Quadriplegia 2
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Transcript of Quadriplegia 2
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Faculty of physical therapy
Cairo University
QUADRIPLEGIA
Presented by:
Abeer abd elmoghny
Asmaa elsayedNermin mounir
Omnia Mohamed
Under supervision ofDr /GEHAN MOUSA
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Quadriplegia
Definition:
It is partial or complete paralysis involving all four limbs and trunk includingrespiratory muscles as a result of damage of the cervical spinal cord.
Causes of lesion:
Trauma to neck, back, spinal cord, or brain Whiplash in a motor vehicle collision Vertebral fracture crushing spinal cord, dislocation causing spinal
cord compression, or disc prolapse
Glioma A brain tumor that is created within the glial cells Metastatic tumors Cancer that spreads from bone to bone Multiple Myeloma A cancer of the white blood cells Osteoporosis A disease of the bone that induces fractures Multiple Sclerosis A disease of the immune system that attacks the
spinal cord
Acute disseminated encephalomyelitis An immune deficiencysimilar to Multiple Sclerosis that attacks the brain
Tuberculosis A deadly disease caused by mycobacteria that attacksthe immune system, bones, and joints
Types of lesion:
1) Complete: the damage is so extensive that no nerve impulses frombrain reach below the level of spinal cord
Loss of voluntary movement of parts innervated by segment, this isirreversible
Loss of sensation Spinal shock
2) Incomplete: where some or all of the nerves escape lesion injury.
Some function is present below site of injury More favorable prognosis overall Are recognizable patterns of injury, although they are rarely pure and
variations occur.
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Clinical picture:
The patient passes through two stages:
1) Spinal shock stage.
2) Spastic stage.
1) Spinal shock stage:
-Loss of consciousness. -Complete sensory loss below level of lesion. -Complete flaccid paralysis of all muscles. -Absence of bladder and bowel reflexes. -Abolishing of superficial & deep reflexes. -Respiration affection. -It may be last from hours to days or weeks (2 to 6 weeks)
depending on whether lesion is complete or incomplete, spinal orcerebral, high or low spinal lesion.
2) Spastic stage:
Gradually the cells in the isolated cord recover independent functionalthough no long controlled by the brain.
The reflexes return and the stage of spasticity begins.Spasticity in the lower limbs extensors more than in the upper limb flexors
(antigravity muscles)
Clinical picture according to level of injury:
C1 to C3 Injuries
Functional Movement
No movement in the arms or legs Very little movement in the neck and head (C3)Respiratory Care
Ventilator dependent for breathing Difficulty speaking clearly and loudly
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Mobility
Can operate a power wheelchair with mouthsticks, chin controls, sip andpuff, tongue controls, and possibly head controls
Power tilt recommended for pressure reliefDaily Living
Fully dependent on caregivers for everything Technology can substitutes many functional losses
C4 Injuries
Functional Movement
Head and neck control Can shrug the shouldersRespiratory Care
Typically not ventilator dependent Many initially require ventilator support but are able to be weaned off Quad cough assistance Patient with complete lesion at c4 has loss of vasomotor control as
result of paralysis of vasoconstrictors ,there is marked vasodilatation
;this causes blockage of nasal air passages which adds to the difficulties
of respiration without tracheostomy ,this phenomena known asGuttmanns sign.
Mobility
Can operate a power wheelchair with head controls or sip and puffcontrols
Daily Living
Fully dependent on caregivers for everything Technology can substitutes many functional losses
C5 Injuries
Functional Movement
Can move arms with shoulder and bicep muscles
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Respiratory Care
No ventilator assistance Quad cough assistanceMobility
Can operate a power wheelchair with hand controls Can operate a manual wheelchair for short distances on flat surfaces (e-
motion wheelchair is the best choice)
Power tilt recommended for pressure relief (manual pressure relief byleaning side to side)
Daily Living
Independence possible with specially designed equipment (drinking,eating, bathing, driving)
C6 Injuries
Functional Movement
Can move head, neck, arms, triceps, and wristsRespiratory Care
Quad cough assistanceMobility
Can use a manual wheelchair for most daily activities Power wheelchairs can be used for convenience No power tilt, can independently perform pressure reliefDaily Living
Independence achieved with training and specially designed equipment(drinking, eating, bathing, driving, turning in bed)
C7 and C8 Injuries
Functional Movement
Can move head, neck, arms, triceps, wrists, and has different degreesof finger function
Respiratory Care
Quad cough assistance
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Mobility
Can use a manual wheelchair Power wheelchairs can be used for convenience No power tilt, can independently perform pressure reliefDaily Living
Independence achieved with training and specially designed equipment(drinking, eating, bathing, driving, turning in bed, manual transfers,
household chores)
Initial management goals in spinal cord injury
1. Prevention of secondary injury and neurological deterioration. The key to
recovery is the number and quality of surviving axons traversing the injured
segment.
The spine should be immobilized. Secondary neuronal injury will be
minimized by maintaining spinal cord perfusion and oxygenation. SCI causes
a functional sympathectomy, the results of which are vasodilatation,
increased venous capacitance and relative hypovolemia, all of which
contribute to hypotension and reduced cord perfusion. Above T4 the
sympathetic drive to the heart is also lost resulting in loss of the ability to
increase cardiac output in response to hypotension. This neurogenic shock
may be exacerbated by hypovolemia due to other injuries Good oxygenationshould be maintained with ventilatory support as required. Systemic
hypotension should be corrected by volume replacement and vasopressors
to maintain the mean systemic arterial pressure at 90mmHg, and central
venous pressure at510mm .Neurogenic shock may be distinguished from
hypovolemic shock secondary to associated injuries by the presence of warm
peripheries and bradycardia.
2. Identification and management of associated injuries. The history and
examination will give clues to both these and the pattern of spinal injury that
is to be expected. The presence of head injury, limb fractures, peripheral
nerve injury, and spinal shock can make an accurate neurological
examination impossible during the initial assessment.
3. Determination of the degree and extent of neurological injury:
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(a) Sensory examination: at each of the key dermatomal points .Two
aspects of sensation are examined: pin prick and light touch. Sensation is
scored as absent (0), impaired (1), or normal (2) and a total score
calculated .Anal sensation is assessed by digital examination. Joint position
sense can also be recorded.
(b) Motor examination: each of the key myotome is assessed.
Treatment of the spinal injury itself is directed towards two parallel
concerns: restoration of spinal alignment/stability and promotion of
neurological recovery. These two aims are not independent; restoration of
alignment is important not only in preventing subsequent painful and
progressive deformity but also in facilitating neurological recovery
Conservative management
The basis of conservative management is fracture reduction and bed-rest
until the fracture is stable enough for mobilization. In the cervical spine
reduction can be achieved and maintained with traction. Following
mobilization, stability can be maintained by an external orthosis.
The role and timing of decompressive surgery
The timing and role of decompressive surgery is even more controversial.The single widely accepted indication for decompression is progressive
neurological deterioration due to spinal cord compression. There is strong
evidence that early decompression improves neurological recovery after SCI.
Even in the presence of an incomplete injury, the evidence for neurological
benefit from surgical intervention is not in controvertible.
Post-operative complications:
Skin Breakdown pneumonia Osteoporosis and Fractures Heterotopic Ossification Spasticity Urinary Tract Infections
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Autonomic Dysreflexia Deep Vein Thrombosis Pulmonary Embolism Orthostatic Hypotension
Cardiovascular Disease Neuropathic / Spinal Cord Pain
1) Pressure sores:
It is skin breakdown caused by unrelieved pressure that damages theskin and underlying tissue.
Stages of pressure sores and how to care forthem: Pressure sores are categorized into four key stages depending on
their age and severity. It is always wise to seek medical advice from a
Doctor or health care giver if you suspect the start of a pressure sore when
away from a hospital environment. As with most potential complications it is
best to intervene as early as possible to prevent the problem
worsening.
STAGE ONE
How to recognize:Skin is not broken but is red or
discolored. The redness or change in color does not fade within 30 minutes
after pressure is removed.
What to do:
1. Keep pressure off the sore!2. Maintain good hygiene. Wash with mild soap and water, rinse well, pat
dry carefully (but gently). Do not rub vigorously directly over the
wound.
3. Evaluate your diet -- are you getting enough protein, calories, vitaminsA and C, zinc and iron? All of these are necessary for healthy skin.
4. Review your mattress, wheelchair cushion, transfers, pressurereleases, and turning techniques for possible cause of the problem.
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5. If the sore seems to be caused by friction, sometimes a protectivetransparent dressing such as Op-Site or Tegaderm may help protect
the area by allowing the skin to slide easily.
6.If the sore does not heal in a few days or recurs, consult your Doctoror health care provider.
STAGE TWO
How to recognize:The epidermis or topmost layer of the
skin is broken, creating a shallow open sore. Drainage may or
may not be present.
What to do:Follow steps 1-4 under Stage One. Consult your health care
provider for further treatment, which may include the following:
Cleanse the wound with saline solution only and dry carefully. Applyeither a transparent dressing (such as Op-Site or Tegaderm), a
hydrocolloid dressing (such as DuoDERM), or saline dampened gauze.
The first two types of dressing can be left on until they wrinkle or
loosen (up to 5 days). If using gauze, it should be changed twice a day
and should remain damp between dressing changes.
Check for signs of wound healing with each dressing change. If there are signs of infection (see Signs of trouble), Doctor or health
care provider for alternative wound care ideas and review of possible
causes (see step 4 under Stage One).
STAGE THREE
How to recognize:The break in the skin extends through
the dermis (second skin layer) into the subcutaneous and fattissue. The wound is deeper than in Stage Two.
What to do:Follow steps 1-4 under Stage One and the additional steps
under Stage Two. Always consult your health care provider. Wounds in this
stage frequently need additional wound care with special cleaning or
debriding agents. Different packing agents, and occasionally, antibiotics
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(creams or oral pills) may be required. You may also qualify for a special bed
or pressure-relieving mattress that can be ordered by your Doctor or health
care provider.
STAGE FOUR
How to recognize:The breakdown extends into the
muscle and can extend as far down as the bone. Usually lots of
dead tissue and drainage are present.
What to do:Consult your Doctor or health care provider right away.
Surgery is frequently required for this type of wound.
Signs of an infected bed sore include:
Bad smell from the sore Redness and/or warmth around the sore Swelling around the sore area. Tenderness around the sore Yellow or green pus
Signs that the infection may have spread or be spreading:
General overall feeling of weakness Fever or chills Mental confusion or difficulty concentrating Rapid heartbeat
Prevention of bed sores:
Appropriate seating / equipment - It is important that anyequipment provided, such as seating or beds, give good support to allareas of the body - spreading load evenly.
Relieving pressure from areas at risk - Pressure should berelieved from the body at regular intervals - especially over bony
prominences or areas of concern.It is important to allow time for blood to flow normally to pressureareas so that skin cell oxygen levels can be restored. If a person
cannot change positions independently, they will need to be assistedby a care giver.
Appropriate manual handling techniques - To reduce theeffect of friction and shear on the skin, appropriate manual handling
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techniques and equipment need to be used. Slide sheets and hoists
can be useful to reduce shear when transferring or repositioningalthough a thorough risk assessment should be completed.
Using pressure relief equipment - Pressure relief equipmentmay include mattresses, cushions, bed cradles and joint protectors.
Some products may have a pressure relief rating to assist healthprofessionals choose the correct products for their client.
These ratings have been provided by the product's suppliers, and are
intended as a guide only. A full assessment by an appropriate healthprofessional in conjunction with product suppliers as required is
strongly advised.
Skin Management
Pressure sores are one of the worst potential complications of a spinal cord
injury. However with appropriate skin management techniques you can
prevent them.
In order to prevent skin sores, you must:
Check your whole body frequently Relieve skin pressure Take routine care of your skin
Check your whole body, but pay special attention to bony
areas: By inspecting your skin regularly, you can spot a problem at the
very beginning. Checking your skin is your responsibility and the way to
spot the warning signals of a problem. Don't just ask someone else how
your skin looks. If you need someone to help you check, you must be able
to tell him or her what to look for.
How
Often?
At least twice daily. Morning and evening
when dressing or undressing are
recommended.
Check more frequently if you are increasing sitting or
lying times.
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Relieve Skin Pressure: In addition to routinely checking your skin, a
second important way to prevent pressure sores is to relieve skin pressure
by changing position or being positioned so that pressure is taken off a bony
area. The purpose of relieving pressure is to let the blood supply get to the
Checking whenever you change position is
recommended
Watch
For?
Any areas previously broken and healed over - scar
tissue breaks easily.
What Are
You
Looking
For?
Redness, blisters, opening in skin, rashes, etc. Feel
for heat in red areas with the back of your fingers.
Equipment
Needed?
Long-handled mirrors. If you need help, ask
someone to position mirrors for you - one at thehead and one over the pressure point.
Which
Parts To
Check?
Check the areas shown in the diagram
below on the front, back, and sides of
your body.
Remember: Bony areas of the body are the most
likely to get sores, so be sure and look at them.
When checking your skin, don't forget your groin
areas for rashes or sores from tight clothing.
Men who wear an external catheter should check the
penis carefully for sores or irritations.
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skin. If pressure is not relieved, blood will continue to be pressed out of a
blood vessel and will not get to the skin to keep it healthy
Pressure Relief in a Wheelchair:Weight shifts are the most
essential techniques for preventing pressure on the skin and muscle of the
sacrum (tailbone) and each hip. Use the method you and your therapists
have found to be the most effective for you. Know your skin tolerance at all
times. The frequencies with which you do weight shifts vary from time to
time.
Cushions: A cushion for your wheelchair is essential. Cushions provide
pressure relief and weight distribution and thus aid in the prevention of
pressure sores. Many types of cushions exist, but there is no "ideal" cushion.
Use the cushion recommended by your physical therapist/physiatrist.
If air is used in the cushion, check to see that it is filled correctly. Ifyou are going to a different altitude, there will be a change in your
cushion.
If your cushion is made of foam, check to see that it is firm and ingood condition. If it gets dry, powdery and loses its firmness, replace
it immediately. Use only good quality foam. Polyurethane foam with a
density of 1.2 and compression of 30 to 35 is recommended.
In case of body weight change, you may need to change the width ofyour chair, the frequency of your weight shifts, and the type of cushion
you use.
Never use rubber air rings or rubber doughnuts. They are dangerous
because they block the flow of blood to the skin inside the leg. Weight shifts
are essential. The cushion alone will not prevent pressure sores.
In Addition:
Make sure the foot pedals of your wheelchair are adjustedto the right height for you. If your foot pedals are too
high, it will put pressure on your hips;
Sit up straight in your chair. Slumping or slouching leads to addedpressure over the end of your tailbone.
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Lifting your bottom from the wheelchair may be managed by liftingthrough your arms and taking your body weight for at least 30
seconds. If you don't have sufficient strength to do this yourself
assisted relief can be practiced by leaning forwards or to one side.
2) Respiratory problems:
Spinal cord injuries can weaken the abdominal and chest muscles;sometimes movement of these muscles is completely impaired. If
diaphragm muscles are completely paralyzed patient will beincubated and may have to stay on a ventilator for a period of time;
some people can learn to consciously breath and can thus stay offthe ventilator for periods of time.
Even if breathing is not directly impaired, pt is still at greater risk ofpneumonia. Pulmonary Embolism
PE - Pulmonary Embolism is caused by part of a Deep Veinthrombosis travelling from the leg to the lungs. This can lead to apartial or complete lung obstruction. Onset of a pulmonary
embolism can be sudden, with symptoms of shortness of breath, afast heartbeat, chest pain, or a blue tinge to the fingers, toes or
lips. Immediate medical assistance is necessary.
Managing respiratory complications: Respiratory exercises. Medication to prevent lung infection. Changing position frequently. Turning in the bed every 2 hours. Chest percussion
3)Osteoporosis and Fractures :
The majority of people with SCI develop osteoporosis. In peoplewithout SCI, the bones are kept strong through regular muscle activityor by bearing weight. When muscle activity is decreased or eliminated
and the legs no longer bear the body's weight, they begin to losecalcium and phosphorus and become weak and brittle. It generally
takes some time for osteoporosis to occur.
In people who use standing frames or braces, osteoporosis is less of aproblem. Generally, though, 2-4 years following SCI some degree of
bone loss will occur. Using the legs to provide support in transferring is helpful in increasing
the load on the bones, which may reduce or slow down theosteoporotic process. Standing using a standing frame or a standing
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table also helps prevent weakening of the bones and so does using
braces for functional or parallel bar walking. Newer techniques, such as electrical stimulation of the leg muscle may
decrease osteoporosis as well.
Unfortunately, at the present time, there is no way to reverseosteoporosis once it has occurred. The main risk of osteoporosis is
fracture. Once the bones become brittle, they fracture easily. Anosteoporotic bone takes much longer to heal.
Fractures are also a potential problem to the newly injured person
often caused by inappropriate handling of their limbs post injury too.
4) Heterotopic Ossification:
Heterotopic ossification is a condition not well understood that occurs inacute spinal cord injury and consists of the laying down of bone outside thenormal skeleton, usually occurring at large joints such as the hips or knees.
The primary problem with Heterotopic ossification, or HO, is the risk for jointstiffening and fusion. Should the hip or knee become fused in a certain
position, a surgical release is necessary to allow range of motion to occur.
Unfortunately, it takes between 12 and 18 months for Heterotopic bone tomature once it has developed.
Activities that are used to prevent the development of HO include range ofmotion programs and other functional activities that move the joints within a
functional range. Currently treatment is limited with the exception ofpreventing the joint fusion (termed amyloses)
5)Spasticity:
After spinal cord injury the nerve cells below the level of injury becomedisconnected from the brain. Following the period of spinal shock changes
occur in the nerve cells that control muscle activity. Spasticity is anexaggeration of the normal reflexes that occur when the body is
stimulated in certain ways. After spinal cord injury, when nerves belowthe injury become disconnected from those above, these responses
become exaggerated.
Muscle spasms, or spasticity, can occur any time the body is stimulatedbelow the injury. This is particularly noticeable when muscles are
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stretched or when there is something irritating the body below the injury.
Pain, stretch, or other sensations from the body are transmitted to thespinal cord. Because of the disconnection, these sensations will cause the
muscles to contract or spasm.
Almost anything can trigger spasticity. Some things, however, can makespasticity more of a problem. A bladder infection or kidney infection will
often cause spasticity to increase a great deal. A skin breakdown will alsoincrease spasms. In a person who does not perform regular range ofmotion exercises, muscles and joints become less flexible and almost anyminor stimulation can cause severe spasticity.
Some spasticity may always be present. The best way to manage orreduce excessive spasms is to perform a daily range of motion exerciseprogram. Avoiding situations such as bladder infections, skin
breakdowns, or injuries to the feet and legs will also reduce spasticity.
There are three primary medications used to treat spasticity, baclofen,Valium, and Dantrium. All have some side effects and do not completely
eliminate spasticity.
There are some benefits to spasticity. It can serve as a warningmechanism to identify pain or problems in areas where there is no
sensation. Many people know when a urinary tract infection is coming onby the increase in muscle spasms. Spasticity also helps to maintain
muscle size and bone strength. It does not replace walking, but it doeshelp to some degree in preventing osteoporosis. Spasticity helps
maintain circulation in the lefts. IT can be used to improve certainfunctional activities such as performing transfers or walking with braces.
For these reasons, treatment is usually started only when spasticityinterferes with sleep or limits an individual's functional capacity.
6) Urinary Tract Infections:
UTI - Urinary Tract Infection is a common complication for individuals with
voiding dysfunction. An infection occurs when bacteria grows in the bladder.
The most common way for a UTI to occur in individuals with spinal cord
injury is for bacteria to enter the bladder while catheterizing. Other ways arefrom delayed use of the toilet or incomplete emptying of urine.
Signs of a Urinary Tract Infection Fever Chills Pain with urination
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Increased spasticity. Blood in urine Cloudy urine
Bladder Management after SCI
Suprapubic Catheter:A tube is inserted through the abdomen and intothe bladder, where a balloon on the end holds it in place. It remains in thebladder and drains constantly, so the bladder is never full.
Indwelling Catheterizations: The bladder is drained by having atube inserted which then drains urine into a bag. Most commonly seen inearly hospital stage of rehabilitation and not normally used again unless
infection is a problem. Tube can be clamped to allow bladder muscle toexpand.
Intermittent Catheterizations: You drain your bladder several timesa day by inserting a small rubber or plastic tube. The tube does not stay in
the bladder between catheterizations. Several different discrete types ofintermittent catheter are available and this is one of the common preferred
methods of bladder management post hospital stay.
External Bladder Control Methods: Condom Drainage
A condom catheter is a way to drain the bladder without putting a catheter
(rubber tube) inside urethra. A condom catheter is a rubber sheath that isput over penis. It is also called a Texas catheter. The catheter allows bladderto empty without using a urinal, bedpan, or toilet. The condom catheter is
hooked to a plastic tube which leads to a bag. The urine stays in the baguntil it is emptied into the toilet.
External Continence Device (ECD)An ECD is a method of continence management that attaches only to the tip
of the penis using hydrocolloid, a hypoallergenic adhesive commonly used inwound care. Urine is directed into a collection bag and does not come in
contact with skin.
Spontaneous VoidingThe bladder muscles contract to start the bladder-emptying process. This
may be under your control (voluntary) or not (involuntary)
Normal Voiding
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This is done under control. When the bladder gets full, messages are sent to
the sacral level of the spinal cord and carried to the brain. The brain sendsmessages back to the bladder to contract and to the sphincter muscle to
open, so patient can void.
SphincterotomyThis surgical process weakens the bladder neck and sphincter muscle to
allow urine to flow out more easily. After this surgery, you will urinate
involuntarily, and must wear a collection device.
Stimulated VoidingVoiding is encouraged in one of several ways, such as: Anal or Rectal StretchThis method for relaxing the urinary sphincter is usually used along with anabdominal corset and valsalva
CredeThis method involves manually pressing down on the bladder. Tapping
The area over the bladder is tapped with the fingertips or the side of thehand, lightly and repeatedly, to stimulate detrusor muscle contractions and
voiding. Valsalva
This method involves increasing pressure inside the abdomen by bearingdown as if you were going to have a bowel movement.
Bladder Augmentation
Surgical enlargement of the bladder.
7) Autonomic Dysreflexia
It is related to disconnections between the body below the injury and the
control mechanisms for blood pressure and heart function. It causes theblood pressure to rise to potentially dangerous levels.
Causes of AD: Skin infection or irritations, cuts, bruises, abrasions Pressure sores (decubitus ulcer) Abdominal discomfort Bone fractures Full bladder Bladder infection Sever constipation
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Signs & Symptoms:
Pounding headache (caused by the elevation in blood pressure) Goose Pimples Sweating above the level of injury Nasal Congestion Slow Pulse Blotching of the Skin Restlessness Hypertension (blood pressure greater than 200/100) Flushed (reddened) face Red blotches on the skin above level of spinal injury Sweating above level of spinal injury Nausea Slow pulse (< 60 beats per minute) Cold, clammy skin below level of spinal injury
Treatment of AD:
The treatment for Autonomic dysreflexia involves removing the reasonfor the stimulation. One of the first things a patient can do is to sit up.This naturally decreases blood pressure. If there is a catheter in place, it
should be checked to be certain that there is not a kink in the tubing. If
there is not a catheter in place, the patient should be catheterized. Thebowels should be checked to be certain there is no stool in the rectum.
If the symptoms are caused by skin breakdown, the patient should getto an emergency department as soon as possible.
Prevention of AD:
The following are precautions can take which may prevent episodes of
Autonomic dysreflexia: Frequent pressure relief in bed/chair Avoidance of sun burn/scalds Maintain a regular bowel program. Well balanced diet and adequate fluid intake Compliance with medications Persons at risk and those close to them should be educated in the
causes, signs and symptoms, first aid, and prevention of autonomic
dysreflexia. If you have an indwelling catheter:
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o Keep the tubing free of kinkso Keep the drainage bags emptyo Check daily for grits (deposits) inside of the catheter.
If patient on an intermittent catheterization program, catheterization asoften as necessary to prevent overfilling.
If patient has spontaneous voiding, make sure he has an adequateoutput.
Perform routine skin assessments. All bladder and bowel related equipment should be kept clean.
8) Orthostatic Hypotension:
Orthostatic Hypotension - occurs when there is an inability for the circulatory
system to adapt to moving to an upright position.Treatment:
Wheel chair with elevated foot rest Tilting table
Physical therapy treatment:
Role of physical therapy in ICU:1) Improve / Maintain Normal or Baseline Ventilation and
oxygenation Clearance of Airways Improve Chest Expansion Improve Breath Sound Improve Cough Effectiveness Improve Breathing Pattern
2) Improve / Maintain Musculoskeletal System within functionalLimit.
Improve ROM Improve Muscle Strength and Endurance Prevent Joint Deformities and Contractures
3) Improve Circulatory System Function Prevent DVT Prevent Swelling
4) Improve / Maintain Neurological System and Cognitive statuswithin Functional Limits.
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5) Improve / Maintain Level of Functional Status within patient'stolerance.
Respiratory exercises:
(A) INTUBATED PATIENTS: (endotracheal tube ortracheostomy)Unconscious1. Pre-treat with bronchodilator if the patient presents with severebronchospasm (20 min. before treatment).
2. Modified postural drainage positions, usually with the head of the bed flatunless patient has an increase in intracranial pressure above 30 mmHg, then
the head of the bed should be elevated to 30 degrees.If there are no other contraindications then the following should be done:
Use pulmonary hygiene techniques to mobilize secretions such asvibration, percussion, rib springs and shaking.
Endotracheal suctioning to clear retained secretions using steriletechniques.
3. The best position for relaxation, decreased dyspnea and improved
ventilation and oxygenation are with the head of the bed elevated to 30
degrees and lying on well aerated lung.ConsciousProceed with the same procedures done with the unconscious patient, andthen encourage the following:
Independent efforts of inspiration and coughing Coordinate upper extremities mobility with inspiration and expiration
to improve lung expansion
(B) EXTUBATED OR NON-INTUBATED PATIENTSUnconsciousModified postural drainage position, usually with the head of the bedelevated to 30 degrees, and then performs the following:
1. If no contraindications, then use pulmonary hygiene techniques tomobilize secretions.
2. Use neurophysiological facilitation of respiration to facilitate deepbreathing, increase lung volume and increase thoracic expansion
3. Use tracheal tickle technique to elicit a cough, if not successful, then usenasopharyngeal suctioning to clear the retained secretions
5. Side lying is the best position to improve oxygenation and ventilation.
Conscious
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Modified postural drainage position, usually with head of the bed elevated to
30 degrees, and then encourages the following:1. Teach patient effective coughing and huffing to clear retained secretions.
2. If cough is non-effective and productive, then nasopharyngeal suctioningshould be performed using sterile techniques
3. If patient has restrictive lung disease, then teach patient segmental,sustained maximal inspiration, diaphragmatic breathing exercises and use of
incentive spirometer to increase lung volume.4. Teach patients with COPD pursed lip breathing exercises to decreasedyspnea and prolong exhalation phase.
ROM exercise
To avoid contractures and deformities, concentrate on the following:Unconscious1. Passive ROM of upper and lower extremities including prolongedstretching.2. Use of splints (by keeping most joints in the neutral or functional
position). Inhibitive casting or patients shoes can also be used.3. Proper positioning for all joints of the body.
ConsciousProceed with the same procedures done with the unconscious patient, inaddition to the following:
1. Active, active assistive ROM of upper and lower extremities.2. Strengthening exercises of upper and lower extremities.
Circulatory exercise
UnconsciousTo prevent DVT and swelling, concentrate on the following:
PROM, elastic bandage, compression unit and limb elevation.
Conscious
Proceed with the same procedures done with the unconscious patient inaddition to the following:1. Use ice pack to decrease swelling.
2. Encourage active exercise of all extremities and trunk
Orientation to the vertical position
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Once radiographic findings have established stability of the fracture site, or
early fracture stabilization methods are complete, the patient is cleared forupright activities.
Initially, upright activities can be initiated by elevating the head of the bedand progressed to a reclining wheel chair with elevating leg rests
Use of the tilt table provides another option for orienting the patient to thevertical position.
TILTING TABLEIndicationsPhysical therapists use tilt tables to provide early weight bearing experiencesfor patients too weak to stand on their own. Tilt tables also help patients
with orthostatic hypotension--a significant drop in blood pressure that occurswhen they move from a prone to a sitting position.
Procedure
To use a tilt table, the patient lies on top of the table on her back. Thephysical therapist secures the safety straps around the patient, and thenslowly elevates the table, putting the patient into a standing position, while
monitoring her blood pressure and heart rate throughout the treatment.Prevention
Tilt table treatments can prevent osteoporosis via weight bearing, as well asankle contractures, blood clots, pulmonary embolism and other bed rest
complications for the hospitalized patient.
Mat programs
1. Rolling : to begin training and to facilitate rolling ,several approachescan be used
Flexion of head and neck with rotation. Extension of head and neck with rotation. Bilateral ,symmetrical upper extremity rocking with outstretched arms Crossing the ankles2.Prone on elbows Weight bearing & weight shifting. Rhythmic stabilization. Manual approximation. Unilateral weight bearing onto one elbow. Forward, backward &side to side progression. Strengthening serratus anterior and other scapular muscles.
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3.Prone on hand: Lateral weight shifting Approximation Scapular depression and prone push up4.Supine on elbows: Lateral weight shifting. Side to side movement.5. Pull ups: the purpose of this activity is to strength the biceps and
shoulder flexors in preparation for wheel chair propulsion.
6. Sitting : Initial activities will focus on practice in maintaining the position,
during early sitting; a mirror may provide important visual feedback.
Manual approximation Balancing activities Sitting push up
TransferTransfer training is generally initiated once the patient has achievedadequate sitting balance
It is necessary prerequisite skill to many other functional activitiesTraining is usually initiated on a firm mat surface and progresses to
alternate surfaces by using a sliding transfer
Long range planning
An important aspect of long range rehabilitation planning involves educatingthe patient in life long management of the disability.
Consideration must be given to housing, nutrition, transportations, andfinance, maintaining functional skills and level of physical fitness & social or
recreational activities.
Sensory reeducation
It is a therapeutic program using sensory stimulation to help sensoryimpaired patients recover functional sensibility in the damaged areaand learn adequate functioning.
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Sensory reeducation uses a variety of therapeutic, rehabilitation andeducational techniques to help sensory impaired patient recoversensibility, fine discrimination abilities and the ability to perform other
tasks involved in daily living and work activities. Some forms of stimulation used are :
Electrical stimulation. Stroking the skin with frictional materials. Massage. Vibration Pressure. Tactile stimulation.