Download Spinal Cord Injury

Spinal Cord Injury
Multidisciplinary rehabilitation program for The Third Hospital of Beijing University
Supervisors:
YYY
Dr.Zhou
Authors:
Karin Al
Lietje Jacobs
Geertje Kotzee
Date:
1 Jan 2006
Lietje Jacobs Karin Al Geertje Kotzee
Hogeschool Amsterdam
Spinal Cord Injury Protocol 2005
Third Hospital of Beijing
1
Foreword
‘Except of the thick layer of air pollution that sometimes blankets the city, Beijing is a reasonably healthy city.
When weighing health risks, always bear in mind other, more immediate dangers - the great danger of
crossing the road.’ [Lonely Planet China, 2005]
In PRC the main cause of spinal cord injuries is traffic accidents. The Third Hospital of Beijing University has
recently started a new Spinal Cord Ward with 20 beds in the orthopedic department.
The 'Hogeschool van Amterdam (HvA)', expect the fourth year students to do a Bachelors thesis. The project
consists of an assignment given to the students by a client. Within the framework of the long lasting
institutional collaboration between 'Hogeschool van Amsterdam' and the Third Hospital of Beijing University,
three students were offered an opportunity to do a Bachelors thesis in Beijing. The Third Hospital of Beijing
University decided to offer Karin Al, Lietje Jacobs and Geertje Kotzee an opportunity to write a protocol for
the new spinal cord ward.
In March 2005 the students started a design phase for the project, four months of practical internship, two
months of theoretic research and one month of preparation activities. In November 2005 they started an
operational phase of two months in which they developed the first draft of a protocol that might be applicable
for the setting of the spinal cord ward of the Third Hospital of Beijing.
We would like to thank Dr. Zhou for this challenging and educating opportunity, Dr Yang Yanyan and Dr Zhang Jing, PT
Wu Tong Xuan, Wang Shu, and Zhao Chen for their interest, help and open mindedness. It wouldn’t have been
possible to make this protocol without your interest and feedback.
Lietje Jacobs Karin Al Geertje Kotzee
Hogeschool Amsterdam
Spinal Cord Injury Protocol 2005
Third Hospital of Beijing
2
Index
Introduction
Flowchart
Protocol
Diagnosis
Spinal cord injury
Information provided by physician
History Taking
Assessment
Analysis
Treatment plan
Treatment: Precautions
a. Bladder and Urinary tract infection
b.
Pressure sores
c.
Maintaining ROM
d.
Muscle contracture
e.
Autonomic dysreflexia
f.
Respiratory complications
g.
Osteoporosis
h.
Heterotopic Ossification
i.
Deep venous thrombosis
j.
Spinal deformities
k.
Syringomyelia
-
Treatment: Rehabilitation
Treatment during the acute phase
1.
Spinal stabilization
-
2.
Independent bladder management
3.
Independent respiratory status
4.
Prevention of complications
Treatment during the rehabilitation phase
1.
Patient and family education
2.
Pain management
3.
Orthostatic hypotension
4.
Regulation of spasticity
5.
Increased muscle strength
6.
Increased transfer ability
7.
Independent gait function
8.
Independent ADL function
9.
Independent bladder management
10.
Proprioception/ coordination
11.
Increased/ maintained respiratory function
12.
Kinesiophoby
Lietje Jacobs Karin Al Geertje Kotzee
Hogeschool Amsterdam
Spinal Cord Injury Protocol 2005
Third Hospital of Beijing
3
Bibliography
Books
….
Protocols
…
Articles
…
…
Internetsites
Appendix
ASIA
….
Functional assessment
…
Modified Barthel Index
…
Modified Ashworth Scale
…
TAMPA scale
…
Lietje Jacobs Karin Al Geertje Kotzee
Hogeschool Amsterdam
Spinal Cord Injury Protocol 2005
Third Hospital of Beijing
4
Introduction
This protocol systematically describes the diagnostic and therapeutic processes involved in the treatment of
patients suffering from a spinal cord injury (SCI). "Standardized approach to treating the patient and
instituting early treatment can markedly influence a patient's maximal recovery. Furthermore, background
knowledge in classification and ultimate treatment goals allows for an effective communication between the
treating team"[21]. The protocol is written for the spinal cord ward of the Third Hospital of Beijing University,
Beijing PRC. The protocol contains the treatment methods that is either proven by clinical evidence or
evidence based. From these options we chose the treatment that suits the Third Hospital of Beijing the best.
The available facilities, techniques employed, current policy, cultural influences and the Chinese healthcare
system were taken in consideration while writing this protocol.
Lietje Jacobs Karin Al Geertje Kotzee
Hogeschool Amsterdam
Spinal Cord Injury Protocol 2005
Third Hospital of Beijing
5
Protocol
Patients admitted to the Rehabilitation ward of the Third Hospital of Beijing University with a spinal cord injury
(SCI) will be assessed by the physicians. Long and short term goals should be developed according to the
Methodical acting flowchart. These goals should be continuously reassessed and modified to meet the needs
of the patient. The Long term goals will be evaluated every two weeks and the short term goals every week.
I
Acute Care (appr. week one and two)
Treatment
stabilization of the spine
- splinting, neck collar and bed positioning
- surgery
bowel and bladder management
weaning from respiratory support
Prevention of complications
prevention of pressure sores
daily ROM to all extremities to maintain joint
mobility and muscle condition
II.
Rehabilitation phase (Average length of stay 25 days).
The team develops the most effective rehabilitation route for each SCI patient.
Week three
Prevention of complications
Pressure sores
Muscle contracture
Osteoporosis
Ossification
Bladder and Urinary tract infection
Autonomic dysreflexia
Syringomyelia
Deep venous thrombosis
Spinal deformities
Respiratory complications
PT
Mobilization
- Systematically conditioning the patient to sitting up.
- Gait training
2 x a day ROM to all extremities
2 x a day spasticity treatment (stretching, strengthening the antagonist)
2 x a day muscle strengthening exercises (PNF, RM -method)
Starting ADL and transfer training
Hypotension
Respiratory dysfunction (breathing exercises)
Providing education program for patient and family/ carer
Teach the family/ carer how to treat the patient on:
Maintaining ROM, muscle strengthening, transfer training and spasticity treatment
Doctor and Nurse
Pain management (medication)
Bowel and Bladder programs established and performed
Lietje Jacobs Karin Al Geertje Kotzee
Hogeschool Amsterdam
Spinal Cord Injury Protocol 2005
Third Hospital of Beijing
6
Providing education program for patient and family/ carer
Respiratory dysfunction (medication, controlling saturation)
Spasticity treatment (medication)
Week four
Determining equipment for immediate needs
Prevention of complications
PT
ADL training
Gait training
5 to 6 hours of intense therapy is prescribed for the patient.
Doctor
Bowel and Bladder training
Prescribe medication
Control the patient's rehabilitation process
Nurse
Skin protection
Assisted care
Electrical stimulation
Week five
Review long term treatment goals and adjust if necessary.
Prevention of complications
PT
ADL training
Wheel chair mobility/Gait training
Doctor
Bowel and Bladder training
5 to 6 hours of intense therapy is prescribed for the patient.
Week six
Treatment according to specific long term and short term goals made in week five
Evaluate treatment goals at the end of the week:
- If the long and short term treatment goals are not achieved
then adjust the goals and if necessary, prolong admission (or transfer to a community hospital).
- If the long and short term treatment goals are achieved
then discharge the patient from the Rehabilitation Hospital
Discharge preparations
1. Family training in preparation for discharge
2. Home exercise program
3. Complete outpatient referrals, as needed (usually by PT)
4. Follow up appointment with physician is scheduled 2-3 months after discharge.
The patient can also phone the hospital for information and advice.
Lietje Jacobs Karin Al Geertje Kotzee
Hogeschool Amsterdam
Spinal Cord Injury Protocol 2005
Third Hospital of Beijing
7
Diagnosis
Spinal cord injury
Causes of Spinal Cord Injury/ Damage
Traumatic: Traffic accidents, Industrial, construction or other work accidents, Sport injuries, Domestic
accidents, Assaults, etc.
Non-traumatic: Transverse myelitis, Tumours, Vascular accidents, Multiple sclerosis, Congenital
malformations, etc.
Classification of the spinal Cord Lesions [36]
Complete Cord Lesions: no motor and sensory functions exist below the level of the lesion. If the spinal
shock is over and there are no motor or sensory reflexes the patient will be diagnosed with a complete cord
lesion.
Incomplete Cord Lesions: No defined pattern of motor and sensory function.
Brown-Sequard's Syndrome; Hemisection of the cord. Destruction of the corticospinal tracts results in
ipsilateral decreased motor function, increased tone and reflexes. Posterior/Dorsal column damage results in
decreased ipsilateral proprioception and vibration. Lateral Spinothalamic tract damage result in decreased
pain and temperature sensation few levels below the lesion.
Anterior Cord Syndrome; Decreased motor function, decreased pain and temperature sensation with
preservation of proprioception and light touch.
Central Cord Syndrome; Central grey matter is involved resulting in anterior and posterior cord
compression. Damage is primarily due to micro vascular compromise to the central cord. Decreased motor
function with upper limbs more affected than with lower limbs. Recovery usually takes place in the legs
followed by arms and then hands.
Sacral Sparing; Sparing of the central cord tracts, good proprioception in the rectum, intact peri-anal
sensation, voluntary sphincter contraction, and intact saddle pattern of cutaneous sensation. A person with a
central cord syndrome quadriplegia, who has complete sacral sparing, may have near normal sexual,
bladder and bowel function.
Cauda Equina Lesions; Spinal Cord terminates at the conus medullaris (L1/L2)
Complete lesions (anterior and posterior nerve roots) result in a lower motor neuron clinical picture as a
result of interruption of the reflex arc. Symptoms present in the patient are: a flaccid bowel, bladder and
decreased sexual function. Damage to the conus medullaris and cauda equina will result in both upper
and lower motor neuron picture.
Nerve Root Lesions; Injury to the nerve roots proximal to and surrounding the spinal cord can also occur.
Recovery can occur through nerve regeneration.
Definition of the level of lesion
Several methods for classification of the level of lesion are currently in use throughout the world. One needs
to state whether it is a complete/incomplete lesion at a given level of the vertebral column, diagnosed by
using the last intact segment. The ASIA impairment scale gives a good definition of the level of the lesion.
Lietje Jacobs Karin Al Geertje Kotzee
Hogeschool Amsterdam
Spinal Cord Injury Protocol 2005
Third Hospital of Beijing
8
Epidemiology
With approximately 200 independent nations around the world and published epidemiology studies for SCI
limited to a handful of nations, it is difficult to establish a complete and accurate picture. There are no official
epidemiological data on the incidence of SCI in China. The number of people who have sustained SCI is
expected to be high given the increased incidence of traffic and construction accidents in this country.
Expected incidence of SCI in China
Cause
Percentage
Country/ population
(millions)
China
1200
Injuries/ annum and
ratio/ million
10.00
8.4
420,000
Car accident
35%
Job- related
29%
Fall
29%
Natural disaster
7%
Population estimated
living with SCI
Cervical
17%
Thorcic
38%
Estimated annual
cost (Local Currency)
Lumbal
45%
Level
Direct Govt.
investment in SCI
cure related research
Type
Complete
Incomplete
53%
47%
Information provided by physician
The information provided by the physician should at least contain the personal data; however more
information should be provided, like surgical interventions and previous diagnoses, although this will be
systematically checked with the patient during the history taking.
Personal data
Date of admission
Name/age/gender/ marital state/ address
Socioeconomic status/ insurances
Diagnosis
Doctor
Physiotherapist
History Taking
Nature and severity of complaints
To understand the mechanism of the injury a description of the trauma or disease (including data on any
pre-existing or similar complaints) that took place right before the injury, or accident-specific information, is
needed.
Present and past surgical interventions and diseases
The present surgical interventions and diseases describe the medical status of the patient after admission.
Lietje Jacobs Karin Al Geertje Kotzee
Hogeschool Amsterdam
Spinal Cord Injury Protocol 2005
Third Hospital of Beijing
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The past surgical interventions and diseases involve any kind of medical problem, previous diagnoses or
operations the patient has had.
Current medication
This includes all medication the patient is currently on, whether prescribed before or after admission.
Coping strategy
During recovery, patients may cope with their complaints either adequately or inadequately, which will
respectively promote or inhibit recovery. Each patient will cope in different ways with the severe changes that
the injury has caused. It depends on the personality of the patient what coping style (combination) is the
most adequate. Examples of coping strategies are: Active problem solving, Seeking distraction, Expressing
of emotions, Ignoring the problem and Talking or writing about the problem.
Coping is also connected to the load a person is bearing (what he does) and to his load-bearing capacity
(what he can do). Load-bearing capacity depends on the patient and is, among other things, determined by
the time that has passed since the injury, which is related to the physiological recovery and by psychosocial
factors. In the treatment objective Kinesiophobia more can be read about load and load bearing capacity.
The emotional impact caused by the injury is determined by the meaning the patient gives to his complaints,
the significance attached to pain and the level of experienced control.
When the coping strategy is adequate, the patient is able to control the health problem and has confidence in
his ability to influence the complaints himself. [23]
Simple information about this subject can be red in "Coping, adjustment to spinal cord injury" [19], a handout
intended to help individuals with spinal cord injury and to help their families help themselves through the
process of adjustment to the unique conditions that follow traumatic injury.
Present and past level of functioning, activity and participation
Present and past level of functioning
During the history taking, the physician should systematically obtain information about the patient’s functions,
activities and social participation before the injury, in comparison to the functions and levels of activity and
participation after injury. The patient will have wishes concerning regain of certain activities; to gain as much
function possible in order to function as close to his life before the injury as possible. The doctor/PT should
compare the past and present situation of the patient and evaluate whether these wishes are realistic.
This has to be taken into consideration while developing a treatment plan, so that the patient has an effective
and individual program. Then the treatment plan should be discussed with the patient and his family/carer to
obtain cooperation, motivation and understanding,.
Activities
The patient’s daily activities before the SCI should be known in order to make a functional treatment plan.
This will enable the patient to gain as much of his previous activities as possible.
The patient’s occupation for instance required; long hours sitting, walking, etc.
The patient’s hobbies for instance required; gardening the ability to kneel, drawing requires fine motor
function, etc.)
The sport/activities the patient participates in for instance required; endurance, strength, etc
The ADL activities of the patient for instance required; the ability to vacuum, groom, shower, dress, etc
Participation:
Lietje Jacobs Karin Al Geertje Kotzee
Hogeschool Amsterdam
Spinal Cord Injury Protocol 2005
Third Hospital of Beijing
10
Family structure/ social support system:
The family structure should be made clear during an interview to understand what kind of activities the
patient has in the home-situation. And to get insight in what psychological, social and medical support is
available by family, friends or other caretakers, during and after admittance. Note that the health state of the
relative or carer is of importance when he/she is taking care of the patient.
Home environment
The home environment is the possibilities and/or limitations of the house and its surroundings. This has an
influence on the ADL, mobility and possibility of independence of the patient.
Community accessibility
Community accessibility gives information about the way the patient moves from one place to another (car,
bike, etc.) and what efforts this takes.
Psychological status
Psychological status is the personal characteristics, the present emotional status, values and beliefs and
behavioural aspects. These factors, together with the coping style have an impact on motivating factors for
life and do influence recovery.
Assessment
The assessment is an essential part of the treatment. The PT/ physician forms an objective view of the
patient’s function, activity and participation level (official assessment forms mentioned can be found in the
appendix). When the evaluations have been completed, realistic goals are set with the patient and family.
Observation
General impression
Skin
Colour
Anatomical deformities
Posture
Palpation
Temperature
Muscle Tone
Heart rate
Blood Pressure
Heart and Lung condition
Function examination
Total Motor Index Score and Sensory Index Score/ ASIA impairment scale
Modified Ashword Scale
Respiratory function
Activity examination
Modified Barthel Index
Lietje Jacobs Karin Al Geertje Kotzee
Hogeschool Amsterdam
Spinal Cord Injury Protocol 2005
Third Hospital of Beijing
11
Functional Independence Measure
Wheel chair mobility
Analysis
Doctors diagnosis [33,34]
For the diagnosis of spinal cord injury the physician uses x-rays, CT-scan and MRI. Medical personnel
typically order these tests on all trauma victims suspected of having a spinal cord injury. X-rays can reveal
vertebral problems, tumors, fractures or degenerative changes in your spine. Computerized tomography (CT)
scan may provide a better look at abnormalities seen on an X-ray. This scan uses computers to form a series
of cross-sectional images that can define bone, disk and other problems. Magnetic resonance imaging (MRI)
is helpful for looking at the spinal cord and identifying herniated disks, blood clots or other masses that may
be compressing the spinal cord. Myelography allows the physician to visualize your spinal nerves more
clearly. After a special dye is injected into your spinal canal, X-rays or CT scans of the vertebrae can suggest
a herniated disk or other lesions. This test is used when MRI isn't possible or when it may yield important
additional information that isn't provided by other tests.
A few days after injury, the physician will conduct a neurological exam to determine the severity of the injury
and to predict the likely extent of recovery (prognosis). This may involve more X-rays, MRIs or more
advanced imaging techniques. The physician does the first physical examination according to the
ASIA-scale.
Differential diagnosis [33]
Spinal cord neoplastic disease
Multiple sclerosis
Herniation
Complications
Prevention of complications is of great importance in a complete rehabilitation program. If complications do
occur the recovery of the patient will be delayed. For SCI the following complications can occur:
Bla[dder and Urinary tract infection
Pressure sores
Muscle contracture
Autonomic dysreflexia
Respiratory complications
Osteoporosis
Heterotopic Ossification
Deep venous thrombosis
Spinal deformities
Syringomyelia
Sometimes it is not possible to prevent these complications. Then the physicians and the PT’s have a
detection function. The treatments of the complications are written under precautions in the protocol.
Lietje Jacobs Karin Al Geertje Kotzee
Hogeschool Amsterdam
Spinal Cord Injury Protocol 2005
Third Hospital of Beijing
12
Risk factors [33,34]
Men: SCI affects a disproportionate amount of men. For example, women account for only about 20% of
the spinal cord injuries in the US.
Young adults and seniors: There is an age peak between 16 and 35 years, and another peak in people
older than 60 years.
People who are active in sports: high risks athletic activities include football, rugby, wrestling, gymnastics,
diving, surfing, ice hockey and downhill skiing.
People with predisposing conditions: a relatively minor injury can cause SCI in people with conditions
that affect their bones or joints, such as spondylosis, arthritis or osteoporosis.
Prognosis
It's often impossible for the physician to make a precise prognosis right away. Immediately after injury the
patient will be in a state of spinal shock for approximately 1-2 weeks. The nerve cells in the spinal cord below
the lesion do not function. No reflexes are present and the limbs are entirely flaccid.
Recovery typically starts between a week and six months after injury, if it occurs, with the majority of recovery
taking place within one year. Physicians generally regard any impairment remaining after 12 to 24 months as
likely to be permanent. Although there is no consensus in the literature on the prognosis of the
consequences of SCI it’s clear that the prognosis can depend on the following two factors: the location of the
injury and its extent. Injuries above the level C4 are the most dangerous. Patients often lose the ability to
breathe on their own. The infection of the respiratory (breathing) tract that can result is the leading cause of
death among patients with this type of spinal cord injury. Overall, 85 percent of SCI patients who survive the
first twenty-four hours after being injured are still alive ten years after the injury. How much control over
bodily functions a patient recovers is impossible to predict. The more moderate the injury to the spinal cord,
the greater the chance for recovery.
Several factors may influence the prognosis:
Outcome assessment
Experience doctor/ PT
Risk factors
Prognosis
Complications
Individual factors
age, motivation, etc.)
Nature and severity
of complaints
Lietje Jacobs Karin Al Geertje Kotzee
Hogeschool Amsterdam
Spinal Cord Injury Protocol 2005
Third Hospital of Beijing
13
Physiotherapeutic indication
The general objectives of the physical therapist are to enable the patient suffering the consequences of SCI
to return to as normal as possible, or desired, levels of activity and participation, and to prevent the
development of complaints. Good inter-disciplinary communication is important, in order to realize these
goals. It is the PT's obligation to inform the other disciplines of the patient's activity/ functional abilities, at
least once a weak at a multi disciplinary meeting.
To optimize the cooperation and communication between the doctors, physiotherapists and nurses, a
specially developed guiding principle should be used. This covers assessment forms, letters of referral,
contact during treatment and writing reports.
Treatment plan
Goals
The goals for the patient’s rehabilitation are different for each patient. The most effective rehabilitation route
is dependent on:
type of injury (disease or trauma - cervical, thoracic or lumbar level)
patient's current level of function
patient's needs and personal goals
patient's socioeconomic and environmental system
Patients with a complete SCI require a different approach in developing short and long term goals than
incomplete SCI patients.
The goals for a complete injury will aim at maintenance of functions that are left and on education about life
long prevention of complications (which means a new life style). These patients need good psychological
support. Attention should also be given to permanent adaptations in the house and to providing braces or
other permanent devices to help with walking, eating, writing etc.
The goals for an incomplete injury will be focused on the attempt to regain as much function as possible
because (partial) recovery is more likely.
The specific and realistic goals should be written in the status of the patient. The time that is needed to reach
the goal should also be mentioned.
Short term goals should be made each week according to the current situation of the patient.
Long term goals should be made according to the patient’s wishes after the assessment; these goals should
be evaluated every two weeks. They can be obtained and otherwise adapted or postponed.
Objectives
The short and long term goals can be developed together with the patient and his family. It should be kept in
mind which treatment is the most important for each week according to the protocol. When the goals are
made the PT/doctor chooses a treatment objective from the column of the flowchart.
Methods
A treatment objective is defined and chosen from the flowchart; in the next column of the flowchart the
treatment method is shortly described. The most evidence based method or the method with the best effect
is placed on the top of the list. If detailed information is needed about the treatment methods, the objective
Lietje Jacobs Karin Al Geertje Kotzee
Hogeschool Amsterdam
Spinal Cord Injury Protocol 2005
Third Hospital of Beijing
14
can be found in the background information of the protocol.
Lietje Jacobs Karin Al Geertje Kotzee
Hogeschool Amsterdam
Spinal Cord Injury Protocol 2005
Third Hospital of Beijing
15
Treatment: Precautions
a. Bladder and urinary tract infection
Individuals with SCI are at a high risk for Urinary Tract Infection. Complications due to UTI are the most
important medical concern.
The source of UTI is bacteria, the bacteria from the skin and urethra are easily brought into the bladder with
ICP, Foley and supra pubic methods of bladder management. Bacteria are also likely to grow in urine that
stays in the bladder of individuals with SCI that is often not able to completely empty their bladder. Most of
the SCI patients have lost the ability to feel the pain that warns the patient of an oncoming infection. The
result of this is that the UTI is discovered in a late stage.
The patient should pay attention to the following warning signs of an oncoming infection [31]
sediment (gritty particles) or mucus in the urine
Cloudy urine
Bad smelling urine
blood in the urine
Increased spasticity
Hyperhydrosis（meaning?）
The patient can do many things to prevent UTI from starting. The key of prevention is to work to prevent the
spread of bacteria into the bladder. [1,3,31]
Keep personal care supplies clean
Keep skin clean
proper techniques
Drink plenty fluids
empty bladder on regular basis
Regular urologic check up
know the warning signs before illness
2.
3.
b. Pressure sores
Sitting or lying in the same position for too long causes the blood flow to be cut of. The skin or underlying
tissue begins to die which results in a pressure sore. Although spasticity producing contractures, postural
deformity, poor nutrition, incontinence and co-morbid factors increase the risk of ulceration, without
ischaemia the ulcers do not arise. Denervated skin is at risk from pressure damage within 20-30 minutes of
injury. If this occurs, it can cause distress and delay in the rehabilitation process. Clinical staff attending
immediately after admission should be vigilant to protect the skin and should report red marks.
The following classification of pressure ulcers by National Pressure Ulcer Advisory Panel (1989) is still used:
Stage:
1. Damage is limited to the top two layers of the skin, the epidermal and dermal layer. The skin is not
broken and the redness does not turn white when touched.
Damage extends beyond the top two layers of the skin to the adipose tissue. The skin is slightly broken.
The sore appears to be an abrasion, blister or small crater.
Damage extends through all the superficial layers of the skin, adipose tissue, down to and including the
muscle. The ulcer appears as a deep crater and damage to adjacent tissue may be present.
Lietje Jacobs Karin Al Geertje Kotzee
Hogeschool Amsterdam
Spinal Cord Injury Protocol 2005
Third Hospital of Beijing
16
4.
-
-
-
Damage includes destruction of all soft tissue structures and involves bone or joint structures.
Undermining of adjacent tissue and sinus tracts may be associated with the ulcers. Surgery is indicated.
Prevention
The most important preventive measures are:
skin checks
use of pressure relief techniques:
“You can put anything you like on a pressure sore, except the patient” (Vilan, citated by Guttmann 1973) !
Skin checks:
For patients lying in bed (high level of spinal cord injury)
Conduct two times a day comprehensive visual and tactile skin inspections, with particular attention to
the areas most vulnerable to pressure ulcer development, including, but not limited to: Ischii, Sacrum/coccyx,
Trochanters and Heels, done by nurse, family member or carer [1, 2, 17, 26, 32].
The physiotherapist has a detection function in pressure sores as well and should take care of the skin
while doing passive movements of other treatments in which stretch or extra pressure is caused to the skin.
For patients sitting in a wheelchair (low level of injury):
The patient is educated about the pressure sore risks and importance of prevention
The patient is taught to check the skin himself and to use a mirror to inspect areas he can’t easily see
(buttocks).
Pressure relief techniques:
For patients lying in bed (high level of spinal cord injury)
Pressure re-distributing mattresses should be used: for example the Egerton Turning bed, the Strykerframe
bed and mattresses with air cells. “Low Air Loss beds”, “air fluidized beds” and “Clinitron-beds” can lower the
pressure sufficiently to make lying on the wound appropriate, however these systems are expensive.
For the calcaneal and cubital surfaces little sacks of water (surgery gloves) can be used. For the sacrum no
rubber air ring or any kind of doughnut should be used: they create a lot of pressure where you don’t want it
and block the flow of blood to the skin inside the ring [17, 26]. If stage 1 on the sacrum is identified, the patient
should be turned.
Turning: Avoid prolonged positional immobilization whenever possible. Pressure for a long time on the skin
areas that are vulnerable for pressure ulcers (Ischii, Sacrum/coccyx, Trochanters, Heels) should be avoided
as soon as emergency medical condition and spinal stabilization allow.
Every two hours the patient should be turned to another side [1, 2, 17, 26]. If this is done disciplined,
development of pressure ulcers will be prevented (Bakker, 1986). If prone lying is possible this is the best
option, together with a cushion under the thighs to relief the knees. Pressure ulcers on the trochanters are
difficult to treat, so in case the skin is denervated in this area, positioning on the side is discouraged [1, 26, 32].
If it is necessary anyway (for prone lying is for example not possible) positioning in 30 degrees is better than
a turn of 90 degrees and the periods should be shorter.
In addition tell the patient to drink 8-10 glasses of water every day and eat a well-balanced diet containing
food with high protein, vitamins and minerals.
Implement an ongoing exercise regimen for the medically stable spinal cord injured patient, to promote
maintenance of skin integrity and blood circulation (and to increase strength of paretic and nonparalyzed
muscles, improve cardiovascular endurance, prevent fatigue and deconditioning etc.).
Lietje Jacobs Karin Al Geertje Kotzee
Hogeschool Amsterdam
Spinal Cord Injury Protocol 2005
Third Hospital of Beijing
17
-
-
-
-
c.
For patients sitting in a wheelchair:
Initially, patients are mobilized in a standard wheelchair, which offers greatest support and stability. Following
a comprehensive assessment, the wheelchair should be correctly fitted and adjusted. Adaptations are made
to provide a well-supported, evenly balanced seating position. The foot-support should be set low and for
tetraplegic patients the arm support should be adjusted to the right height. The cushion is equally important,
taking account the need for protection of the pressure areas.
Weight shifts should be performed every 15 minutes for 30 seconds [1, 2, 17, 26, 32].
For lesions at level C4 above a power tilt wheelchair should be used.
At C5 and C6 the patient can lean forward himself or lean side-to–side for regular pressure-relief.
For lesions at level C7 or lower the patients can perform a wheelchair push-up with the arms. Before allowing
the patient to mobilize by wheelchair, make sure good understanding about this complication and sufficient
arm-strength is established.
The patient should learn to have attention for wrinkles in his clothing and wear for example a suitable belt. He
also should not place objects at the seating (for example a mobile phone or wallet) because this disturbs the
pressure balance of the cushion or the right sitting position of the patient.
In addition tell the patient to drink 8-10 glasses of water every day and eat a well-balanced diet containing
food with high protein, vitamins and minerals.
Implement an ongoing exercise regimen for the medically stable spinal cord injured patient, to promote
maintenance of skin integrity and blood circulation (and to increase strength of paretic and nonparalyzed
muscles, improve cardiovascular endurance, prevent fatigue and deconditioning etc.).
Maintaining ROM
-
-
-
Kinesiotherapy
Passive Range of Motion: Passive movements are commenced from the first day of injury. Care must
be taken not to overstretch structures or perform an extreme ROM, because:
When reflex activity returns a spastic pattern can be re-enforced
Micro trauma may be a predisposing factor in the formation of peri-articular ossification.
The bone structure can develop osteoporosis after a long period of immobilization and forced
rotation can cause twist fractures.
For lumbar and low thoracic injuries leg movements are performed once a day [2]. The family can be taught in
one or two days how to do this. If there is sparing of muscle function, these movements should be performed
as active assisted exercises. If the patient is able to move himself, the program should be taught to the
patient to make him maintain his ROM independently.
Hip flexion. It should be kept below 30 degrees to avoid lumbar flexion until stability is established.
Hip abduction
Hip internal and external rotation can be added, but care must be taken during rotations for the
bone structure can develop osteoporosis after a long period of immobilization and forced rotation can cause
twist fractures...
Knee flexion -when performing hip flexion, knee flexion is naturally established as well. It must be
performed in Taylor’s position (‘frogging’) until stability of the lumbar spine is established.
Ankle flexion and extension
For cervical spinal cord injuries arm movements are performed at least twice a day, because the shoulder
Lietje Jacobs Karin Al Geertje Kotzee
Hogeschool Amsterdam
Spinal Cord Injury Protocol 2005
Third Hospital of Beijing
18
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joint is very vulnerable for stiffness thus for decrease of load bearing and great limitation in ROM in a later
stage.[2] Again the family can be taught in one or two days how to do this. If there is sparing of muscle
function, these movements should be performed as active assisted exercises. If the patient is able to move
himself, the program should be taught to the patient to make him maintain his ROM independently.
Stretch finger flexors with wrist in neutral to preserve tenodesis grip
Ensure a full fist can be attained with wrist extension
Pronation and supination in both elbow flexion and extension. Care must be taken during rotations
for the bone structure can develop osteoporosis after a long period of immobilization and forced rotation can
cause twist fractures.
Full elevation and lateral rotation of the shoulder from day one. Make sure again not to make an
extreme ROM with power.
Stretch long head of triceps-arm in elevation with elbow flexion.
Stretch rhomboids, bilaterally to avoid twisting of the cervical spine
Stretch upper fibres of trapezium muscle
Stretching
Passive movements of paralyzed limbs are continued until the patient is mobile and thus capable of ensuring
full mobility through their own activities, unless there are complications such as excessive spasm or stiffness.
In addition a stretching program can be developed, for example to maintain hamstring length for transfers
from bed to wheelchair and back. Or to prevent the gastronemius tendon from shortening (while performing
ankle flexion and extension for the ROM, hold the flexion at least ten seconds to obtain a stretch of the
tendon). Normal movement patterns are used during exercises rather than isolated muscle activities, to
encourage functional movement.
Positioning [2]
Crucifix position. This is only indicated when enough space around the bed is available.
Where increased flexor tone is a problem (tetraplegic patients), the patient is placed in the crucifix position,
with elbows extended and shoulders alternated between lateral and medial rotation. When placing the patient
in this position is not possible, extra attention should be given to maintaining ROM and muscle length.
Modified crucifix position.
Incomplete cervical lesions are particularly prone to muscle shortening imbalance, resulting in partial
subluxation and pain. Length of the medial rotators of the shoulder should be maintained by a modified
crucifix position (flexed elbows, with shoulders in lateral rotation)
Tenodesis grip
When the wrist is actively extended, the fingers are pulled into flexion to produce a functional grip: the
tenodesis grip. With complete lesions from C4 or C5 there is no active flexion of the fingers, so it is
appropriate to allow shortening of the long flexors to encourage function of the tenodesis grip. However, the
ROM of individual joints at the wrist must be maintained. To shorten the long finger flexors:
Let contracture occur naturally by placing a small roll under the hand and maintain wrist ROM or:
- Encourage shortening by splinting.
d. Muscle contracture
Contractures are the chronic loss of joint motion due to structural changes in non bony tissue. These non
bony tissues include muscles, ligaments and tendons. If the contracture is of a significant degree, pain can
result even without any voluntary joint movement.
Lietje Jacobs Karin Al Geertje Kotzee
Hogeschool Amsterdam
Spinal Cord Injury Protocol 2005
Third Hospital of Beijing
19
Contractures can be devided in [1,3];
Articular contractures(shortened muscles/ capsule deformity)
Peri articular contractures(caused by neurogenic heterotopic ossification)
The primary causes of joint contraction are [1,3];
Muscle imbalance
Pain
Prolonged bed rest
Immobilization
Prevention [1,2,3]
Prevention is achieved through a program of positioning, splinting if appropriate and ROM exercises.
Positioning and splinting goes hand in hand. The splinting assists in keeping the body joints in a neutral
position to prevent muscle imbalance. When a joint is being splint the therapist should take care to prevent
pressure sores.
ROM exercises should be given to mobilize the joints, maintain muscle length and circulation. The ROM
should be done at least twice a day for all joints.
e. Autonomic dysreflexia
When the spinal reflex activity beneath the lesion has returned, afferent stimulation beneath the lesion level
causes a sympatric response resulting in vasoconstriction. This cannot be controlled and regulated by the
vasomotor centre in the medulla oblongata because it is disconnected with the sympatric region. With lesions
at level T4 -T6 or higher the dysreflexion can involve the total nervus splanchnic region. Because of the
vasoconstriction the blood pressure can then reach dangerous high levels, increasing risks to cerebral,
cardiac and other sorts of complications. A first attack of autonomic dysreflexia usually occurs within 3 to 4
months after injury. To prevent these attacks the following should be done:
Elimination of the triggering afferent stimulating irritations.(over-full bladder, constipation or impaction of
the bowel, pressure sores/ skin problems, visceral problems, urinary tract infections, stone development.)
Many times just emptying the bladder is the solution.
Verticalization without abdominal bands and therapeutic stockings. Release the patient from tight
clothes.
Medicine under tongue.
In case of an attack: an attack of autonomic dysreflexia should be treated as an emergency, because the
hypertension can rise sufficiently to induce cerebral hemorrhage. The physiotherapist should keep the
possibility of this complication in mind during treatment; the physician should be alarmed in case the blood
pressure increase/ the symptoms suddenly occur and the patient should be
sat up,
given appropriate medication
and the underlying cause treated.
Symptoms of an attack are: headache, pilo-erection, capillary dilation, sweating, pallor below the lesion level,
skin vasoconstriction and bradycardia.
f.
Respiratory complications [36, 37]
Lietje Jacobs Karin Al Geertje Kotzee
Hogeschool Amsterdam
Spinal Cord Injury Protocol 2005
Third Hospital of Beijing
20
Respiratory problems can be prevented by training the respiratory muscles from the acute phase onwards.
With lesions above Th 8 you have to help/teach the patient how to cough and teach them breathing
techniques. (See Increased / maintained respiratory function)
Common complications:
Pneumonia
Pulmonary embolism.
Ventilatory failure
Atelectasis
Sleep apnea
g. Osteoporosis
Osteoporosis is a loss in bone mass without any alteration of the ratio between mineral and the organic
matrix. It is thought that immobilization for long periods and a sedentary life lead to an increase in bone
resorption, thus causing osteoporosis. There is an interest in preventing bone loss early in the course of the
spinal cord injury, since a rapid decrease of Bone Mineral Density is seen in the paralyzed limbs of
approximately 4% per month during the first year in areas rich in trabecular bone an of approximately 2% per
month in areas containing mainly compact bone [27]. The osteoporosis may be sufficient to cause fractures of
long bones during relatively simple maneuvers, such as transfer or passive movements. Researchers
suggest the combination of voluntary muscle contractions and weight bearing through the long axes of the
bones may effectively prevent and possibly reverse osteoporosis (Penn State Milton S. Hershey Medical
Center). Standing (whether in a tilt table or more active) has a positive effect to the bone-density, thus to
prevention of osteoporosis. It also positively affects spasticity, flexion contractures in the hips and the knees,
defecation, ossification and pressure sores.
Prevention
During the treatment of muscle strengthening, while treating hypotension in a tilt-table, or by practicing
transfers, standing or gait, development of osteoporosis is prevented at the same time. Each day the patient
should bare weight through the long axes of the bones as much as possible, whether or not in combination
with another treatment objective.
h.
Heterotopic Ossification
Ossification is a process of creating bone that is of transforming cartilage (or fibrous tissue) into bone.
Heterotopic ossification (HO) is the development of bone in abnormal areas, usually in soft tissues. HO
develops most commonly in individuals who have an injury that result in neurological deficits. For SCI the
incidence rate for HO is 16 to 53 percent and will always occur below the level of injury. HO is most
commonly found in hips, knees, shoulders and sometimes elbows and ankles. It can also occur at the base
of pressure sore.
HO usually begins forming in the intramuscular connective tissue within four months after the SCI. This
causes contractures which results in decreased mobility and self-care abilities.
Symptoms of HO; all the symptoms of an inflammatory process.
There is no known prevention other than maintaining joint mobility (ROM).
Once HO forms, surgery is the only viable option.
.
Lietje Jacobs Karin Al Geertje Kotzee
Hogeschool Amsterdam
Spinal Cord Injury Protocol 2005
Third Hospital of Beijing
21
i.
Deep Venous Thrombosis [1,25]
Deep Venous Thrombosis (DVT) mainly affects the veins in the lower leg and thigh. It involves the formation
of a clot in the larger veins of the area. This clot could interfere with circulation and it could break off and
travel through the blood stream (embolism).
The risks for DVT are prolonged sitting, bed rest, immobilization, surgery and fractures.
Symptoms
Leg pain ( in one leg)
Leg tenderness ( in one leg)
Swelling (edema)
Increased warmth
Changes in skin color.
Prevention
Anticoagulants may be prescribed as a preventive measure for high risk people.
Minimize immobility of the leg
j.
Spinal deformities
Spinal deformities can occur when the patient maintains a bad posture in the wheel chair/in bed/standing for
a long period of time.
To prevent the development of spinal deformities, a patient should understand and know what the best body
posture is.
The PT should show the patient and family/ carer the good body positions to prevent spinal deformities.
k.
Syringomyelia [38]
Syringomyelia is a disorder in which a cyst forms within the spinal cord. This cyst, called syrinx, expands and
elongates over time, destroying the center of the cord. This damage may result in pain, weakness and
stiffness in the back, shoulders, arms or legs. Other symptoms may include headaches and loss of sensibility.
Syringomyelia can also affect sexual functions and bladder and bowel control. Surgery is usual
recommended of patients with syringomyelia. In some patients it may be necessary to drain the syrinx.
There is no known prevention other than avoiding trauma to the spinal cord. The physicians and the PT’s
have a detection function in syringomyelia. Prompt treatment reduces progression of this disorder.
Lietje Jacobs Karin Al Geertje Kotzee
Hogeschool Amsterdam
Spinal Cord Injury Protocol 2005
Third Hospital of Beijing
22
Treatment: Rehabilitation
Treatment during the acute phase
Following the injury or disease process, the patient is usually stabilized in the acute care setting and
preparation begins for rehabilitation. The criterion to start the rehabilitation program is when the patient is
medically stable.
Focus of treatment in acute care may include the following:
Prevention of complications
- prevention of pressure sores
- daily ROM to all extremities to maintain joint mobility and muscle condition
Treatment
- stabilization of the spine
1. splinting, neck collar/ brace and bed positioning
2. surgery
- bowel and bladder management
- weaning from respiratory support.
1．Stabilization of the spine
Stabilization of the spine after traumatic injuries or dislocations can be done either by splinting, providing a
neck collar or lumbar/ thoracic brace and bed positioning with pillows and other means of support, or with
surgery.
2．Bowel and bladder management [1,3]
In the first few days after the spinal cord damage the bladder and bowel are totally paralyzed and flaccid.
During this period of spinal areflexia, all bladder reflexes and muscle actions are abolished. The patient will
develop acute bladder retention, followed by passive incontinence due to overflow from the distended
bladder. Treatment will be directed to:
Achieving a satisfactory method of emptying the bladder and the bowel.
Maintaining sterile urine
Enabling the patient to remain continent
The damage to the bladder and bowel function, caused by the SCI can only be determined after the spinal
shock phase.
3．Weaning from respiratory support
In acute care the patient with a complete lesion between C5 and Th8 usually needs respiratory support. The
respiratory muscles and the lungs should be trained from the first day of admission by means of breathing
techniques (See Increased/maintained respiratory function). This increases the patient’s chances of
breathing without support faster and it prevents pneumonia/other possible lung complications. As the spinal
shock wares off the doctor can gradually decrease the respiratory support as medically appropriate.
Lietje Jacobs Karin Al Geertje Kotzee
Hogeschool Amsterdam
Spinal Cord Injury Protocol 2005
Third Hospital of Beijing
23
4. Prevention of complications
Performing preventive interventions for all possible complications is started in the acute phase and continued
through out the entire rehabilitation process. Information on how to prevent the most common complications
for SCI patient can be found under the heading ‘precautions’ in this protocol.
Treatment during the rehabilitation phase
-
1. Patient and family education
Involving and educating the patient and his family or carer(s) is part of a complete rehabilitation program.
Every step in the rehabilitation process should be discussed and the reason for each choice should be given.
This creates understanding and insight in the injury and its consequences. This stimulates an active problem
solving attitude towards the complex situation a spinal cord patient has to cope with. And it will result in a
better cooperation and compliance during the treatments. Besides this verbally given motivation it is
important to physically motivate the patient by simply letting him try an activity, or experience a movement, of
which he thought he could not do. This is why a curious, active attitude should be encouraged by letting the
patient do or try as much as possible himself.
Just like the patient the relatives can be traumatized by the severe change in the level of functioning (in other
words: activities and participation). Therefore it is important to involve them in the rehabilitation process as
well. In Spinal Cord Rehabilitation they are of great importance for the recovery of the patient. The PT
should teach the relatives/ carer(s):
How to perform ROM,
How to make safe transfers/ help with transfers,
How to prevent pressure sores and lung problems,
How to manage bladder function and prevent urinary tract infection,
And how to find a balance between helping the patient and training the patient for ADL.
Understandable is that relatives mostly start acting overly careful or start patronize the patient. The family/
carer(s) should be educated about the remaining abilities and the abilities the patient is able to regain. They
should be made aware of the fact that the more the patient does or tries to do himself, the more he practices
for independence. An overview of what activities a patient with a complete lesion at a given level of injury
should be able to do can be seen in the scheme under the treatment objective ‘Independent ADL’. This can
help the patient and his family to understand what possibilities are left, but only if the patient and the family
underestimate the patient’s abilities. A positive approach with realistic expectations is essential for the
patient’s well-being.
Similarly, the patient can become victim of fear for moving due to a persisting underlying anxiety state. More
education and treatment for kinesiophobia is indicated (see treatment objective: Kinesiophobia). Next to this,
the patient may be in denial for his situation or express anger and stubbornness. A depression can develop
which may include stating the desire to die. This means psychological help of a psychologist or psychiatrist is
necessary.
Simple information can be found on websites aimed at the patient and his family [5] (In English). Informative
folders should be handed out when the patient and the family desire them.
Lietje Jacobs Karin Al Geertje Kotzee
Hogeschool Amsterdam
Spinal Cord Injury Protocol 2005
Third Hospital of Beijing
24
2.
-
-
Pain management
Pain management is continued the same way as during acute care, though the doctor should always look out
for the possibility of hidden pathologies
In pain management several professions should work together to accomplish the best effect.
Combinations of treatment methods mostly give better results than the sum of each method on its own.
Treatment of neuropathic pain
Medication (prescribed by physician)
Electrotherapy -> TENS, interferential therapy (applied by nurse) and spinal cord stimulation
(these appear only to be sometimes effective for radicular pain [1])
Invasive blocks (given by physician)
Neurosurgical techniques (performed by surgeons)
Behavioural treatment - Graded activity and counselling.
Counselling involves providing support, information and advice (see [29] for an informative website aimed on
the patient and his family). The physiotherapist teaches the patient how to cope with the pain and how to
react to a reversal in or an aggravation of the condition. It is important that the patient keeps gradually
increasing his levels of activity and participation to prevent for instance the development of a fear of
movement or an imbalance between load and load-bearing capacity.
Graded activity implies a gradual increase of the load on the patient during rehabilitation in which pain no
longer plays a central role:
First a base line is determined by testing three times the current physical condition and muscle
strength.
Then 70% of this base line should be the starting point of a fixed program (then the program will
never overload the patient). The fixed program builds up the load every treatment, without giving attention to
pain and by stimulating the patient to do more than he thinks he can do.
Progression is listed in diagrams on forms to keep control over the program and to motivate the
patient by showing what progression is made.
Treatment of orthopedic pain
Cause aimed treatment: the treatment depends on the cause of the pain, for example spasticity,
overload, pressure sores, postural deformities etc. In pain caused by spasticity the treatment method for
spasticity is the most suitable (like stretching), in pressure sores good wound care and all the preventive
interventions should be performed, etc.
-
If the cause of pain is not clear and/or the current treatment methods have no effect, then the following
methods can have added value.
Medication
Behavioural treatment (See Graded activity at treatment of neuropathic pain)
Alternative therapies
Cold packs ( causes vasoconstriction),
Massage (relax hyper tone muscles and inhibit stress hormone production),
Ultrasound, TENS, low-level laser, infra red and short Wave-therapy could be an effective
method for an individual patient, but are not listed as effective methods [1, 14,16,13,11].
Acupuncture has many advantages [8] but no modern medicine research is done yet to prove it has
additional value besides the phenomenon 'placebo-effect' [1,10]. To be clear: modern/ Western medicine has
Lietje Jacobs Karin Al Geertje Kotzee
Hogeschool Amsterdam
Spinal Cord Injury Protocol 2005
Third Hospital of Beijing
25
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no insight in the energetic mechanisms and ideas of Traditional Chinese Medicine, which is why the
effectiveness of it has not been scientifically proven. However, since acupuncture (and herb-therapies or
other Traditional Chinese treatment methods) has effect when performed by professionals, it should be used
when it is indicated (in spinal cord injuries: in combination with modern treatment methods).
Other alternative therapies can be used like those of the Traditional Chinese Medicine (for
example the cream Chuang shang zhi tong ru gao which decreases pain temporarily).
3. Orthostatic hypotension
In spinal cord injured patients the readjustment of vasomotor control is deregulated. The blood vessels in the
viscera and the arteries are unable to constrict when the body is raised from the horizontal to vertical position.
For spinal cord injuries above T6 this leads to postural hypotension and eventually fainting. Stasis occurs in
the veins, which causes oedema and an increased risk of Deep Venous Thrombosis. This is seen especially
in patients with flaccid pareses, since spasticity provides a ‘muscle pump function’.
Training sitting and standing with orthostatic hypotension
Verticalization
Unless contraindicated, gradually standing is commenced as soon as possible using a tilt-table to improve
this systemic body function, but also for the benefits to the respiratory an psychological functioning and
maintenance of bone density.
Abdominal binders are recommended for lesions at T6 and above. They should be applied before tilting
or sitting. They maintain intra-thoracic pressure to reduce pooling of the blood from lack of abdominal action.
Anti-embolism stockings, applied before tilting.
In case of autonomic dysreflexia: Verticalize without abdominal binders and therapeutic stockings.
Treatment of oedema
In the evening the legs should be placed high and should be dressed.
The sitting surface of a wheelchair should keep the vessels of the back of the knees free by leaving a
space between the back of the knees and the edge of the sitting surface. Also during sitting anti-embolism
stockings can be worn as prophylaxis against DVT.
When the patient is capable of making ankle and knee extension and flexion he should repeat these
movements himself. (Again stimulate to move as much as possible, not only to establish circulation
increase).
4. Regulation of spasticity [3,22,28]
Spasticity has been defined as an increase in muscle tone due to hyper-excitability of the stretch reflex. The
pathophysiologic base of spasticity is incompletely understood. The changes in muscle tone probably result
from alterations in the balance of inputs from reticulospinal and other descending pathways to the motor and
interneuron circuit of the spinal cord, and the absence of an intact corticospinal system.
A lag time may exist between injury and spasticity onset. Once spasticity is established the chronically
shortened muscle may develop physical changes such as shortening and contracture that further contribute
to muscle stiffness.
The goals for spasticity treatment [22]
To reduce pain
Lietje Jacobs Karin Al Geertje Kotzee
Hogeschool Amsterdam
Spinal Cord Injury Protocol 2005
Third Hospital of Beijing
26
To allow stretch of shortened muscles, strengthening of antagonistic muscle, and appropriate orthotic fit
To prevent orthopaedic deformity, contractures, pressure sores, and the need for corrective surgery
Therapeutic interventions [22]
A stepladder approach from conservative to aggressive measures often is used, sometimes combining
therapies from various levels. The progression is as follows:
Preventive measures
- pressure areas
- infections/ noxious stimulus (e.g. bladder, toenail, ear, skin)
- deep venous thrombosis
- constipation
- bladder distension
- fatigue
- cold temperature/ weather
- mal-positioning
-
-
Therapeutic interventions and physical modalities [1]
- Spasticity could be the substitute for strength, allowing standing, walking and gripping
- Stretching forms the basis of spasticity treatment. Stretching helps to maintain the full range of
motion of a joint and helps prevent contracture. To prevent muscle tearing, the stretching must be
applied slowly and held, not forced, for at least 15seconds. This should be repeated 3 times with 5
seconds break in between each stretch.
- Active movement and weight bearing, which will not exceed the patients ability, by means of
walking, cycling slowly, standing table etc.
- Strengthening exercises are used to stimulate a weak muscle or to oppose the activity of a stronger,
spastic one. It may reduce spasticity for short periods, since activity of the antagonist muscle
inhibits the spastic muscle. Electrical stimulation is most often used as a functional aid to walking or
hand function (FES) [12]. No literature is available to support the application of electrical stimulation
in spasticity management [9].
Brief application of cold packs to spastic muscles may be used to improve tone and function for a
short period of time or to ease pain.
Positioning/ orthotics
Application of orthoses casts and braces allows a spastic limb to be maintained in a normal
position.
Serial casting gradually stretches out a contracted limb.
Proper limb positioning improves comfort and reduces spasticity.
Oral medications
Injectable medication
Surgical interventions
5. Increased muscle strength [1,3,15,34,35]
Spinal cord lesions cause destruction of nerve fibres that carry motor signals from the brain to the torso and
Lietje Jacobs Karin Al Geertje Kotzee
Hogeschool Amsterdam
Spinal Cord Injury Protocol 2005
Third Hospital of Beijing
27
limbs leading to muscle paralyses. Muscle cells adapt to the extra workload by enlarging (hypertrophy) and
recruiting greater numbers of nerve cells to aid contraction (neural adaptation).
Strengthening exercises has the following advantages;
Improves possibility for ADL activities and transfers
Prevents osteoporosis
Improves general condition of the patient
Reduces spasticity
Muscle strength are graded using the following Medical Research Council (MRC) scale 0-5
0 - No movement
can not be trained with strengthening exercises though the muscle may still be stimulated by means of
passive movements, stretching exercises or weight bearing
1 - A flicker of movement
to increase the muscle strength may take more effort than usual. The muscle should be stimulated as often
possible with manual strengthening exercises using momentum to move the extremity and/or in combination
with electrical stimulation.
2 - Movement with gravity eliminated
the strengthening exercises shouldn't be done against gravity or with weights. The exercises must be
repeated at least 2 times a day with 3 sets and 15 repetitions
3 - Movement against gravity but not against resistance
- PNF
- The strengthening exercises must be done against gravity at least 2 times a day with 3 sets and 15
repetitions with a 30 seconds break [15,35]
4 - Moderate movement against resistance
5 - Normal power
The same strategy of muscle strength training can be used with muscle strength 4 -5
Muscle strength training methods:
- PNF ( for muscle strength 4)
- RM-method.
RM-method;
1 RM is the maximal voluntary contraction of a muscle. This is determined by gradually increasing the
resistance after each muscle contraction until the muscle can't contract against the resistance anymore, that
resistance will be the variable of 1RM. It is the resistance needed for the muscle to make a maximum
voluntary contraction.
The intensity, sets, repetitions and the type of contraction has an influence on the treatment and must
therefore match with the goal for the muscle strength training.
The following is a guideline to determine the intensity of the muscle strength training
Muscle strength: 60%-75% of 1 RM
The best muscle strength training for the patient will consist 10 -15 repetitions, 3 sets, with a 1 second
contraction and 3 seconds extension
Muscle endurance: 50% of 1RM
The best muscle endurance training for the patient will consist of 20-25 repetitions, 3-4 sets, with 2 second
Lietje Jacobs Karin Al Geertje Kotzee
Hogeschool Amsterdam
Spinal Cord Injury Protocol 2005
Third Hospital of Beijing
28
contraction and 2 seconds extension
6. Increased transfer ability
To achieve as much functional independence as possible, transfers are taught. A stable cardiovascular
situation, an in tact, loadable skin, not-disturbing spasticity, muscle strength and joint mobility, insight to
perform the right order of actions and a good sitting balance all make transfer training appropriate.[1,2,30]
To make the tetra- or paraplegic patient go sit from lying (to high sit = with the legs down over the edge
of the bed) the patient should be asked to turn to one side. Then the legs can be hung over the edge and the
trunk has to be brought to vertical. For this the patient needs to push with the one hand and push with the
other elbow on the bed and will need some more support of a helper. When the patient has enough strength
in the arms, the legs should be swung over the bed the same time as the trunk lifts. This way momentum for
speed is used and the patient needs less effort for pushing up. Since the patient’s legs are flaccid a big
lateral rotation and rotation is made when moving the legs only. So in case of recent lumbar surgery or other
contra indications for rotation, the legs and trunk should be moved at the same time.
Then the patient can be placed in a wheelchair. Depending on his abilities (level of injury) transfer
training extended in several ways, from small/ easy to difficult/ independent.
To maintain the right sitting posture (straight and in the back of the chair) the patient should be able to
correct himself with a small transfer.
Depending on the level of the lesion and functional ability, a sliding board may be used for legs-up and
legs-down transfers from sitting to the bed.
From lesions at C6 to C8, for some women or to prevent damage of delicate skin, simple transfers can
be made using the sliding board.
This can then be progressed without a board where possible.
Transfers are then progressed to lifting from various levels: high to low; low to high; floor to chair; chair
to car; chair to easy chair and from sitting to standing.
When fear for transferring occurs supervision and good verbal guidance is necessary.
Several times a day transfers should be practiced.
Teaching a transfer to a patient should always be done in presence of the family/ caretakers. They will
see what the patient is capable of and they can support the patient in training for independence. If help of
family/ caretaker is necessary, they have to be advised on how to handle and lift the patient whilst paying
attention to skin care and their own safety and back care.
Every attempt to transfer is training for increased independence.
7. Independent gait function [1,3]
The approach to gait training is different for each patient. The PT should consider factors like the energy cost,
expertise, athletic ability, weight, safety (especially in cases with severe spasticity) and the patient’s
motivation. Before enhancing in gait training the patient should be able to keep his balance (static and
dynamic) while standing. Patients with no control of the muscles in their legs can use an orthosis to stabilize
the limb. Many types of orthosis exist though the following orthosis are most often used: KAFO (knee ankle
foot orthosis), AFO (ankle foot orthosis). This orthosis is unsuitable for patients with severe spasticity or
edema of the feet and lower legs
The benefits of standing are that muscle length are maintained, spasticity is decreased, circulation increases,
Lietje Jacobs Karin Al Geertje Kotzee
Hogeschool Amsterdam
Spinal Cord Injury Protocol 2005
Third Hospital of Beijing
29
bone density is maintained and it is good exercise (strength, balance).
Gait training should be approached methodically. First the patient must be able to stand and bear weight on
his limbs in order to start the gait training.
A method to bring the patient to stand:
- Patient sits well back in chair and lean forward
- Place the hands at the end of the bars with the elbows vertically above the wrists.
- Stretch upward not forward
- Hyperextend the hips and extend the head and retract the shoulders
Posture correction during standing:
- Weight goes through the heels
- Legs are inclined only a few degrees forward of 90 at the ankle
- Hips are slightly extended so that the line of gravity lies behind the hip joints, through the knee joints
and slightly in front of the ankle joints to prevent the jack knife fall forward
- Spine is as upright as possible. Some adjustment must be made in the upper thoracic spine to
compensate for the hyper extended hips. Over correction must be avoided
- Bars are held with the hands approximately level with the toes
- Shoulders are relaxed
When the patient is able to stand safely, he should be taught the best type of gait to fit his abilities. Patients
with an incomplete lesion can profit of functional gait training according to Perry and use of a walking aid (like
crutches, walking frame). Complete lesions or severe incomplete lesions can benefit from the three types of
gait, described in the next paragraph. It should be considered whether walking is worth the cost of energy,
sometimes the goal of gait training should not be to gain the ability to walk but on functional muscle
strengthening.
Conditions for gait training
Controlled walking is achieved only through perseverance, perfect timing, rhythm and coordination the
patient is taught to:
Move the hands first
To walk slowly and place his feet accurately
To take the weight through the feet and so ensure that the hands can relax between each step
To lift the body upwards and not to drag the legs forward
-
There are three types of gait used; usually used for patients with a complete lesions or a severe incomplete
lesion
Four point gait
Swing to gait (used for patients with lesions above T10, it is also the safest type)
Balance in the hyper extended position
Move the hands either separately or together forward along the bars approximately half a foot
length in front of the toes
Lean forward with the head and shoulder over the hands and lift the legs, which will swing forward
to follow the position of the head and shoulders. The step is short and the feet must drop just behind the level
of the hands. To achieve this, the lift must be released quickly, otherwise the feet will travel too far and land
between or in front of the hands when on crutches, it is unstable and therefore dangerous to have the feet
Lietje Jacobs Karin Al Geertje Kotzee
Hogeschool Amsterdam
Spinal Cord Injury Protocol 2005
Third Hospital of Beijing
30
-
-
-
and hands in line. It must therefore be avoided in the bars. The swing to gait is a staccato gait with no follow
through: lift and drop.(The therapist assists from behind)
Four point gait (This is a slow and difficult type)
Place the right hand forward about half a foot length along the bar and the left one just in front of
the hip joint
Take the weight on the right leg, so that the hip is over the right foot and the knee and ankle in a
vertical line.
With the left shoulder slightly protracted, push on the left hand and depress the shoulder. The effort
is to lift the leg upwards.
As the left leg is lifted, it swings forward to follow the shoulder. The lift is released when a large
enough step has been made
Take the weight over the left leg
Move the left hand forward along the bar in preparation for moving the right leg. Pelvic rotation must
be avoided.
Swing through gait (fastest and most useful, though the patient must have a good balance)
place the hands forward along the bars as for the swing to gait
Lean forward and take the weight on the hands
Push down on the bars, depress the shoulder girdle and lift both legs. The lift must be sustained
until the legs have swung forward to land the same distance in front of the hands as they were originally
behind.
As the weight is lifted and the legs swing forward, hyperextend the hips, extend the head and
retract the shoulders.
To move the trunk forward over the feet push on the hands extending the elbows and adducting the
shoulders. When the weight is firmly on the feet, move the hands along the bars for the next step.
8. Independent ADL [1]
The scheme gives an overview of what ADL functions a patient with a complete lesion at a given level of
injury should be able to do.
The goal of ADL training is to increase independence so that the patient can reintegrate into society.
The patient should be challenged by activities; the family/carer should give the patient a chance to
achieve activities without their help, even when it is difficult.
The patient should be taught the applying techniques and encouraged to train the techniques during the
day to improve independence.
The therapist should focus the training on the factors that the patient will need to improve its
independence like for instance muscle strengthening exercises, maintaining ROM, etc.
Lietje Jacobs Karin Al Geertje Kotzee
Hogeschool Amsterdam
Spinal Cord Injury Protocol 2005
Third Hospital of Beijing
31
Functional goals for rehabilitation in relation to the level of a complete SCI [2,3]
Segmental level and
Personal independence
key-muscle control
Wheelchair management
Transfers
Electrical wheelchair
Dependant
Gait
C4
M. Sternocleidomastoideus
Type,
turn
pages,
use
M.Trapezius p. ascendus
telephone and computer with
M.Levator scapulae
mouth stick
Diaphragm
C5
Mm. Biceps brachii
M. Deltoideus
Rotator cuff muscles
Type
Manipulate brake of manual
Brush teeth/hair
wheelchair
Feed by means of a strap
Push on flat grounds
C6
Drink, wash, shave, brush hair,
Wrist extensors
dress upper half, sit up, lie
Supinators
down in bed, write
Dependant
Remove armrests and floor
Chair – bed/toilet/car
plates
Push on sloping ground
Turn chair
C7
Mm. triceps brachii
Turn in bed
Pick up objects from floor
Chair – toilet
M. lattisimus dorsi
Dress lower half
Wheel over uneven ground
Chair – chair
M. Flexor digitorum
Skin care
Bounce over small elevations
Chair – bath
Bladder and bowel care
Negotiate kerbs
Chair – bath
Stand in frame
Mm.flexor capri radialisl+b
C8
Upper limb muscles except
M. lumbricales and Mm.
Stand in frame
interossi
T1 –T5
Varying
intercostal
and
Trunk support
back muscles
T6-T9
Abdominal muscles
Balance on rear wheels
Pull wheelchair into car
Trunk control
Chair crutches
L1-L2
M. Psoas major,
M. Tibialis anterior
L5
Swing to on crutches or
rollator stairs
Knee extention
All
Dorsi flexion of the ankle
crutches,
All
Eversion
Mm.Peronei
Swing-to in bars
crutches,
M. Iliopsoas
Quadriceps muscle
Stand in frame
All three gaits on
Hip flexion
L3-L4
Chair – floor
three
three
crutches,
S1-S5
Mm.Glutei, Bladder and
Hip extention
Normal gait
bowel, Sexual function
Lietje Jacobs Karin Al Geertje Kotzee
Hogeschool Amsterdam
Spinal Cord Injury Protocol 2005
Third Hospital of Beijing
32
gaits
on
gaits
on
9. Independent bladder management [1, 2, 3, 7, 31]
Disturbance of bladder function can produce many complications which constitute a lifelong threat to the
patient. Statistics show that renal disease was responsible for the majority of deaths among patients with
spinal lesions. This means that co
ntinuing bladder care is essential if complications are to be prevented.
The sub-acute phase
the patient can be diagnosed with an automatic- or autonomous bladder. The doctors will decide on the best
management option for the patient, which is determined individually. A patient that has enough muscle
strength, static- and dynamic balance and the socioeconomic ability should be taught to catheterize himself.
The different management options for the automatic and autonomous bladder are discussed below.
Automatic/reflex bladder (common in lesions above T12) [3]
Reflex tone returns to the detrusor muscle which contracts in response to a certain degree of filling pressure.
The returning power of the sphincter is overcome and micturation occurs. The major problem is that you do
not know when or if the bladder will empty.
Management options:
The urinary sphincter should be relaxed for voiding to occur, this can be encouraged by;
- stroking the inner aspect of the thigh or pulling the pubic hair.
crede (manually emptying the bladder)
- rhythmic tapping over the abdominal wall above the symphysis pubis
Once the stimuli on which the patient's body reacts the best, has been found the patient's body should learn
to only empty the bladder on that specific stimuli. The bladder should be emptied on a regular basis with this
technique.
Voiding urine can also occur by using catheters to empty the bladder.
indwelling catheter (Foley) a tube is inserted through the urethra or abdomen and into he ladder,
where a balloon on the end holds it in place. It remains in the bladder for a maximum of six days
and a minimum of two days, depending on the patient and the possibility of urine tract infection
This catheter drains constantly, so the bladder is never full.
ICP; The bladder is drained several times a day (every 4-6 hours) by inserting a small rubber or
plastic tube, the tube does not stay in the bladder between catheterizations.
The frequency by which the bladder should be emptied, can be determined by the by means of
the highest residu:
Above the 600 ml:
empty the bladder 6 times a day
From 500 – 600 ml:
empty the bladder 5 times a day
From 400 – 500 ml:
empty the bladder 4 times a day
From 300 – 400 ml:
empty the bladder 3 times a day
From 200 – 300 ml:
empty the bladder 2 times a day
From 100 – 200 ml:
empty the bladder 1 time a day
If the patient has taken to much fluids the bladder should be emptied an extra time.
Condom catheter (men)
Lietje Jacobs Karin Al Geertje Kotzee
Hogeschool Amsterdam
Spinal Cord Injury Protocol 2005
Third Hospital of Beijing
33
Autonomous/ non reflex bladder (common in lesions below T12) [3]
The bladder is atonic and thus occurs where reflex action is interrupted. There is no reflex action of the
detrusor muscle. The patient can't feel when the bladder is full therefore it can become over-distended or
stretched.
Management options:
The patient can manage his bladder by emptying his bladder on a regular basis (every 4-6 hours), using the
ICP catheterization method.
The bladder function can also be managed by various interventions like:
Surgery
Medication
10. Proprioception and Coordination
Damage to the posterior/dorsal column results in a decrease of proprioception which causes coordination
loss. The Anterior Cord Syndrome also decreases the proprioception.
With sports and games focused on coordination, the proprioception can be increased.
Placement-exercises stimulate awareness of position and movement of the affected limbs
Teaching the patient to have extra attention and care for the limbs or regions which have
proprioception loss is necessary, since the risk for forgetting to lift in walking, placing the foot in for example
inversion, damaging to bed, wheelchair or objects etc. is increased.
11. Increased / maintained respiratory function [1,2, 36, 37]
Patients suffering from spinal cord injury at any level, complete or incomplete are at increased risk for
developing respiratory complications. Any loss of respiratory muscle control weakens the pulmonary system,
decreases one's lung capacity, and increases respiratory congestion.
Ventilatory compromise in spinal cord injury is caused by one or more of the following:
Inspiratory or expiratory muscle paralysis leading to decreased lung volume,
Loss of effective cough,
Diminished chest wall mobility,
Reduced lung compliance,
Increased energy cost of breathing and paradoxia chest wall movement.
Common complications:
Pulmonary embolism. - Ventilatory failure
Atelectasis - Pulmonary embolism - apnea
Airway clearance techniques [24]
The aims should be to reduce airway obstruction by improving the clearance of secretions, to reduce the
severity of the infection by evacuating infected material and to maintain optimal respiratory function and
exercise tolerance.
The Active Cycle of Breathing Techniques: This consists of a combination of deep breathing exercises
(DBE); thoracic expansion exercises (TEE); forced expiratory technique (FET) and breathing control. The
Active Cycle of Breathing Techniques (ACBT) is not a rigid treatment method and is modified to suit all ages
and individual needs.
Lietje Jacobs Karin Al Geertje Kotzee
Hogeschool Amsterdam
Spinal Cord Injury Protocol 2005
Third Hospital of Beijing
34
Thoracic expansion: exercises with the emphasis on inspiration, expiration being quiet and relaxed.
The forced expiration technique or huff: is used to mobilise and clear secretions. One or two forced
expirations (with open glottis) are combined with a period of breathing control. A huff from high lung volume
(when a breath has been taken in) will clear secretions from the upper airways and a huff from mid to low
lung volume will clear secretions from the lower more peripheral airways.
Postural drainage: This may be used in conjunction with other techniques, e.g. ACBT, positive expiratory
pressure (PEP) and percussion - it involves positioning to allow gravity to assist drainage of secretions based
on bronchial tree anatomy.
Percussion / Chest clapping ('battre a l'air comprimee): Can be performed with cupped hands over the
area being drained. It should be performed for approximately 15-20 seconds with pauses for 5 seconds or
longer to minimise the risk of desaturation in patients with moderate or severe lung disease. Mechanical
percussors have not been shown to increase sputum clearance or lung function. Percussion in short bursts
can be used with ACBT until independent effective treatment can be performed by the individual.
Self treatments consist of postural drainage, thoracic expansion exercises, breathing control and forced
expiratory technique. Self treatment is initially supervised and this continues until the patient, family/
caretaker and physiotherapist consider the treatment is carried out effectively. At the time of respiratory
exacerbations, assisted treatments are usually preferable.
Positive expiratory pressure ("PEP") bottle: This bottle is used to open up and recruit obstructed lung
and alveoli, allowing air to move behind secretions and assist in mobilising them. Breathing out against a
slight resistance (10 to 20 cm of water) prevents the smaller bronchial tubes from collapsing down and thus
permits the continuous upward movement of any secretions. The technique also allows the patient more
independence. The treatment can be performed in the sitting or postural drainage position. Most benefit is
obtained by patients who produce sputum and have obstructed airways, where premature airway closure
during expiration contributes to retained secretions.
Physical activity: Regular vigorous exercise is beneficial for the patient and should be encouraged.
Swimming, cycling, skipping, tennis, squash and jogging are all excellent forms of exercise.
Conclusions: There is evidence that even in patients with mild chest involvement, regular daily physiotherapy
maintains the chest in better condition than when this treatment is omitted (Reisman et al, 1988).
12. Kinesiophoby [20]
Kinesiophoby refers to “an excessive, irrational, and debilitating fear of physical movement and activity
resulting from a feeling of vulnerability to painful injury or (re)injury” (Kori, Miller, & Todd, 1990). To test if the
patient has kinesiophoby the Tampa-Scale can be used. The Tampa Scale of Kinesiophoby is a 17-item
scale designed to measure this construct.
Physical coaching:
- Verbal movement guidance
- Graded activity training
Psychological coaching
- Providing information and advice to the patient (see [29] for an informative website aimed at the patient
and his family)
- Giving instructions to the relatives
- Focus on what the patient can do instead of can't do (see treatment objective ‘Independent ADL
function’)
Lietje Jacobs Karin Al Geertje Kotzee
Hogeschool Amsterdam
Spinal Cord Injury Protocol 2005
Third Hospital of Beijing
35
- Improve coping strategies [19]
Lietje Jacobs Karin Al Geertje Kotzee
Hogeschool Amsterdam
Spinal Cord Injury Protocol 2005
Third Hospital of Beijing
36
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4.
Asbeek .F.W.A. van, Handboek Dwarslaesie Revalidatie. Bohn Stafleu Van Loghum, 2001
Susan Edwards, Neurological physiotherapy: a problem-solving approach 2nd edition, Edinburgh:
Churchill Livingstone 2002
Martha Freeman, Somers, Spinal cord injury: functional rehabilitation 2nd edition .Upper Saddle River,
NJ prentice Hall 2001
KNGF guideline, Whiplash
Protocols
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Onze Lieve Vrouwe Gasthuis, Protocol fysiotherapie Dwarslaesie, April 2002
Walton Rehabilitation Hospital USA, protocol spinal cord injuries
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Rehabilitatiecentrum de Hoogstraat, protocol blaasbeleid, April/August 1994
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Acupuncture institute. Researching what patients say about treatment. Health Visions. 2000:
1-800-735-2968
Bajd.T, Gregoric M.,Vodovnik L. Benko H. Electrical simulation in treating spasticity resulting from spinal
cord injury. Arch.Phys.Med.Rehabil 1985 Aug.66(88): 515-7
Consensus Developmental Panel. Acupuncture. National Institutes of Health Consensus Development
Conference Statement. 1997, nov. 3-5
Ernst F. Massage therapy for low back pain: a systematic review. Journal of Pain Symptom Manage.
1999:17:65-9
Gordon T., Mao J. Muscle atrophy and procedures for training after spinal cord injury. Phys.Ther. 1994
Jan: 74 (1): 50-60
Gam AN et al. The effect of low-level laser therapy on musculoskeletal pain: a meta-analysis( Pain).
1993: 52:63-6
Gam J.N. Johanssen J. Ultrasound therapy on musculoskeletal pain: a meta-analysis (Pain). 1995: 63:
85-917
J. Haley (Kinesiologist), Recreation services, five more muscle faqs
Heijden GJMG van der, et al. TENS for musculoskeletal disorders: a systematic review.
Gezondheidsgraad, the effectivity of
Journal Spinal Cord Med Pressure ulcer prevention and treatment following spinal cord injury Journal
Spinal Cord Med. 2001: Spring: 24 (suppl 1): S40-101
J.U. G. Inst. Of Neurosciences. 4th Military Medical Univ. China. 1997 Health Ministry Estimate. Quoted
via email to Luba Vikhanski, Dana Brain Foundation Oct 2000.(epidemiologie)
Klebine P. Coping, and adjustment to spinal cord injury. UAB Medical RRTC, UAB Spain Rehab. Center,
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Hogeschool Amsterdam
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Third Hospital of Beijing
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Birmingham 2001
Kori, S.H., Miller, R.P., & Todd, D.D. (1990). Kinesiophobia: A new view of chronic pain behaviour.
Pain Management, 3, 35-43
Lippincott Willimas and Wilkins Inc. Evaluation and treatment of spinal cord injury in the patient with
poly trauma. Clinical Orthopaedics and Related Research 2004 (422): 43-54
E. A. Moberg - Wolff MD, Spasticity, June 2005 www.emedicine.com/pmr/topic177 htm
Mortz.E et al, Predictors of psychosocial adaptation among people with spinal cord injury or disorder,
Arch.Phys.Med.Rehabil 2005 June; 86 (6): 1182-92
Reisman JJ, Rivington-Law B, Corey M, Marcotte J, Wannamaker E, Harcourt D et al. Role of
conventional physiotherapy in cystic fibrosis. J Pediatr 1988; 113: 632-636 airway clearance technique
D. Schreiber, Deep venous Thrombosis and Thrombophlebitis, 27 Oct 2005
UAB Model SCI Care System Birmingham. SCI information network, National Institute on Disability and
Rehabilitation Research, US, 2003
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www.emedicine.com/emerg/topic337
www.mayclinic.com/health/spinal-cord-injury/DS000460/DESECTION=4
www.tascnetwork.net/muscleweakness.asp
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Lietje Jacobs Karin Al Geertje Kotzee
Hogeschool Amsterdam
Spinal Cord Injury Protocol 2005
Third Hospital of Beijing
38
APPENDIX
Lietje Jacobs Karin Al Geertje Kotzee
Hogeschool Amsterdam
Spinal Cord Injury Protocol 2005
Third Hospital of Beijing
39
Lietje Jacobs Karin Al Geertje Kotzee
Hogeschool Amsterdam
Spinal Cord Injury Protocol 2005
Third Hospital of Beijing
40
Functional Assessment
Mat mobility
Date
Date
Date
Rolling
Supine - prone
Prone - puppy
Four point kneeling
Supine - sitting
Sidely -High sitting
High sitting
Long sitting
Shifting on mat
Seated push up
Own stretches
Chair mobility
Date
Date
Date
Sitting posture and balance
Pressure relief
Transfer - mat
Transfer - toilet
Transfer - bath
Transfer - floor
Transfer - car
Feeding
Dressing
Grooming
Washing
Fine Motor function
Lietje Jacobs Karin Al Geertje Kotzee
Hogeschool Amsterdam
Spinal Cord Injury Protocol 2005
Third Hospital of Beijing
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Lietje Jacobs Karin Al Geertje Kotzee
Hogeschool Amsterdam
Spinal Cord Injury Protocol 2005
Third Hospital of Beijing
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Lietje Jacobs Karin Al Geertje Kotzee
Hogeschool Amsterdam
Spinal Cord Injury Protocol 2005
Third Hospital of Beijing
43
The Ashworth Scale
Score
Ashworth
Scale (1964)
Modified
Ashworth Scale Bohannon &
Smith (1987)
0 (0)
No increase in tone
No increase in muscle tone
1 (1)
Slight increase in tone
giving a catch when the
limb was moved in flexion
or extension
Slight increase in muscle tone, manifested by a catch
and release or by minimal resistance at the end of the
range of motion when the affected part(s) is moved in
flexion or extension.
Slight increase in muscle tone, manifested by a catch,
followed by minimal resistance throughout the reminder
(less than half) of the ROM (range of movement).
1+(2)
2 (3)
More marked increase in More marked increase in muscle tone through most of
tone but limb easily flexed. the ROM, but affected part(s) easily moved.
3 (4)
Considerable increase in
Considerable increase in muscle tone passive, movement
tone - passive movement
difficult.
difficult.
4 (5)
Limb rigid in flexion or
Affected part(s) rigid in flexion or extension.
extension.
Lietje Jacobs Karin Al Geertje Kotzee
Hogeschool Amsterdam
Spinal Cord Injury Protocol 2005
Third Hospital of Beijing
44
Tampa scale voor Kinesiophoby
Miller, R.P., Kori, S.H. & Todd, D.D. (1991)
Vlaejen J.W.S., Kole-Snijders A.M.J., Crombez G., Boeren R.G.B. & Rotteveel A.M. (1995)
Give an indication which statement is true, by means of choosing the appropriate statement numbered
1-4. The numbers are associated with the following meaning
1 = I totally disagree
2 = I disagree
3 = I agree
4 = I totally agree
I am afraid that I might get injured when I am doing any physical exercise.
1
2
3
4
The pain will increase if I ignore it and continue with the current activity
1
2
3
4
The pain means that there is something seriously wrong with my body
1
2
3
4
The pain will decrease if I participate in physical exercise.
1
2
3
4
My health situation is not being taken serious by other people
1
2
3
4
My body will be in danger for the rest of my life because of the pain.
1
2
3
4
The pain means that there is something physically wrong with my body
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
If there was nothing seriously wrong with me I would have had less pain
1
2
3
4
It will be better to be physically active, even though it is painful
1
2
3
4
1
2
3
4
I would advise against activity to anyone with the same condition than I have
1
2
3
4
I can’t do what normal people do, because I get injured more easily then they
1
2
3
4
Even though my pain is severe, I don’t believe that it is dangerous
1
2
3
4
I should not have to do any exercises when I am in pain
1
2
3
4
It does not necessarily mean that my body is in danger, if the pain increases
because of something.
I am afraid of injuring myself by accident
The safest way to prevent further increase in pain is to avoid unnecessary
movements
The pain tells me when to stop exercising my body to prevent any further
damage.
Lietje Jacobs Karin Al Geertje Kotzee
Hogeschool Amsterdam
Spinal Cord Injury Protocol 2005
Third Hospital of Beijing
45