Concorde Career College Physical Therapist Assistant

1
Concorde Career CollegePhysical Therapist
Assistant

• PTA 150 Fundamentals of Treatment II
• Day 13 14
• Spinal Cord Injury

2
Lesson Objectives

• Describe the pathophysiology of spinal cord
  injury
• Describe physical and neurological disorders
  associated with spinal cord injury
• Identify functional outcomes for patients with
  spinal cord injury at various spinal cord lesion
  levels
• Describe physical therapy treatment interventions
  for patients with spinal cord injury

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Spinal Cord Injury

• 11,000 new SCI cases in the US yearly
• Etiology traumatic vs. nontraumatic
• Traumatic is most common MVA, fall, GSW
• Nontraumatic usually result from disease or
  pathological influence
• Vascular malfunctions (AVM, thrombosis, embolis)
• Vertebral subluxations (secondary to RA or DJD)
• Infections such as syphilis or transverse
  myelitis
• Spinal neoplasms
• Multiple sclerosis, amyotrophic lateral sclerosis

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Mechanism of Injury

• Indirect force produced by head or trunk movement
• Flexion force (head-on collision blow to back of
  head)
• Lateral flexion force
• Compression force (diving, falling objects)
• Hyperextension force (strong rear-end collision,
  fall hitting chin )
• Flexion and rotational force (rear-end collision
  with passenger rotated towards driver)
• Direct force trauma

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Types of Injury

• Complete (ISNCSCI)
• No motor or sensory functions is preserved in the
  sacral segments S4 to S5 (anal sensation and
  voluntary external and sphincter contraction)
• Partial/Incomplete
• Partial motor or sensory functions below the
  level of lesion

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Spinal Cord Injury (SCI)

• Partial or complete spinal cord lesion may result
  in
• Paralysis
• Paresis
• Sensory loss
• Altered autonomic nervous system function
• Altered reflex activity

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Spinal Cord Injury (SCI)

• Injury often accompanied by
• Fracture of the vertebra, body, laminae, spinous
  process
• Stretched or torn ligaments
• Disc herniation
• Disk compression
• Malalignment of spinal vertebrae

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Designation of Lesion Level

• American Spinal Injury Association (ASIA)
• International Standards of Neurological
  Classification of Spinal Cord Injury (ISNCSCI)
  standardizes the way in which severity of injury
  is determined
• Neurological Level most caudal level of spinal
  cord w/ normal motor sensory function
  bilaterally
• Motor Level most caudal level of spinal cord w/
  normal motor function bilaterally
• Sensory Level most caudal level of spinal cord
  w/ normal sensory function bilaterally

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ISNCSCI Scoring

• Motor
• Most caudal segment with normal motor function
  (B)
• Uses the same scale as MMT
• Cannot test one muscle and assume this represents
  an entire myotome
• Sensation
• Defined in the same way in terms of sensory
  function
• Usually tested with light touch and pin prick
• 0 absent,1 impaired, 2 normal

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ASIA Impairment Scale
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SCI Classification

• Tetraplegia/Quadriplegia
• Complete paralysis of all 4 extremities trunk
• Upper Motor Lesion
• C1 C8 (Trunk, Limbs)
• Paraplegia
• Complete paralysis of all or part of trunk both
  LEs
• Upper Motor Lesion
• T 1 T12, L1
• Lower Motor Lesion
• Below L1

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Clinical Syndromes

• Brown-Sequard Syndrome (incomplete)
• Hemisection of spinal cord
• Usually secondary to penetration wound GSW,
  stab
• Ipsilateral sensory loss of sensation, reflexes,
  vibration and position sense (lateral and dorsal
  columns)
• Contralateral sensory loss of pain and
  temperature sense (spinothalamic tract)
• Cauda Equina Injury
• Lesion is below L1 vertebra
• Peripheral injury (lower motor neuron injury)
• Flaccidity, absent reflexes

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Clinical Syndromes

• Anterior cord syndrome
• Injury site anterior spinal cord or ant. spinal
  artery
• Usually related to flexion injuries, compression
  from fracture, dislocation or cervical disc
  protrusion)
• Characterized by loss of motor function
  (corticospinal tract) pain and temp
  (spinothalamic tract)
• Central cord syndrome
• Injury site center of the spinal cord
• Most commonly occurs because of hyperextension
  congenital or degenerative narrowing of spinal
  canal
• Most common with hyperextension of cx region
• Posterior cord syndrome
• Injury site posterior spinal cord or posterior
  spinal artery

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Clinical Syndromes

• Posterior cord syndrome
• Injury site posterior spinal cord or posterior
  spinal artery
• Characterized by preserved motor function, sense
  of pain and temperature and light touch loss of
  proprioception and epicritic sensations (ie 2
  point discrimination) below the level of the
  lesion
• Sacral Sparing
• refers to incomplete lesion clinical signs
  include perianal sensation and external anal
  sphincter contraction

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Clinical Manifestations

• Spinal Shock
• Motor and Sensory Impairments
• Autonomic Dysreflexia
• Postural hypotension
• Impaired temperature control
• Respiratory Impairment
• Spasticity
• Bowel and Bladder dysfunction (Micturition Crede
  maneuver)
• Sexual Dysfunction

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Acute Medical Care

• Stabilize respiratory status
• C1 to C4 lesions effect the phrenic nerve
  diaphragm
• Patient placed on respiratory ventilator
• Minimize spinal shock and edema that results from
  the injury
• Steroids
• Control of hydration and nutrition to avoid over
  hydration and further cord necrosis

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Acute Medical Care

• Catheterization bladder
• Spinal stabilization
• Surgery to realign vertebra spinal cord
• Insertion of halo to head spine
• Rigid to semi-rigid cervical collar
• Thoracolumbarsacral Orthoses (TLSO)
• Immobilize patient in bed
• Stryker Frame, air support beds

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TLSO
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Spinal Cord Injury Disorders

• Respiratory Impairment
• Impairment is directly related to
• Lesion level
• Residual respiratory muscle function
• Additional trauma at time of injury
• Premorbid respiratory status
• Will be dependent on artificial ventilation or
  phrenic nerve stimulation with C1 C3 injury
• Low respiratory endurance (C4 to T12)
• Higher level lesions may result in difficulty
  with coughing

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Spinal Cord Injury Disorders

• Complete to partial motor and sensory dysfunction
  below the level of the lesion
• Autonomic Dysreflexia (Hyperreflexia)
• Deep Vein Thrombosis
• Inactivity diminished muscle contraction effect
  circulation
• Sympathetic Pain, Phantom Pain
• Dyesthesia
• Heterotrophic bone formation in soft tissue
• Orthostatic Hypotension (aka Postural
  Hypotension)
• ? in BP when assuming an erect or vertical
  position
• Caused by loss of sympathetic vasoconstriction
  and lack of muscle tone
• Example supine to sitting, sit to stand

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Spinal Cord Injury Disorders

• Pressure Sores/Decubitis Ulcer
• 2 ? sensation, difficulty w/ positional changes
• Motor Impairment
• Spasticity
• Varies in range, mild to severe
• Influence by internal and external stimuli
• Can be managed via drug therapy, injections,
  surgery
• Flaccidity
• Muscle weakness
• Muscle atrophy

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Spinal Cord Injury Disorders

• Bladder and Bowel Dysfunction
• UTIs are a common early complication
• Lesions above conus medullaris typically develop
  a reflexive/spastic bladder bowel (automatic
  bladder bowel)
• Conus Medullaris and Cauda Equina lesions
  typically develop a nonreflex/flaccid bladder
  bowel (autonomic bladder bowel)
• Calcium Absorption (renal calculi)
• Osteoporosis

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Spinal Cord Injury Disorders

• Contractures
• Autonomic Nervous System Disturbances
• Loss of thermal regulation
• Vasodilation does not occur in response to heat
• Vasoconstriction does not occur in response to
  cold
• Absence of sweating
• Often associated with compensatory excessive
  sweating above the level of the lesion-
  diaphoresis
• Flushing, headaches
• Sexual Dysfunction

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Spinal Cord Lesion Level Functional Outcomes

• Refer to OSullivan, Table 23.6, page 961

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C1 to C3

• Muscles preserved Face and Neck Muscles
• Respiration Ventilator dependent
• Bed Mobility Dependent
• Transfers Dependent
• Self Care Dependent (Groom, Dress, Bath, Feed) -
  Full time attendant
• Wheelchair Power, microswitch or sip-and-puff
  controls

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C4

• Muscles preserved All of above
• Diaphragm, Trapezius
• Endurance Low
• Bed Mobility Dependent
• Transfers Dependent
• Self Care Dependent
• Wheelchair Powered head/chin/mouth control or
  sip-and-puff control
• Attendant Care

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C5

• Movement preserved All of the above
• Scapula elevation, adduction
• Shoulder abduction, ER, flexion (limited)
• Elbow flexion supination
• Endurance Low
• Bed Mobility Dependent
• Transfers Dependent ? Assistance
• Self Care Dependent
• Wheelchair Powered with joystick or adapted UE
  controls or manual with hand rim projections

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Hand Rim Projections
Joystick
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C6

• Muscles preserved All of the above
• Scapular abduction upward rotation
• Shoulder flexion, extension, IR and adduction
• Forearm pronation
• Wrist extension (Tenodesis grasp)
• Endurance Low
• Bed Mobility Assistance (Rolling, Sit, Mobility)
• Transfers Assistance?Independent (Slide board)
• Self Care Assistance
• Wheelchair Powered or manual with projections or
  friction surface hand rims

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C7

• Movement preserved All of the above
• Elbow extension
• Wrist flexion
• Fingers extension
• Endurance Low
• Bed Mobility Independent
• Transfers Assistance ? Independent (Slide board)
• Self Care Assistance ? Independent
• Wheelchair Manual with friction surface hand
  rims

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C7 Continued

• Ambulation Spinal Orthoses, Long leg braces,
  Pelvic Band
• Drag to gait

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C8 to T1

• Movement preserved All of the above
• Full UE innervations including fine coordination
  strong grasp
• Endurance Low
• Bed Mobility Independent
• Transfers Independent
• Self Care Assistance/Independent
• Wheelchair Independent with manual chair
• Ambulation Spinal Orthoses, Long leg braces,
  Pelvic Band, Drag to gait

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T4 toT6

• Movement preserved All of the above
• Improved trunk control
• Pectoral girdle stabilization
• Endurance Increased
• Bed Mobility Independent
• Transfers Independent
• Self Care Independent
• Wheelchair Independent, improved skills
• Ambulation Minimal distances with assist
  bilateral knee-ankle-foot orthoses with spinal
  attachment

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T9 to T12

• Movement preserved All of the above
• Thoracic Extensors, Lower Abdominal Muscles
  (Flexion) Improved trunk control
• Endurance Increased
• Bed Mobility Independent
• Transfers Independent
• Self Care Independent
• Wheelchair Independent, used to conserve energy
• Ambulation Functional with bilateral long leg
  braces walker or crutches swing thru, 4 point,
  2 point gait

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L2 to L4

• Muscles preserved All of the above
• Hip flexion and adduction
• Knee extension (quadriceps)
• Endurance Increased
• Bed Mobility Independent
• Transfers Independent
• Self Care Independent
• Wheelchair Independent, used to conserve energy
• Ambulation Functional with bilateral KAFO and
  crutches 4 point, 2 point gait

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L4 to L5

• Muscles preserved All of the above
• Stronger hip flexion
• Stronger knee extension, weak knee flexion
• Improved trunk control
• Endurance Increased
• Bed Mobility Independent
• Transfers Independent
• Self Care Independent
• Wheelchair Independent used to conserve energy
• Ambulation (B) AFO w/ crutch or cane, 2 pt.
  gait

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PT Examination

• Respiratory Examination
• Integumentary examination
• Sensation
• Tone and DTR
• MMT
• ROM
• Functional Status

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SCI Outcome Measures

• Functional Independence Measure (FIM)
• Wheelchair Skills Test (OSullivan, pg 966)
• Examining walking ability
• SCI Functional Ambulation Inventory SCI-FAI
  (OSullivan, pg 967)
• Walking Index for Spinal Cord Injury (WISCI)

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Physical Therapy Intervention

• Respiratory Management
• Diaphragmatic breathing
• Glossopharyngeal breathing
• Assisted coughing
• Abdominal support
• Stretching pectorals and chest wall muscles
• Postural draining

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Physical Therapy Intervention

• ROM
• Spinal motion is normal in the acute phase
  depending on the level of injury
• ROM in supine prone (if cleared by MD)
• Less than full ROM of joints is often beneficial

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Physical Therapy Interventions

• Positioning
• Splints for wrist, hands fingers
• Ankle boots or splints
• Once cleared, tolerance to prone position is
  important
• Therapeutic Exercise
• Passive, Active Assistive, Active, Strengthening
  Functional exercises
• Must be aware of contraindications in acute phase

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Physical Therapy Interventions

• Orientation to vertical position
• Mat/Bed Exercises
• Achievement of stability within a posture
• ?
• Controlled mobility
• ?
• Skill in functional use

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Physical Therapy Interventions

• Mat/Bed exercises
• Often individual components of a functional skill
• Sequenced from easiest to most difficult
• Complete mastery of one skill is not always
  required to move on to the next skill
• Degree of independence and rate of progression
  depends on level of spinal lesion and the
  individual

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Physical Therapy Interventions

• Mat Programs Progression
• Rolling (Prone, Supine, Sidelying)
• Prone on elbows
• Prone on hands (paraplegia)
• Supine on elbows
• Pull ups (tetraplegia)
• Sitting (long sitting sitting at edge of bed)
• Quadruped
• Kneeling
• Transfers

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Physical Therapy Interventions

• Rolling
• Easiest to begin supine to prone
• If applicable, easier to roll towards weaker side
• Should always encourage independence, however
  adaptive devices may be used if unable to perform
  activity independently
• Bed rails, ropes, canvas ladders, trapeze

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Physical Therapy Interventions

• Rolling assists with bed mobility, pressure
  relief and dressing
• Rolling techniques
• Flexion of head neck w/ rotation for
  supine?prone
• Extension of head neck w/rotation for
  prone?supine
• Pendular motion with outstretched UEs
• Crossing the ankles
• Place pillows under the patients pelvis
• PNF patterns UE D1 Flexion, D2 Extension

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Physical Therapy Interventions

• Prone on elbows
• Assists with improved bed mobility preps for
  quadruped and sitting later
• Facilitates head, neck and shoulder girdle
  strength
• May need assistance from therapist initially
• Caution with thoracic and lumbar injuries!

49
Physical Therapy Interventions

• Prone on elbows activities
• Weightbearing improves shoulder stability
• Weightshifting lateral 1st, progressing to
  anterior and posterior movements
• Rhythmic stabilization
• Manually applied approximation
• Unilateral weightbearing on one elbow
• Strengthening the serratus anterior other
  scapular muscles

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Physical Therapy Interventions

• Prone-on-Hands
• Promotes extension of the hips and low back
• Assists with standing and ambulation
• Can use bolster, wedge, pillows to assist with
  tolerance and independence with position
• Activities may include weight shifting,
  approximation, scapular depression and prone push
  ups

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Physical Therapy Interventions

• Supine-on-Elbows
• Assists with bed mobility and preparing for long
  sitting, strengthens shoulder extensors and
  scapular adductors
• Assuming the position can be accomplished by
• Using abdominals if sufficient strength
• Wedging hands under hips, hooking thumbs into
  belt loops and pull up while lateral weight
  shifting
• Can be done from sidelying, lower elbow
  positioned first and then roll supine extending
  the opposite arm and landing on the elbow

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Physical Therapy Interventions

• Supine-on-Elbows activities
• Lateral weight shifting
• Side-to-side movement assists with aligning the
  trunk and LEs necessary for positional changes
• Be cautious of shoulder pain, ? pressure placed
  on the anterior shoulder joint capsule in this
  position

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Physical Therapy Interventions

• Pull-Ups
• Strengthens the biceps shoulder flexors
  necessary for wheelchair propulsion
• Patient is supine while therapist is squatting
  over the patient, therapist grabs the patients
  supinated forearms just above the wrists, patient
  pulls to sitting and then lowers back to the mat
• May also use a trapeze bar

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Physical Therapy Interventions

• Sitting
• Long and short sitting are essential for daily
  activities (dressing, transfers, WC mobility)
• Good sitting balance (static and dynamic) is
  necessary to progress to standing
• Sitting posture varies depending on level of
  lesion
• What does sitting look like for these patients?
• Patient with triceps and abdominal muscles
  initially find stability through shoulder
  hyperextension and ER, elbows and wrists extended
  and fingers flexed
• W/o tricep function, patients lock the elbows

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Physical Therapy Interventions

• How to get to a sitting position
• Start in supine-on-elbows, shift weight from
  side-to-side, with sufficient momentum the
  patient tosses one arm behind and bears weight on
  the hand, repeats with opposite arm pt. then
  walks the arms forward
• Start in prone-on-elbows, pt. creeps sideward
  using elbows and forearms, trunk in flexion
  allows the forearm to hook under knees and pulls
  them forward pt. tosses the opposite UE behind
  followed by the 2nd UE patient then walks arms
  forward

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Physical Therapy Interventions

• Sitting activities
• Initially, focus on maintaining the position
  mirror may provide helpful visual feedback
• Manual approximation at the shoulder
• Decrease UE support
• PNF
• Challenge limits of stability balloon tapping,
  ball throwing, reaching for cones
• Sitting push ups
• Movement within the sitting posture

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Physical Therapy Interventions

• Quadruped
• Important for progression to ambulation
• Initially position is assumed from the
  prone-on-elbows position
• Quadruped activities
• Maintaining the position
• Manual approximation
• Weight shifting in all directions
• Rocking
• Decreasing UE support
• Movement within the position

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Physical Therapy Interventions

• Kneeling Position
• Promotes trunk and pelvic control, good for
  upright balance and progression to ambulation
• Easiest to assume position from quadruped
• Patient can initially find UE support using a
  wall ladder, therapists shoulders and eventually
  mat crutches
• Kneeling activities
• Maintain the position
• Decrease UE support
• Weight shifting
• Hip Hiking

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Physical Therapy Interventions

• Transfers
• Initiated with achievement of adequate sitting
  balance
• Mat/bed to wheelchair
• Progression WC to toilet, shower chair, car,
  floor, stairs
• Lateral scoot transfer w/ or w/o slide board
• 3 important components of transfer
• Momentum
• Muscle substitution
• Head-hips relationship
• Helpful exercise to improve transfers push-ups

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Physical Therapy Interventions

• Wheelchair Mobilization/Prescription
• Manual or Powered, Tilt-in-space, Standing frame,
  Sport chairs
• Fitting the wheelchair
• Wheelchair skills
• Setting and releasing locks
• Removing foot and arm rests
• Forward, backward, turns, surfaces, wheelies for
  curbs
• Pressure relief techniques (discussed later in
  lecture)

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Physical Therapy Interventions

• Standing Progression
• Compression (corset) trunk and lower extremities
• Tilt Table
• Monitor Blood Pressure
• Start at 15 degrees
• Purpose of Tilt Table
• Aids circulation skin integrity
• Assists bowel and bladder function
• Weight bearing, diminishes bone demineralization
• May improve sleep
• Psychological benefits to be upright

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Physical Therapy Interventions

• Donning and doffing braces on mat/bed
• Sit to Stand Activities
• Practiced in parallel bars initially
• Progress from pulling up on bars to using arm
  rests on wheelchair to push to standing
• In upright position, patient pushes down on hands
  and tilts pelvis forward

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Physical Therapy Interventions

• Standing in Parallel Bars (braces)
• Balance Exercises
• Maintaining static balance in hips extended
  position
• Trunk flexion, trunk extension (with MD
  clearance)
• Weight shifting
• Eyes closed
• Releasing 1 hand support from the bar
• Placing hands in front of and behind the body
• Push up
• Push up and drag or swing body forward (beginning
  gait training)

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• Wheelchair that transitions to standing position

Standing Frame
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Physical Therapy Interventions

• Gait Training
• Be realistic with the patient
• Consider orthotic devices, assistive devices,
  adequate ROM, strength CV endurance
• Consider incomplete vs. complete SCI
• Other limiting factors spasticity, loss of PPC,
  pain
• Is the patient motivated?
• Start in parallel bars

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Physical Therapy Interventions

• Gait training Parallel Bar Activities
• Achieve adequate level of standing balance first
• Turning around
• Jack knifing
• Practice various gait patterns swing to, swing
  through, 2 point, 4 point

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Physical Therapy Interventions

• Progressing ambulation outside the parallel bars
• Choosing an AD
• Forearm crutches, walker, cane(s)
• Standing from wheelchair with AD
• Balancing with AD (crutches, walker w/incomplete)
• Practice different gait patterns, progress timing
  speed
• Travel activities
• Sideways, backward, turning, negotiating
  doorways/ elevators
• Practice with variable surfaces, indoors
  outdoors
• Stairs, curbs

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Ambulation after SCI Videos

• http//www.youtube.com/watch?vAQDCFMYGuGQ
• http//www.youtube.com/watch?vFf3QUler05A
• T3 injury with RGOs
• http//www.youtube.com/watch?vjJvxYQklHfs
• http//www.youtube.com/watch?vr3F_a_jqDmw
• http//www.youtube.com/watch?vBhWZajGXtPk

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Physical Therapy Interventions

• Fall Recovery training
• Locomotor Training
• Means of intensely practicing the distinct and
  specific task of walking (OSullivan, pg. 983)
• Provides the sensory experience of walking
• Body weight support treadmill training
• Means of progression
• Decrease body weight supported percentage
• Treadmill speed
• Amount of manual assistance

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Body Weight Support Systems
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Ambulation after SCI Videos

• http//www.youtube.com/watch?vAWj9O-oMFyo
• http//www.youtube.com/user/ryanclausing?blend24
  ob5p/u/0/E5s9uetONYw

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Physical Therapy Interventions

• Reinforcement of Bowel and Bladder Program
• Education regarding skin inspection
• Gradually the patient becomes more responsible
  for regular inspection
• Involves both visual inspection and palpation
  daily
• Use of a long handled mirror, wall mirrors
• Pressure relief
• 10-15 seconds of relief for every 10 minutes of
  sitting
• Techniques WC push ups, hook lean forward or
  sideways

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Areas Susceptible to Pressure

• Supine

• Prone

Sidelying

• Occiput
• Scapulae
• Vertebrae
• Elbows
• Sacrum
• Coccyx
• Heels

• Ears
• Shoulders
• Iliac Crest
• Male genital region
• Patella
• Dorsum of feet

• Ears
• Shoulders
• Greater Trochanter
• Head of Fibula
• Knees
• Lateral Malleolus
• Medial Malleolus

OSullivan, pg. 957 Table 23.5
74
Physical Therapy Interventions

• Reinforcement of Self Care Activities
• Grooming, Bathing, Dressing, Feeding,
• Recreation, Sports
• Energy Conservation
• Cardiovascular training
• Aquatic Exercises
• Patient and Family Education

75
Assess for Understanding

• What is the effect of Autonomic Dysreflexia
  (Hyperreflexia) and how does the therapist handle
  the situation?
• What are the symptoms of Autonomic Nervous System
  Disturbances/ increased sympathetic activity?
• Upper motor neuron spinal lesions are located
  between which spinal segments?
• Lower motor neuron spinal lesions are located
  between which spinal segments?

76
References

• Physical Rehabilitation, 5th ed., Susan B.
  OSullivan and Thomas J. Schmitz, 2007 F.A.
  Davis, Company. Chapter 23
• PTA Exam The Complete Study Guide, Scott M.
  Giles, 2011 Scorebuilders.
• PTA Examination Review and Study Guide, Karen
  Ryan and Becky McKnight, 2010 International
  Educational Resources.
• Functional Significance of Spinal Cord Lesion
  Level, C. Long MD E. Lawton PT, MA, Archives of
  Physical Medicine and Rehabilitation, September,
  1955.

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Peripheral Nerve System Disorders

• PTA 150 Fundamentals of Treatment II
• Day 12

78
Lesson Objectives

• Define peripheral nerve
• Discussing major functions of peripheral nerves
• List and describe the major peripheral
  neuropathies and their pathogenesis
• Discuss entrapment syndromes specifically naming
  each, identifying the structural considerations
  that are involved
• Discuss the fundamental rehabilitation of LMN
  lesions

79
Peripheral Nerve Defined

• Nerves outside the Central Nervous System
• Connects CNS to limbs and organs
• Provide motor and sensory function
• Cranial nerves and spinal nerves
• 31 pairs of spinal nerves

80
Terminology

• Neuropathies
• Myopathy
• Polyneuropathy
• Mononeuropathy
• Radiculopathy
• Causalgia
• Entrapment syndrome

81
Major Pathologies

• Bells palsy swelling/inflammation of facial
  nerve (CN VII)
• Usually caused by a viral infection
• SS facial droop, weakened taste, sound
  sensitivity, weak facial expressions
• Trigeminal neuralgia - compression of trigeminal
  nerve (CN V)
• AKA tic douloureux
• SS episodes of intense pain (like electric
  shock) in the face

82
Major Pathologies

• Poliomyelitis
• Viral infection
• SS flu like symptoms, loss of reflex, muscle
  ache/spasm, flaccid limbs
• Post-polio syndrome
• New onset of weakness and severe fatigue
  occurring years after recovery from acute
  poliomyelitis
• SS severe long lasting fatigue that does not go
  away with rest, new onset of weakness in muscles
  thought to be strong, new loss of functional
  abilities

83
Major Pathologies

• Guillian-Barre Syndrome
• Associated with autoimmune attack often occurs
  after recovery from an infectious disease
• Demyelinating LMN motor cranial and peripheral
  nerves
• SS weakness, tingling, loss of sensation,
  difficulty breathing progresses from lower
  extremities to upper extremities and from distal
  to proximal may result in quadriplegia and
  respiratory failure

84
Major Pathologies

• Myasthenia gravis
• Grave muscular weakness
• Autoimmune disorder in which there is a
  production of antibodies that combine with
  acetylcholine receptors at motor end plates
  destroys the receptor sites
• SS fluctuating weakness, usually affects eye
  movements first, more noticeable in proximal
  muscles, dysphagia, gagging, muscle function
  better after rest, fatigue, double vision

85
Major Pathologies

• Complex regional pain syndrome - vasomotor
  dysfunction to chronic sensory stimulus
• SS severe pain, swelling, changes in the skin,
  loss of motion
• AKA reflex sympathetic dystrophy
• Diabetic neuropathy/Peripheral Nerve Neuropathy -
  occurs with advanced diabetes mellitus, occurring
  in limbs
• Capillary fragility with diminished distal
  circulation
• Hypoesthesia of the feet and hands

86
Radicular pathology

• Foraminal stenosis - intervertebral foramen is
  narrowed by something such as osteophytes (bone
  spurs)
• Structural
• Functional
• Postural
• Activity dependent overhead work computer use

87
Entrapment syndromes

• Thoracic outlet syndrome
• Compression of the subclavian artery and vein,
  brachial plexus
• Neurovascular compression
• Cervical rib
• Postural and overuse of anterior chest wall
  muscles
• Cubital tunnel syndrome
• Entrapment of the ulnar nerve at the elbow

88
Entrapment syndromes

• Pronator teres entrapment
• AKA Pronator syndrome
• Median nerve compression at the pronator teres
  muscle
• Carpal tunnel syndrome (CTS)
• Entrapment median nerve at the wrist
• Usually caused by repetitive motions of the wrist
• SS numbness, tingling, pain, clumsiness with
  hand activity, weak grip, swelling

89
Entrapment syndromes

• Piriformis syndrome
• Entrapment of the sciatic nerve through or under
  the piriformis muscle
• Tarsal Tunnel Syndrome
• Tibial nerve entrapment at the medial aspect of
  the ankle
• Burning pain and paresthesias behind the medial
  malleolus that radiate to the plantar surface of
  foot

90
Rehabilitation

• P.R.I.C.E
• Protection from nerve compression
• Padding, positioning, splinting
• Resolve acute inflammation in area of nerve
  compression
• Cool to warm
• Gentle massage for swelling (instruct patient)
• Gentle compression wrapping

91
Rehabilitation

• Control repetitive motions and continuous
  pressures
• Normalize poor ergonomics and biomechanics of
  work, ADL and recreation
• Normalize posture and utilize assistive
  supporting devices as necessary

92
Rehabilitation

• Restore normal ROM and strength
• Take care not to overstretch nerve as this will
  increase symptoms
• Passive ROM to active resistive strengthening
• Maintain stability
• Support co-contraction and coordinated patterning
  
• EMG biofeedback
• Electrical stimulation for muscle re-education

93
Rehabilitation

• Normalize soft tissue mobility and resolve
  binding/entrapping scars
• Be very careful not to aggravate nerve
• Conditions that are long standing often require
  longer periods of rehab
• Ergonomic and biomechanics training

94
Rehabilitation

• Postural training
• Strategies for postural awareness
• Alignment - static using supportive devices
• Alignment dynamic stabilization within
  movement
• Proper alignment enhances proprioception, balance
  and economy of energy

95
Rehabilitation

• Sensory considerations
• Monitor skin for pressure and irritation in
  patients with hypoesthesia
• Pad and protect skin from pressure
• Frequent changes in position
• Aerobics training for enhanced skin circulation

96
Rehabilitation

• Sensory integration
• Desensitization
• TENS
• Increase sensory input of varying types and
  intensities
• Recognize normal by comparative contralateral
  awareness
• Recognize appropriate response and level
• Comparison to norms
• Comparison to functional ability

97
Summary

• Define peripheral nerve
• Discussing major functions of peripheral nerves
• List and describe the major peripheral
  neuropathies and their pathogenesis
• Discuss entrapment syndromes specifically naming
  each, identifying the structural considerations
  that are involved
• Discuss the fundamental rehabilitation of LMN
  lesions

98
Questions
99
References

• Physical Rehabilitation, 5th ed., Susan B.
  OSullivan and Thomas J. Schmitz, 2007 F.A.
  Davis, Company. Chapter 13