Case Study: SPINAL CORD INJURY
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Transcript of Case Study: SPINAL CORD INJURY
Cueto, Cunanan, Dadgardoust, Daguman, Damo, David, H.,
David, H., De Guzman, J., De Guzman, R., De Leon, De Mesa,
De Vera, Dela Cruz, C., Dela Cruz, F., Dela Cruz, I., Dela Rosa
excruciating pain could not move his trunk and lower extremities
immediately after hitting his head on the floor of the pool (sustained neuromuscular injury)
MMT◦ normal muscular strength (5/5) on both elbow flexor◦ moderate resistance (4/5)on both elbow extensors◦ both finger flexors can perform full range of motion with
gravity eliminated (2/5)◦ trace muscle contraction (1/5) of both finger extensors◦ no muscle contraction (0/5) on both lower extremities
(hip flexor, knee extensor, ankle dorsiflexor, long toe extensor, and ankle plantar flexor)
- 80% sensory deficit from little fingers for pinprick (fast pain) and light touch bilaterally- normal muscle stretch reflexes (MSR) on both upper extremities - absent muscle stretch reflexes on both lower extremities
Imaging: fracture dislocation of C7 to C8
• Most caudal neurologic segment of the SC that retains normal sensory & motor function in both sides of the body
• PE must record most caudal sensory and motor level on each side
• Key muscles/ dermatomes should be tested on each side (10 myotomes,28 dermatomes/side)
• Muscles are graded 0-5 (rostral to caudal)– MOTOR SCORE (max: 50/ side)
• Sensory : light touch/pinprick score: 0-2– SENSORY SCORE (max: 56/ side)
RECTAL EXAM – sensation in mucocutaneous region
COMPLETE LESION – absence of sensory/motor function in the lowest sacral segments
INCOMPLETE LESION – either sensory/motor function is preserved (SACRAL SPARING)
Sensory:◦ 80% sensory deficit from little fingers for both
pinprick & light touch bilaterally MSRs: ++ (B) UE
0 (B) (-) Bulocavernosus reflex Xray: C7-8 fracture dislocation
55421
55421
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No
C7 C7
Neurological level:
MOTOR
maximum: 56/side, 112/bilateral
80% sensory deficit from little fingers for both pinprick & light touch bilaterally
Neurological level:
SENSORY
C7 C7C7 C7
C7 C7C7 C7
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0 00
5 555
4 42 21 1
5 5 5 5
1 1 2 2 4 4
17 17 34
0 0 0
0 0 0 0 0 0
0 0 0 0
1 1 1 1 2 2 2 2
0 0 0 0
33 3333 33 66
66
X
Ability to feed self independently during mealtimes. Food may need cutting.
Able to make hot drinks , may require an adapted kettle using a "kettle tipper".
Independent in upper body showering and dressing, lower body dressing and showering may need assistance.
Independent in grooming, usually without palm straps.
Independent in upper body showering and dressing
Easier to dress upper body while in wheelchair
Some methods will be easier if you have good shoulder strength and relatively good
balance
Independent in oral/facial hygiene
lower body dressing and showering may need some assistance
May need help with bladder care (e.g. intermittent catheterization)
Shower chair is needed for safe bathing
Rectal stimulation for bowel movement
Independence in bed mobility transfers
May benefit from full electric hospital bed or full to king standard bed
- ability to transfer independently (bed to chair, chair to car)
- car transfers may need assistance depending on upper body strength (transfer board)
- may require assistance moving over uneven surfaces
Manual wheelchair : independent propulsion in the community ( short distances of flat surfaces)
Electrical wheelchair : for long independent travel or uneven outdoor surfaces (going over curbs)
Independent in standing (standing frame)
May need some assistance depending on body strength
• Independent level surface transfers (although they may require assistance with moving over uneven surfaces)
• Wheelchair use outdoors (power chair for school and work)
• Manual wheelchair propulsion in the community (with the exception of going over curbs)
• Propel chair (curbs and wheelies)• Wheelchair-to-car transfers
The FIMTM instrument refers to a scale that is used to measure one's ability to function with independence
score is collected within 72 hours after admission to the rehabilitation unit, within 72 hours before discharge, and between 80 to 180 days after discharge.
score ranges from 1 to 7, with 1 (Total Assistance) being the lowest possible score and 7 (Complete Independence) being the best possible score.
Self care Eating 1Grooming 3Bathing 1Dressing upper body
3
Dressing lower body 1Toileting 1
Sphincter control
Bladder management
1
Bowel management 1Transfers Bed, chair, wheel
chair1
Toilet 1Tub, shower 1
Locomotion Walking, wheelchair 1Stairs 1
Keith RA, Granger CV, Hamilton BB, et al. The functional independence measure: a new tool for rehabilitation. Adv Clin Rehabil. 1987;1:6-18.
Keith RA, Granger CV, Hamilton BB, et al. The functional independence measure: a new tool for rehabilitation. Adv Clin Rehabil. 1987;1:6-18.
Communication Comprehension 7Expression 7
Social interaction
Problem solving 7
Memory 7
Phenomena surrounding physiologic or anatomic transection of the spinal cord that results in temporary loss or depression of all or most spinal reflex activity below the level of the injury.
Reflex arcs above level of injury may be severely depressed Schiff-Sherrington phenomenon
Hypotension due to loss of sympathetic tone is a possible complication
Mechanism of injury that causes spinal shock is usually traumatic in origin
Flaccid paralysis (bowel and bladder) and occasionally, sustained priapism develops
End of the spinal shock phase of spinal cord injury is signaled by the return of elicitable abnormal cutaneospinal, bulbocavernosus reflex or muscle spindle reflex arcs
PHASE 1 Characterized by a complete
loss -- or weakening -- of all reflexes below the SCI.
The neurons involved in various reflex arcs normally receive a basal level of excitatory stimulation from the brain.
After an SCI, these cells lose this input, and the neurons involved become hyperpolarized and therefore less responsive to stimuli.
Time PE findingUnderlying physiological event
10-1d Areflexia/
HyporeflexiaLoss of descending facilitation
21-3d Initial reflex
returnDenervation supersensitivity
31-4w Hyperreflexia
(initial)
Axon-supported synapse growth
41-12m Hyperreflexia,
Spasticity
Soma-supported synapse growth
PHASE 2 Characterized by the return of
some, but not all, reflexes below the SCI. The first reflexes to reappear are polysynaptic in nature, such as the bulbocavernosus reflex.
Restoration of reflexes is not rostral to caudal as previously (and commonly) believed, but instead proceeds from polysynaptic to monosynaptic. The reason reflexes return is the hypersensitivity of reflex muscles following denervation -- more receptors for neurotransmitters are expressed and are therefore easier to stimulate.
Time PE findingUnderlying physiological event
10-1d Areflexia/
HyporeflexiaLoss of descending facilitation
21-3d Initial reflex
returnDenervation supersensitivity
31-4w Hyperreflexia
(initial)
Axon-supported synapse growth
41-12m Hyperreflexia,
Spasticity
Soma-supported synapse growth
PHASE 3 Monosynaptic reflexes, such
as the deep tendon reflexes, are not restored until Phase 3.
Phases 3 and 4 are characterized by hyperreflexia, or abnormally strong reflexes usually produced with minimal stimulation.
Interneurons and lower motor neurons below the SCI begin sprouting, attempting to re-establish synapses. The first synapses to form are from shorter axons, usually from interneurons.
Time PE findingUnderlying physiological event
10-1d Areflexia/
HyporeflexiaLoss of descending facilitation
21-3d Initial reflex
returnDenervation supersensitivity
31-4w Hyperreflexia
(initial)
Axon-supported synapse growth
41-12m Hyperreflexia,
Spasticity
Soma-supported synapse growth
PHASE 4 is soma-mediated, and as it
takes longer for axonal transport to push growth factors and proteins from soma to the end of the axon, it takes longer.
Time PE findingUnderlying physiological event
10-1d Areflexia/
HyporeflexiaLoss of descending facilitation
21-3d Initial reflex
returnDenervation supersensitivity
31-4w Hyperreflexia
(initial)
Axon-supported synapse growth
41-12m Hyperreflexia,
Spasticity
Soma-supported synapse growth