓練和關節活動度訓練床上運動轉移坐起及坐位時活動站立及站立時活動步行MODULE C4/CSDLM/2013/NR Traumatic Spinal Co

27、rd Injury31呼吸功能管理如果可以，安靜狀態下使用腹式呼吸模式深呼吸訓練吞咽呼吸 使用聲門來吞咽一口空氣到肺里面，以此增加吸氣量。對于呼吸機依賴的患者可能有用 胸壁活動在坐位下考慮腹肌的支持 (舉例, 用一根繩索) 來改善靜脈回流和增加血容量體位引流，叩診，振動排痰，吸痰人工輔助咳嗽治療師或者患者把手放在上腹部咳嗽隨著手向上向內的壓力同時快速進行MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury32Assisted CoughMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury33

28、呼吸功能管理高位頸段損傷患者( C3 及以上) 將依賴呼吸機進行呼吸C3-5 損傷患者可能要在夜間睡眠時使用呼吸機 MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury34皮膚護理患者（或護工）應該檢查有壓瘡傾向的皮膚區域，至少一天一次高位頸段損傷患者應當兩小時翻身一次輪椅應該有恰當的壓力緩沖墊骨盆應該放置在中立對稱的位置上在輪椅上患者應該每15分鐘緩解下受壓部位的壓力(獨自或者依靠幫助)撐起側傾前傾MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury35側傾Side Lean撐起Push

29、Up前傾Forward LeanMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury36Skin CareIf the patient develops an ulcer, the patient should be referred to a wound care specialist to facilitate healing and to prevent infectionPatient should not put pressure on the ulcer until it is healed - for example, a pa

30、tient with a right greater trochanter ulcer cannot lie on the right side until the wound is healedMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury37Early Strengthening and Range of Motion ExercisesStrengthen all innervated musclesWatch for substitutionFor example, patient may use shoulder extern

31、al rotators to substitute for elbow extensorsDo not stretchFinger flexors to protect tenodesisLower trunk muscles so that patient can lean on ligaments for sittingStretch Hamstrings - to assure a straight leg raise to 100 degrees Hip flexors to assure patient has 10 degrees of hip extensionAnkle pla

32、ntar flexors to assure patient has 10 degrees of dorsiflexionMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury38Sitting Patient usually experiences postural hypotension in sitting or standingInitially, bring the patient to sitting slowlyUse an abdominal binder and elastic (pressure) stockings to

33、assist venous returnGradually elevate the head and upper trunk in bedMay also use a tilt-in-place wheelchair with elevating leg rests or a tilt tableBiomechanical principles for mat activitiesHead-hips relationshipUnweight the body part first before moving itUse momentum MODULE C4/CSDLM/2013/NR Trau

34、matic Spinal Cord Injury39SittingBe aware that the patient is using very small muscles (in upper extremities) to move a heavy load (the whole body)Protect patients shoulders and wrists from Day 1 of physical therapy - patients with chronic spinal cord injury often experience shoulder problemsFor sco

35、oting sideways or up and down in bed (or on mat), patients need to clear buttocks from the supporting surface in order to move - hence, patients with short arms and a long trunk will need push-up blocks for mat activitiesPatient need to learn the new center of mass for functional movementsMODULE C4/

36、CSDLM/2013/NR Traumatic Spinal Cord Injury40Sitting After the patient can tolerate sitting in the upright position, the patient can begin mat activities that may includeRolling from supine to proneProne positionProne on elbowsProne to supineSupine to long sittingScooting side to side in long sitting

37、Scooting up and down in long sittingMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury41Long sitting, lean on upper extremities, shoulders in extension and external rotation, and elbows extended MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury42Moving sideways in long sittingMODULE C4/CSDLM/20

38、13/NR Traumatic Spinal Cord Injury43Sitting Balance TrainingPatient learns to use trunk ligamentsPatient in long sitting on matLift one arm firstLift both arms Catch a ball with both armsPatient sits on a bench with feet flat on the floor and thenLift one armLift both armsTry to catch a ballMODULE C

39、4/CSDLM/2013/NR Traumatic Spinal Cord Injury44Transfer Mat to WheelchairTetraplegiaUsually needs a sliding boardParaplegiaOften may do without a sliding boardPark wheelchair at 45 degree angle to the mat and lock the wheelsRemove arm rest and leg rest next to matUse momentum to assist transferPush d

40、own on supporting surface with both arms and at the same time twist head and trunk away from wheelchairPatient with lower extremity spasticity can bear weight on legs to ease weight on upper extremitiesMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury45Patient with paraplegia transferring from ma

41、t to wheelchair at the same heightMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury46Patient with paraplegia transferring from mat to wheelchair to a higher surface MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury47Patient assisted sliding board transfer: #1 - therapist assists the patient; #

42、2 - patient place left hand on sliding boardMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury48StandingStanding program is good for the skeletal system and the cardiovascular systemCheck patients blood pressure in sitting firstPatient may need abdominal binder and elastic stockingsStart in parall

43、el barsPatient may need lower extremity orthotics and/or spinal orthoticPatient first presses down on parallel bars, lifts one arm, and then lifts both armsMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury49WalkingMust determine if walking is a reasonable goalFor patients with a spinal cord injur

44、y, walking consumes a tremendous amount of energyPatients have strong upper extremity muscles, no contractures, and strong motivation are candidates for walking trainingMost patients are not going to be community ambulators Potential gait patternsSwing toSwing throughFour pointTwo pointMODULE C4/CSD

45、LM/2013/NR Traumatic Spinal Cord Injury50WalkingPatients with a T12 above level will need bilateral knee and ankle orthoses (e.g. Craig Scott orthoses) to walk using a swing through or swing to gaitPatients with a T12 or below level will need bilateral knee and ankle orthoses and can walk with a reciprocal gait pattern (four point or two point)Patients with an L4-5 level or below will need ankle foot lorthoses to walk reciprocally and are best candidates for reciprocal gait trainingRef: Uustal H. and Baerga E Orthoti