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Beth W. Jacobs, RN, CCM, CRRN
Clinical Coordinator
Spinal Cord System of Care - MossRehab
List the major components of the spinal cord injury
(SCI) neurological exam
Discuss the correlation between SCI neurological
diagnosis and level of function
Describe care strategies which directly affect lifelong
health maintenance
Identify care resources for the spinal cord injured
individual
Spinal cord injury anatomy & physiology
The SCI neurological exam
Functional presentation
Lifetime management
Recognizing and treating autonomic dysreflexia
Maintaining a healthy musculoskeletal system
Establishing a bladder program
Preventing pressure ulcers
Role of neuroplasticity in mobility
Tetraplegia
Paraplegia
Central nervous system
The brain and spines main means of
communicating, interpreting and initiating all
motor and sensory impulses to and from the
body
Protects the spinal cord from injury
Divided into four sections
Cervical
Thoracic
Lumbar
Sacral
Largest nerve in the body
Protected by a vertebral bony structure
Extends from the base of the brain down to the
lumbar spine through the spinal canal as upper
motor neurons
At L1 exits the spinal canal as nerve roots
resembling a horses tail as
lower motor neurons
Nerve roots exit to and enter from the body
throughout the spinal cord
Comprised of bundles of electrical nerves
called tracts
Ascending tracts carry sensory messages to
the brain
Descending tracts carry motor messages to
the body
Sensory tracts
Spinothalamic
Anterior part of cord
Pain, temperature,touch
Spinocerebellar
Posterior part of cord
Position sense/proprioception, vibration
Motor tracts
Upper body movement
Center of cord
Lower body movement
Perimeter of cord
Part of the nervous system which controls
our automatic bodily functions
Heart beating
Blood pressure regulation
Breathing
Digesting food
Control of urination
Control of defecation
A system of balance and counter balance
to maintain homeostasis
Parasympathetic
Brain stem
Sacral cord
Sympathetic
Cervical through lumbar cord
There is a neurological change in
presentation due to:
Cord compression, inflammation,
loss of blood supply
Vertebral body fracture, dislocation
Anterior ligament injury
Posterior ligament injury
Disruption of vertebral arteries with ischemia
Disruption of myelin sheath
Can be due to a trauma vs non-traumatic
event or disease based injury
What is it?
International Standard for Neurological
Classification of Spinal Cord Injury
Endorsed by the American Spinal Injury
Association
Neurological Level
Motor Score
Sensory Score
Complete or Incomplete
(AIS or ASIA impairment scale)
Zone of Partial Preservation
Clinical Syndromes
10 major muscle groups
5 upper body
5 lower body
Amount of strength
0 – 5 rating
NT = not testable
Upper Body
C5
C6
C7
C8
T1
Elbow Flexors
(elbow bent)
Wrist Extensors
(wrist up)
Elbow Extensors
(arm out straight)
Finger Flexors
(bend middle finger)
Finger abductors
(little finger to thumb)
Lower Body
L2
L3
L4
L5
S1
Hip Flexors
(knee up)
Knee Extensors
(kick out)
Ankle Dorsiflexors
(ankle up)
Long Toe Extensors
(toes to your nose)
Ankle Plantar Flexors
(step on the gas)
56 Sensory Dermatomes
28 on the right side of the body
28 on the left side of the body
Type of Sensation
Light touch
Pinprick
Level of Sensation
0 - Absent
1 - Impaired
2 – Normal
NT = not testable
In absence of ability to test Abdominal
Muscles
T2
T3
T4
T5
T6
Axilla
Third intercostal space
Nipple Line
Midway btw 4 & 6
xiphisternum
T7
T8
T9
T10
T11
T12
L1
Midway btw 6 & 8
Midway btw 6 & 10
Midway btw 8 & 10
Umbilicus
Midway btw 10 & 12
Inguinal ligament
perineal region
The lowest intact level of motor or sensory
function
Must be bilateral
NOTE - If the patient is 3/5 with a string of 5/5 at
every level above they are diagnosed at the 3/5
level
Motor & sensation should be tested throughout
Confirm Complete or Incomplete diagnosis
AIS A – No motor or sensory preservation below level of injury,
testing of S4-S5 anal reflex
AIS B – Some sensory preservation below level of injury
AIS C – Some motor preservation but weak
AIS D – Some motor preservation but stronger
Incomplete injuries can have unusual motor
preservation &/or spotty sensation throughout
Zone of partial preservation
Clinical syndromes can be more clearly diagnosed
Loss or impaired movement
Loss or impaired sensation
Loss or impaired pain, temperature and
proprioception
Loss or impaired bladder & bowel function
Loss or impaired sexual function
Clinical Syndromes
Central Cord
Brown Sequard
Anterior Cord
Posterior Cord
Conus Medullaris
Cauda Equina
Central cord
More motor impairment of upper extremities vs lower
9% of traumatic SCI (TSCI) - most common
Hyperextension injuries, cervical spondylosis
Oldest age group
Brown-sequard
Same side (ipsilateral) proprioception & motor loss with
opposite side (contralateral) pain & temp loss
1 – 4% of TSCI
Best ambulatory prognosis – 75 – 90% are Independent at
discharge
Anterior cord
Anterior portion of cord affected negatively impacting on
pain, temperature, touch
2.7% of TSCI
10 – 20% chance of muscle recovery
Posterior cord
Posterior portion of cord affected negatively impacting on
proprioception, vibration
<1% of TSCI – least common
Conus medullaris
Lumbarsacral nerve roots within canal are affected causing
bowel & bladder involvement with mixed UMN & LMN
presentation (usually areflexic)
Trauma & tumors
typically AIS B
Cauda equina
Lumbarsacral nerve roots within the neural canal are
affected causing pure LMN areflexic bowel & bladder
impairment
Trauma, tumors, stenosis, disc compression, postsurgical
epidural hematoma
Better prognosis since peripheral nerve roots may be able to
regenerate
Recognizing and treating autonomic dysreflexia
Maintaining a healthy musculoskeletal system
Establishing a bladder program
Preventing pressure ulcers
Role of neuroplasticity in mobility
Does not occur during phase of
spinal shock
Injuries at T6 or above
Intact sensory afferent impulses below level of
injury, ascend via spinothalamic and posterior
columns
Inhibitory sympathetic outflow response is blocked
Sudden elevation in blood pressure – most commonly
presenting as headache
Heart rate drops to compensate for severe
vasoconstriction – bradycardia
Inhibitory sympathetic response above level of injury is
intact – diaphoresis, skin flushing of upper body
Inhibitory sympathetic response below level of injury is
blocked – vasoconstriction unopposed & blood
pressure continues to rise
Signs & Symptoms
Pounding headache, bradycardia,
profuse sweating, piloerection, cardiac
arrhythmia and other abnormalities,
flushing of skin, blurred vision, spots in
visual fields, nasal congestion,
apprehension/anxiety, (silent AD)
Blood Pressure Elevation
Adults
Importance of knowing baseline BP
Only 20-40 mm HG above baseline may be AD
Children/Adolescents
Children – 15 mm HG above
Adolescent – 15-20 mm Hg above
Causes
80% is bladder related
Bladder distention due to
Blocked foley catheter
CIC with no spontaneous void – time to cath!
UTI
Kidney/bladder stones
Causes
Bowel distention
Pressure ulcers
Ingrown toenails
Tight clothing
Infections
Fractures
PE/DVT
Sexual intimacy
Action to Take
Sit upright
Loosen clothing
Monitor VS
Rule out bladder as cause
Contact MD
Determine source of stimuli & eliminate
Possible antihypertensive administration
Post AD episode
Monitor for 2 hours to assure no reoccurrence
Documentation
Education
Recurrent episodes –
frequent re-evaluations over time
Spasticity
Contracture development
Heterotopic ossification
Disruption of CNS communication between the
spinal cord and brain
Not typically seen during acute injury due to
areflexic spinal shock state
Seen in UMN injuries
Severity can increase suddenly or over time
Must rule out infectious source
Benefits
Can be triggered to improve function
May be early sign of infection or problem
Risks
Negatively affect function
Painful for incomplete injuries
Impact on sleep pattern
Cause pressure/friction problems
Decrease joint ROM
Rehab management
Routine ROM exercise
Weight bearing activities to stretch muscles
Oral medication use
Nerve blocks
Benefits are temporary
Phenol
Botox
Intrathecal baclofen pump
Advantages
Administered directly into cerebral spinal fluid via the
intrathecal space
Reduction of typical oral medication side effects
Dosing frequency and timing can be individually
established and managed
Spinal cord
Epidural
space
Capillary
absorption
Dural
membrane
Intrathecal
space
Catheter
CSF
Drug
Vertebra
Spinal cord
Epidural
space
Capillary
absorption
Dural
membrane
Intrathecal
space
Catheter
CSF
Drug
Vertebra
Screening process to qualify
Disadvantages
Surgical procedure
Will need to be replaced q 5-8 years
Requires diligent follow up with specialist
Injury to the spinal cord increases excitabilty of
neural circuits that control muscle tension.
Spastic muscles resist changes of tension by
contracting.
Contraction results in shortening of muscles, tendons and
ligaments
Can be a secondary complication of severe spasticity
Prevention
Routine ROM to all joints, stretching or muscles
Control spasticity
Therapeutic use of functional electrical stimulation
Can be functionally devastating
Rehab management
Aggressive therapy
Serial casting, customized splinting
Medication management of spasticity
Motor nerve blocks with phenol, botox
Surgical interventions – tendon lengthening
Pathophysiology unclear
Inflammatory process with increased blood flow
Bone is mineralized and laid down in soft tissue
around joints
Matures in 6 – 18 months
Incidence is 16-53% in SCI
Clinically significant in 18-27%
Involves joint ankylosis in 3-5%
How to diagnose?
Assess changes in ROM
Observe for hot swollen joints
Primary site - hips & knees but can develop in UE
Elevation of alkaline phosphatase, triple phase
bone scan
Identification early is crucial
Rehab management
Active-assistive and passive ROM – treatment
controversial
Didronil and/or indocin
Surgical excision
Micturation – Urination
Bladder fills/distends
CNS Cerebral awareness of fullness
Voluntary use of abdominals
ANS - mixed innervation
Sympathetic –T11-L2
Compliance of volume
Internal sphincter control
Parasympathetic – Sacral arc S2-S4
Detrusor muscle contraction
External sphincter control
Physiology of kidney and bladder function intact
Awareness of bladder fullness impaired
Use of abdominal muscles impaired
Use of complex coordinated reflexes altered to
achieve complete emptying
Detrusor Sphincter Dysenergia (DSD) may result
Goal is low bladder pressure with adequate
bladder emptying
Preservation of upper tracts
Reduce possible bladder stretch injury
Prevent hyperactive detrusor
Program will be determined by type of bladder
Complete urodynamic testing to determine
presence of reflux, outlet obstruction, DSD,
hydronephrosis - annual urologic follow up
Medications to reduce hyperactivity
Anticholinergics, botox injection
Options
Long term indwelling urethral catheter
Suprapubic Catheter
Chronic intermittent catheterization
Volumes must be under 500 cc consistently
Allowed reflex voiding determined by urodynamics
Surgical procedures
Sphincterotomy
Bladder augmentation
Urinary diversion
Mitrofanoff procedure
2011 National Spinal Cord Injury Statistical Center (NSCISC) Annual Statistical Report
35
30
% of total
25
20
15
At Discharge
1 year post
10 years post
10
5
0
25 years post
2011 NSCISC Annual Statistical Report
35
30
% of total
25
20
15
At Discharge
1 year post
10 years post
10
5
0
25 years post
National Quality Forum (NQF) 2003
“hospital never events”
Medicare Patient Safety Monitoring System
(MPSMS)
2006-2007
Adverse Event “When unintended harm, injury, or loss occurs that
is more likely associated with an individual’s
interaction with the healthcare system than with
disease”
HAPU incidence 4.5%
Present on admission (POA) 5.8%
16.7% developed at least one additional PU
Concomittent co-morbidites
CHF, COPD, CVD, DM, use of corticosteroids, obesity
Those with hospital acquired pressure ulcers (HAPU)
significantly more likely to
Have longer length of stay (LOS) –
11.6 days vs 4.9 days
Be readmitted within 30 days after discharge
Die while hospitalized
Medicare Payment Reform Demonstration
(MPRD)
2010
Standardize all post-acute data collection Continuity and Record Evaluation (CARE) tool
Identify new Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PIA) outcome
measures
Affordable Care Act
2010
Acute rehab quality indicators
Catheter acquired urinary tract infections (CAUTI)
Hospital acquired pressure ulcers (HAPU)
Considered a never event
Monitoring/reporting began October 1, 2012
Not reporting? - 2% reduction in MC payment 2014
Once data established – they are considering - hospitals in
the bottom 25% of quality outcome reporting will receive a
99% reimbursement payment
Prevalence
34% acute hospitalization
15% one-year post
20% five-year post
23% ten-year post
24% 15 year post
29% 20 year post
Incidence
73% assessing 4,065 SCI individuals
Consortium for Spinal Cord Medicine Clinical Practice Guidelines , Pressure Ulcer Prevention and
Treatment Following Spinal Cord Injury 2000
Autonomic nervous system disruption
- Level of injury increases risk
T6 and above
Altered body temperature control
Reflex sweating is lost
Altered collagen biosynthesis
Catabolic state
Decrease tensile strength
Lower O2 tension over sacrum
Overall decreased blood supply
Mechanical issues
Microvessels and capillaries close at lower levels of pressure
Capillary refill may be altered
First sign is typically skin color changes
Loss of muscle mass over bony prominences
Additional risk factors
Demographics, physical,psychosocial
Age, yrs post injury, cognitive, education, social supports,
cultural beliefs
Smoking
Diabetes
CVD
Second leading cause of death
Infective & parasitic diseases usually (88.6%)related
to septicemia
Pressure ulcers
Urinary tract infections
Respiratory infections
Disease of the skin is the second most common
cause of rehospitalization (30.1%)
*2011 NSCISC Annual Statistical Report
Education
Treatment must include a rehabilitation
focus – impact of functional limitations on skin
Lifetime rehabilitation management
Ongoing equipment determination and
procurement
Understanding DME insurance coverage limitations in-home support surfaces
Importance of customized wheelchair procurement wheelchair clinic
Customized seating systems - use of pressure mapping
#1BM Alt LAL 30 degrees
#1BM Powered-air 30 degrees
attends/underpad/drawsheet
attends/underpad/drawsheet
#1BM Standard LAL 30 degrees
attends/underpad/drawsheet
#2LS Powered-air 60 degrees
#2LS Alt LAL 60 degrees
attends/underpad/drawsheet
attends/underpad/drawsheet
#2LS Standard LAL 60 degrees
attends/underpad/drawsheet
#3EM Standard LAL 60 degrees
#3EM Powered-air 60 degrees
attends/underpad/drawsheet
attends/underpad/drawsheet
#3EM Alt LAL 60 degrees
attends/underpad/drawsheet
Neuroplasticity
The central nervous systems ability to
reorganize itself by forming new neural
connections
An old dog CAN learn new tricks!
neurons can rearrange & create new pathways for
communication
sensory information is interpreted and transmitted via
new electrical connections & inefficient connections are
deleted
“synaptic pruning”
Increased neuronal activity improves the synaptic
transmission
Perceived importance
Repetitive activities
Impact for rehab
across the continuum
Activity-based therapy is the foundation for the
rehabilitation of walking
Recovery is task dependent
The re-education of walking is an effective
rehabilitative strategy
Re-education – not compensation promotes
recovery
Reo Go
TM
Armeo
TM
G-eo
TM
Lokomat
TM
Complete injuries (AIS A)
80 – 90% remain complete
Incomplete injuries (AIS B,C,D)
50 - 66% of patient’s motor return at 1 yr post
injury was achieved within first 2 months
recovery continues but slows between 3 –6 months
continued recovery can occur up to 2 yrs post
Outcomes Following Traumatic Spinal Cord Injury, Consortium for Spinal Cord Medicine 1999
AIS B
50% ambulatory
AIS C
75% community ambulators
AIS D
100% ambulators
Younger patients with better prognosis
50-60 age with poorer prognosis
Outcomes Following Traumatic Spinal Cord Injury, Consortium for Spinal Cord Medicine 1999
90
80
70
60
50
1 year post
40
10 years post
30
25 years post
20
10
0%
Wheelchair use
> 40 hrs/wk
Walk 150 ft
Walk 1 street Walk up 1 flight
block
of stairs
*2011 NSCISC Annual Statistical Report
Exoskeleton that allows
for overground training
Has only been used as
orthotic device to this
point
Individuals with motor
complete injuries
Overground training may
be more task-specific
May allow for increased
practice for training
“In the middle of every difficulty lies an
opportunity”
Albert Einstein
Beth W. Jacobs, RN, CCM, CRRN
[email protected]
Acute Management of Autonomic Dysreflexia. Consortium for Spinal Cord Medicine 2001.
Bladder Management for Adults with Spinal Cord Injury. Consortium for Spinal Cord Medicine
2006.
Dunlop, Sarah. Activity-dependent plasticity: implications for recovery after spinal cord injury.
Trends in Neurosciences, vol. 31 No. 8, 2008.
Lyder, et al: Hospital-Acquired Pressure Ulcers: Results from the National Medicare Patient
Safety Monitoring System Study. Journal of the American Geriatric Society 60:1603-160,8 2012.
Lynskey, et al. Activity-dependent plasticity in spinal cord injury. Journal of Rehabilitation
Research & Development. 2008.
McKinley, William, et al. Functional Outcomes per Level of Spinal Cord Injury.
http://emedicine.medscape.com/article/322604, August 2011.
McKinley, William, et al. Incidence and Outcomes of Spinal Cord Injury Clinical Syndromes.
Journal of Spinal Cord Medicine 2007; 30(3): 215–224.
Medicare Patient Safety Monitoring System Database – online –
http://www.ahrq.gov/downloads/pub/advances/vol2/Hunt.pdf
National Quality Forum. Serious Reportable Events in Healthcare: A Consensus Report.
Washington, DC: National Quality Forum, 2002.
National Spinal Cord Injury Statistical Center, UAB, Annual Statistical Report, 2011.
Outcomes Following Traumatic Spinal Cord Injury, Consortium for Spinal Cord Medicine 1999.
Pressure ulcer Prevention and Treatment Following Spinal Cord Injury: Consortium for Spinal
Cord Medicine. 2008