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

00000

00000

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

00000

00000

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

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.


10-1d Areflexia/




31-4w Hyperreflexia

(initial)



Spasticity


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.


10-1d Areflexia/




31-4w Hyperreflexia

(initial)



Spasticity


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.


10-1d Areflexia/




31-4w Hyperreflexia

(initial)



Spasticity


case study: spinal cord injury

Documents

upper body showering

sensory deficit

sensory score max

dela cruz

normal sensory motor

little fingers

independent travel

independent propulsion