Idea Transcript
27/04/59
บาดเจ็บไขสันหลัง คือ การ บาดเจ็บที่เกิดขึ ้นกับส่วนของไข สันหลัง ตังแต่ ้ บริ เวณ foramen magnum จนถึงส่วนปลายคือ conus medullaris ซึง่ จะอยู่ ประมาณขอบล่างของกระดูก L1 หรื อบนกระดูก L2 รวมทัง้ ส่วนของ cauda equina ด้ วย
SPINAL CORD INJURY Rehabilitation unit, Nakornping hospital
Primary Cause of Death
การตรวจทางระบบประสาทเพื่อจาแนกความรุนแรงในผู้ป่วยบาดเจ็บไขสันหลัง American Spinal Injury Association (ASIA) guidelines
การตรวจระบบประสาทรับความรู้ สกึ 28 key dermatomes ที่ตอ้ งตรวจ
pinprick & light touch ของร่างกาย
ทัง้ 2 ซีก คะแนน 0ไม่สามารถแยกความรู ส้ ึ กแหลมกับทูไ่ ด้ คะแนน 1 แยกแหลมกับทูไ่ ด้แต่ความรู ส้ ึ กแหลมไม่เท่ากับใบหน้า คะแนน 2 ความรู ส้ ึ กแหลมเป็ นปกติเท่ากับใบหน้า
sacral sparing ทาโดยการ PR ถ้าผูป้ ่ วยรู ส้ ึ กถึงการสัมผัส หรื อแรงกด ถื อว่ายังมี sacral sparing
การตรวจ
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Key Muscles
C5-elbow flexors
C6-wrist extensors
C7-elbow extensors
C8-finger flexors (distal phalanx of 3rd finger)
T1-small finger abductors
ตรวจประเมิน UE
Key Muscles
L2- hip flexors
L3- knee extensors
L4- ankle dorsiflexors
L5- long toe extensors
S1- ankle plantar flexors
PR for sphincter tone assessment
ตรวจประเมิน LE
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ความรุนแรงของการบาดเจ็บแบ่งตาม ASIA impairment scale (revised 2000)
ASIA:A (complete)
ASIA:B (incomplete)
ASIA:C
ASIA:D
ASIA:E
Expected Functional Outcomes by Neurologic Level of Injury
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Rehabilitation Phase of Injury Goal
Interdisciplinary Team physician
:
Social worker
maximizing
physical independence becoming independent in direction of care Preventing secondary complications pressure ulcer joint stiffness urinary tract GI tract
Family members
Recreation/v ocational therapist
PT
Patient Psychologist
etc.
OT
Dieticians
Nurses Aids
Interdisciplinary Team physician Social worker
Interdisciplinary Team The patient and family members need to be educated aboutPTthe nature of an SCI and the patient’s prognosis and the OT uncertainty of such
Family members
Recreation/v ocational therapist
Patient Psychologist
Dieticians
Nurses Aids
Rehabilitation nurses, physician in addition Social to performing worker their standard nursing duties, provideRecreation/v ocational therapist education on prevention Patient and treatment of secondary Psychologist complications, in addition to training in bowel and bladder Dieticians management.
Family members
PT
OT
Nurses
Aids
Interdisciplinary Team
Physical Skill Training
physician Social worker
Family members
Physical and occupational therapists in the acute hospital should facilitate prevention of secondary complications such as contractures, pressure ulcers, and disuse atrophy. This is done Recreation/v ocational maintenance of joint ROM, PT through therapist splinting, positioning, and selective musclePatient strengthening.
Mobility
self-care skills
other activities of daily living (ADL)
- ROM of all joints isperformed and taught by the therapists to Psychologist OT people with SCI and their caregivers as soon as it is medically safe to do so. - Performance of an adequate daily stretching program can prevent joint contractures. Dieticians Nurses - Splinting of joints, with either Aids an off-the-shelf or a custom splint fabricated by an occupational therapist, is also often used to provide a prolonged stretch, to facilitate a functional joint position, and to prevent skin breakdown.
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Practices (PT)
joint ROM and strength
Mat activities1
rolling
prone on elbows positioning
prone on hands positioning
supine on elbows positioning,
long sitting
short sitting
quadruped positioning,
transfer training
Transfer training
Transfer training
complete paraplegia/lower tetraplegia
stand-pivot and sit-pivot transfers
Transfer training
complete paraplegia/lower tetraplegia
1. Lift feet onto bed and wheel the chair forward against bed. Put on brakes. Then bend forward and lift butt forward on chair.
Transfer training
The floor-to chair transfer
1. Sit with legs straight, Pull seat to your side opposite the wheelchair (a person's knee can also be used).
2. With hands on each chair, push up, with your head forward over knees
2. With one hand on the cushion and one on the bed, lift the body sideways onto the bed.
3. Repeated lifts and lifting of legs may be needed.
Transfer training
The floor-to chair transfer
3. Swing onto the seat. 4. Now, with your head forward over your knees, swing body onto the wheelchair.
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Standing
Wheelchair Skills
**with caution in individuals with chronic SCI**
complete thoracic level injuries
KAFO
Other
Spinal Cord Injury Education
Home and Environmental Modifications
Driver Training
Vocational Training
Secondary Conditions
Pulmonary System
Pulmonary complications are the leading causes of death for people with SCI
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THE POSITION OF THE DIAPHRAGM
Management of Pulmonary Complications
lung expansion
Intermittent positive pressure breathing
bilevel positive airway pressure
Continuous positive airway pressure (CPAP)
Atelectasis pneumonia, pleural effusion, empyema
Secretion mobilization techniques Postural drainage Percussion Vibration
Postural drainage
Contraindication
Severe hemoptysis
Untreated acute condition
severe pulmonary edema
congestive heart failure
large pleural effusion
Pulmonary embolism
pneumothorax
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Contraindication
Precaution
Cardiovascular instability
Hemoptysis
cardiac arrhythmia
Postoperation
severe hypertension or hypotension
Geriatric
recent myocardial infarction
Malignancy
Unilateral lung abscess
Recent neurosurgery
Right and Left upper lobe
Right and Left upper lobes
Right and Left lower lobes
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Percussion
Vibration
Right and Left lower lobes
Chest percussion
Orthostatic Hypotension
Immediately after SCI a complete loss of sympathetic tone neurogenic (“spinal”) shock with hypotension, bradycardia, and hypothermia the sympathetic reflex activity returns normalization of blood pressure Supraspinal control: absent in those individuals with high-level and neurologically complete SCI
orthostatic hypotension
Vascular System
Deep venous thrombosis (DVT)
Pulmonary embolism
Management
elastic stockings
abdominal binders
hydration
gradually progressive daily head-up tilt
administration of salt tablets, midodrine, orfludrocortisone.
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Autonomic Dysreflexia
syndrome and clinical emergency that affects people with SCI usually at the T6 level or above
symptoms
pounding headache
Systolic and diastolic hypertension
profuse sweating
cutaneous vasodilatation with flushing of the face, neck,and shoulders nasal congestion
pupillary dilatation
bradycardia
Autonomic Dysreflexia
Triggered by a noxious stimulus below the injury level
Distended bladder
fecal impaction
pathology of the bladder and rectum
ingrown toenails
labor and delivery
surgical procedures, orgasm
Etc.
Autonomic Dysreflexia
Treatment of acute AD
identification of the precipitating stimulus
sat up
Loosen constrictive clothing and garments
blood pressure monitored every 2 to 5 minutes
Evacuation of the bladder done
Resolved fecal impaction
* Local anesthetic agents should be used during any manipulations of the urinary tract or rectum*
Administered fast-acting antihypertensive agents
Bowel Management
Pathophysiology of neurogenic bowel dysfunction reflexic or UMN bowel Upper
motor neurogenic bowel (UMNB)
Suprasacral lesion
areflexic or LMN bowel
Lower
motor neurogenic bowel (LMNB)
Conus medullaris, Cauda equina lesion
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Upper motor neurogenic bowel
↓Colonic motility
Constipation
↓ Ability to sense the urge
Loss volitional control incontinence
Intact spinal reflex (sacral)
Normal or increase anal sphincter tone
Summarize
LMNB constipation with a high risk of frequent incontinence through a lax external sphincter mechanism UMNB constipation with fecal retention behind a spastic anal sphincter require a chemical or mechanical trigger for defecation
Lower motor neurogenic bowel
Prolonged transit time constipation
↓ anal tone
incontinence
Anorectal reflex is absent or decrease
Anocutaneous reflex is absent or decrease
Bowel Level
Outcome
Expected Outcome
Equipment
C1–4 C5
• Total assist for digital stimulation, insertion of minienema or suppository, and perineal hygiene
• Padded reclining commode chair with head support •
C6–C7
• Some to total assist for setup and perineal hygiene
• Padded commode chair • Suppository inserter • Digital bowel stimulator • Mirror
C8 T1–T12 L1–S5
• Independent digital stimulation, suppository or minienema insertion, and perineal hygiene
• Padded commode chair
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Management Neurogenic bowel management
Goal of bowel program 1. effective and efficient colonic evacuation Bowel evacuation at a consistent time of day 2. preventing incontinence 3. preventing constipation. social continence - Predictable - Scheduled - Adequate defecation without incontinence at other time
Bowel program
Fluid
Diet
Timing
Frequency
Medication
Bowel care
Fluid
Must be balanced with bladder management
Adequate fluid: [40xBw]+500 cc
Procedure to periodically evacuate stool from the colon
Diet
Adequate fiber intake (No less than 15 grams of fiber daily) Whole
grain breads and cereals, esp.
bran Wheat Fruits
germ and vegetables
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Timing+Frequency
Aim Timing Frequency
• To avoid chronic colorectal overdistention
• based on personal lifestyle needs • Schedule at the same time of day • bowel routine after a meal can take advantage of the gastrocolic response
Preparation
Positioning
Checking for stool
Rectal stimulation
4 general categories
Stool softener
Bulk former
Peristaltic stimulant and prokinetic agent
Contact irritant
• every day in the beginning. • later on at least once every 2 days
Scheduled Bowel care
Medication
RECTAL STIMULATION
Pelvic nerve mediated recto-colic reflex Caution: Autonomic Dysreflexia* (T6 and above)
Mechanical
Recognising completion Clean up
Digital stimulation
Suppositories
Manual Evacuation
Mini-enema
* typically performed by a person with an LMN bowel
Inserting a gloved
lubricated finger into the rectum
inserting a gloved
slowly rotating the finger in a circular movement until relaxation of the bowel wall is felt, flatus passes, or stool passes
lubricated finger into the rectum to break up or hook stool
pull it out
typically occurs within 1 minute
repeated every 10 minutes until
*Abdominal wall massage, starting in the right lower quadrant and progressing along the course of colon
cessation of stool flow
palpable internal sphincter closure
absence of stool results from the last two digital stimulations
Chemical
Digital Stimulation
Digital evacuation
* typically effective only for people with a UMN bowel
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pulsed water irrigation
colostomy
Bladder
Bladder Level
reflexic or UMN bladder
Outcome Expected Outcome
Equipment
C1–4 C5
• Total assist for inserting • Foley catheter or external indwelling catheter catheters (transurethral or suprapubic) • Urine drainage bags or applying an external catheter to penis
C6–C7
• Total assist for inserting indwelling catheter • Independent selfcatheterization through a continent urinary diversion
• Bimanual catheter inserter • Foley, straight, or external catheters • Urine drainage bags
T1–T12 L1–S5
• Independent intermittent catheterization
• Straight catheters
The sympathetic innervation
to the bladder and bladder neck or internal urethral sphincter,
which modulates relaxation of the body of the bladder and narrowing of the bladder neck to inhibit voiding, is provided by the hypogastric nerves, which exit from the spinal cord at segments T11-L2.
Areflexic or LMN bladder
The parasympathetic innervation to the bladder, which
contraction of the urinary bladder with opening of the bladder neck to allow modulates
voiding, is provided by the pelvic splanchnic nerves, which exit from the spinal
cord at segments S2-S4.
The somatic pudendal nerve, also originating from segments S2-S4, innervates the external urinary sphincter
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Bladder dysfunction
In spinal shock, clinical will be similar
UMN type
LMN type
Lesion above sacral center
Lesion peripheral to sacral center or complete destroys sacral center
Detrusor sphincter dyssynergia.
Characterized by
low urinary volume
high bladder pressure
uninhibited detrusor contraction
Management of Neurogenic Bladder
goal of management
achieve a socially acceptable method of bladder emptying
avoiding complications
Hypotonic of detrusor
Infections
and/or sphincter
Hydronephrosis with renal failure
urinary tract stones
AD
2 possible cilinical senarios Urinary retention: sphincter + / detrusor -
May trigger autonomic dysreflexia. (if lesion above the T6 vertebrae)
Continuos incontinence sphincter - / detrusor +/-
CARE IN ACUTE PHASE
Immediately after the injury (shock phase)
best option for the long-term bladder management
physiologic advantage of allowing for regular bladder filling and emptying
requires general level care
the social acceptability of not needing a drainage appliance
Indwelling catheter
fewer complications than with other methods.
Intermittent bladder catheterization (IC)
Intermittent bladder catheterization (IC)
total fluid intake of approximately 2000 mL/day
Reflex voiding
option for men with UMN bladder
Contractions can be triggered by various stimulation techniques
target catheterized volume of 500 mL UMN bladder: combined with anticholinergic medications
http://www.elearnsci.org/
squeezing the penis or scrotum
tapping on the suprapubic area
A condom catheter is a tube-vented condom that depends on a watertight seal for successful use
completeness of voiding can be determined by measurement of a postvoid residual urine volume
reflex voiding elevated voiding pressures vesicoureteral reflux, hydronephrosis, and eventual renal failure
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indwelling catheter
reasonable option for
tetraplegia who are unable to perform IC
men who are unable to effectively maintain an external catheter on their penis
suprapubic cystostomy
Prostatitis
Epididymitis
hypospadias
complication
with UTI
bladder stone formation
Epididymitis
prostatitis,
Hypospadias
bladder cancer
Other method
Avoid IC complication
Urodynamic study
Augmentation cystoplasty
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Spasticity
Upper motor neuron
Velocity dependent, increase muscle tone and stretch reflex
Spinal cord injury spinal shock flaccid flexor spasticity extensor spasticity
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Benefit of spasticity
Indication for treatment of spasticity
Delay muscle atrophy
Interfere ADL
Decrease risk of DVT
Interfere walking, transfer, wheelchair ambulation
Decrease osteoporosis
Sleep disturbance
Improve standing and walking
Pain
Joint stiffness
Management of spasticity
Stretching of spastic muscles
Identify and get rid of noxious stimuli
Steady static stretching
Physical therapy: prolong stretching, tilt table standing, physical modalities
ROM exercises
Proper positioning
Medications: baclofen, diazepam, Tizanidine hydrochloride
Nerve block, motor point block: phenol, alcohol, botulinum toxin
Intrathecal baclofen
Surgery: rhizotomy, myelotomy
Steady static stretching
ROM exercises
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Proper positioning: supine
Proper positioning: sitting
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