Spinal Cord Injury (SCI)

[Part 1: Brief Overview]

By: Gan Quan Fu, PT

Contents1. Introduction2. Overview of Spinal Cord3. Classification and Symptoms in

Patient’s with Spinal Cord Lesion4. Clinical Manifestations5. Physiotherapy Examination6. Physiotherapy Intervention7. Summary8. References

By: Gan Quan Fu, PT

Introduction• Low incidence, high-cost disability

requiring tremendous changes in an individual lifestyle

• Divided into 2 categories:o Traumatic injuries (MVA, Fall, Gunshot etc.)o Nontraumatic damage (Thrombosis, embolus

etc.)

• Typically divided into 2 broad functional categories:o Tetraplegiao Paraplegia

By: Gan Quan Fu, PT

Overview of Spinal Cord

By: Gan Quan Fu, PT

Anatomy• 31 pairs spinal nerve

o 8 Cervicalo 12 Thoracico 5 Lumbaro 5 Sacralo 1 Coccygeal

• Spinal Tractso Ascending Tracts (Sensory)

• Spinothalamic• Dorsal Column Tract• Spinocerebellar Tract

o Descending Tracts (Motor)• Lateral Corticospinal• Anterior Corticospinal

By: Gan Quan Fu, PT

Spinal Tracts

By: Gan Quan Fu, PT

Spinal Tracts

By: Gan Quan Fu, PT

Spinal Tracts

By: Gan Quan Fu, PT

Ascending TractsTracts Function

Spinothalamic Tracts (Lateral) Pain & Temperature

Spinothalamic Tracts (Anterior) Light Touch & Pressure

Posterior Column Pathway 1. Deep touch & pressure2. Proprioception3. Vibration sensation

Spinocerebellar Tracts Posture and Coordination

By: Gan Quan Fu, PT

Ascending Tracts

By: Gan Quan Fu, PT

Descending Tracts

By: Gan Quan Fu, PT

Classification and Symptoms in Patient’s

with Spinal Cord Lesion

By: Gan Quan Fu, PT

Designation of Lesion Level

• Important for clinician to accurately determine the extent of neurological impairment in terms of motor and sensory loss.

• American Spinal Injury Association (ASIA) had created the International Standards of Neurological Classification of Spinal Cord Injury.o Standardize the way in which severity is

determined and documented.• Better communication between and among

professionals• Provide guidance for establishing prognosis• Important tools for clinical research trials

By: Gan Quan Fu, PT

Dermatome

By: Gan Quan Fu, PT

Myotome

By: Gan Quan Fu, PT

Myotome

By: Gan Quan Fu, PT

Complete Injury, Incomplete Injury and Zone of Partial

Preservation• Complete Injury No sensory or motor function in lowest sacral segments (Determine by Anal Sensation and Voluntary External Anal Sphincter).

• Incomplete InjuryHaving motor and /or sensory function below the neurological level including S4 & S5.

• Zones of Partial PreservationHaving motor and /or sensory function below the neurological level but no function at S4 & S5.

By: Gan Quan Fu, PT

ASIA Impairment Scale

By: Gan Quan Fu, PT

Clinical Syndromes

• Central Cord• Brown-Sequard• Anterior Cord

By: Gan Quan Fu, PT

Central Cord Syndrome

• Result of compressive forces which give rise to hemorrhage and edema in central aspect of cord.

• More severe neurological involvement of upper extremities than lower extremities.

• Varying degrees of sensory impairment but less severe than motor deficits.

• Normal sexual, bowel and bladder function

• Typically recover the ability to ambulate with some remaining distal upper extremities weaknessBy: Gan Quan Fu, PT

Brown-Sequard Syndrome

• Damage to one side (causes: Penetration wound)

• Asymmetrical clinical features.

• Ipsilateral side of lesion Loss of sensation in dermatome segment in the level of lesion (depending on area involve)

• Contralateral side of lesion Loss of pain and temperature if damage to spinothalamic tracts, loss begins several dermatome segments below.

By: Gan Quan Fu, PT

Anterior Cord• Loss of motor function

(corticospinal tract); Loss of sense of pain and temperature (spinothalamic tract)

• Proprioception, Kinesthesia and vibratory sense are generally preserved

By: Gan Quan Fu, PT

Clinical Manisfestation

By: Gan Quan Fu, PT

Spinal Shock• Period of areflexia after SCI • Relates to the loss of all neurological activity below the

level of injury. This loss of neurological activity include loss of motor, sensory, reflex and autonomic function.

• The mechanism for spinal shock involves the sudden loss of conduction in the spinal cord as a result of the migration of potassium ions from the intracellular to extracellular spaces.

• Return of reflexes between 1-12 months post injury are characterised by hyper-reflexia, or abnormally strong reflexes usually produced with minimal stimulation. Inter neurons and lower motor neurons below the SCI begin sprouting, attempting to re-establish synapses.

By: Gan Quan Fu, PT

Autonomic Dysreflexia• Also known as

hyperreflexia, • Over-active Autonomic

Nervous System, which causes an abrupt onset of excessively high blood pressure.

• Usually due to compression of anterior cord

By: Gan Quan Fu, PT

Other Direct Clinical Manisfestation

• Postural Hypotension• Impaired Temperature Control• Respiratory Impairment• Spasticity• Bladder and Bowel Dysfunction• Sexual Dysfunction

By: Gan Quan Fu, PT

Indirect Impairments and Complications

• Respiratory complication (such as pneumonia)• Pressure sores• Deep Vein Thrombosis• Contractures

By: Gan Quan Fu, PT

Prognosis

By: Gan Quan Fu, PT

Prognosis• Influences on potential for recovery:

o Degree of pathological changes imposed by traumao Precaution taken to prevent further damage (eg during rescue)o Prevention of additional compromise of neural tissue from hypoxia and

hypertension during acute management.

• Formulation of prognosis is initiated after spinal shock has subside and is guided by whether or not the lesion is complete (in complete lesion, no motor improvement is expected other than which may occur from nerve root return.)

• Good prognosis for incomplete lesion. Improvement usually begins after the cessation of spinal shock.

• In time, rate of recovery will decrease and plateau will be reached. When no new muscle activity is observed for several weeks or months, no additional recovery can be expected. By: Gan Quan Fu, PT

Physiotherapy Examination

By: Gan Quan Fu, PT

Physiotherapy Examination

• Respiratory Examinationo Function of respiratory muscleso Chest Expansiono Breathing Patterno Cougho Vital Capacity

• Integument• Sensation• Tone and Deep Tendon Reflex• Manual Muscle Test and Range of Motion• Functional Status

By: Gan Quan Fu, PT

Physiotherapy Intervention

By: Gan Quan Fu, PT

Physiotherapy Intervention(Acute

Phase)• Emphasis on respiratory management • Prevention of indirect impairments and

complications• Maintaining ROM• Facilitate active movement in available

musculature

By: Gan Quan Fu, PT

Physiotherapy Intervention(Acute

Phase)• Respiratory Management

o Deep Breathingo Glossopharyngeal Breathingo Airshift Maneuvero Strengthening Exerciseo Assisted Cougho Abdominal Supporto Stretching, chest physiotherapy etc.

• Range of Motion and Positioning• Selective Strengthening• Orientation to the Vertical Position

By: Gan Quan Fu, PT

Physiotherapy Intervention (Active

Phase)• Emphasis of treatment on maximizing functional

independence• Initially includes basic skills eg: bed mobility,

transfer and wheelchair mobility• Progress to skills necessary for work, home and

community reentry.• Individuals who are not able to accomplish

specific functional task should be educated on how to instruct another person to perform task for them (eg: those with high cervical lesion)

By: Gan Quan Fu, PT

Physiotherapy Intervention (Active

Phase)• Continue Rx as in acute phase• Educate patient on self skin inspection (with

mirror)• Mat Activities

o Rollingo Prone on elbowso Sittingo Transfers, etc.

• Prescriptive wheelchairo Wheelchair Skills

• Ambulation• Functional Electrical Stimulation• Educate on prevention, health promotion, fitness

and wellness.By: Gan Quan Fu, PT

Take Home Message

• There is no specific recipe of treatment for SCI patients. ‘All intervention planned comes with appropriate reasoning and justification base on your assessment/examination’

By: Gan Quan Fu, PT

References• O’Sullivan. S.B. and Schmitz. T.J. (2008) ‘Physical

Rehabilitation’, 5th edn. Philadelphia; F.A. DAVIS COMPANY.

By: Gan Quan Fu, PT

By: Gan Quan Fu, PT