创伤性脊髓损伤物理治疗

nullPhysical Therapy for Adults with Traumatic Spinal Cord InjuryPhysical Therapy for Adults with Traumatic Spinal Cord InjuryAcknowledgement: International educators for the China Self-Directed Learning Modules MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjuryTraumatic Spinal Cord Injury (SCI) Traumatic Spinal Cord Injury (SCI) Majority of traumatic SCI occurs in young adult males Traumatic spinal cord injury is a non-progressive pathology Motor and sensory function on both right and left sides is determined by the level of injury A patient with C6 level injury has intact motor and sensory function bilaterally at and above the C6 level MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjurynullMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjuryTraumatic Spinal Cord Injury Traumatic Spinal Cord Injury Based on the International Standards for Neurological Classification of Spinal Cord Injury (published by the American Spinal Injury Association, ASIA), patients can be grouped in five categories depending on the severity of impairment from A to E A is complete spinal cord injury with no motor or sensory function below the level E is normal even though patient may have initially exhibited symptoms of spinal cord injury, but is now normal MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjurynullASIA Impairment Scale MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjuryTraumatic Spinal Cord Injury Traumatic Spinal Cord Injury Definitions Paraplegia – is defined as an impairment or loss of motor and/or sensory function of all or part of the trunk and both lower extremities Tetraplegia – is defined as an impairment or loss of motor and/or sensory function in both upper extremities in addition to trunk and both lower extremities; respiration is often affected MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjurySpinal Cord AnatomySpinal Cord AnatomySpine has 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal spinal nerves (levels) Spinal cord ends around L1 vertebral level The cervical spinal levels control sensory and motor function of head/neck and upper extremities and the diaphragm (phrenic nerve, C3-5) The thoracic spinal levels control chest and abdominal muscles and sensory function of the trunk The lumbar spinal levels control motor and sensory function of the lower extremities The sacral spinal levels control the sensory function of the back of lower extremity and buttocks, bowel and bladder control, and sexual functionMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjurySymptoms of Spinal Cord InjurySymptoms of Spinal Cord InjuryMotor impairment Paralysis or weakness of affected muscles (following the myotomes) Sensory impairment Loss or impaired sensation of affected areas (following the dermatomes)MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjurynullDermatomesMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjurySymptoms of Spinal Cord InjurySymptoms of Spinal Cord InjuryAutonomic dysreflexia Often occurs in patients with high level spinal cord injury (lesion level above T5) Caused by distended bladder, distended rectum, blocked catheter, or other stimuli about the sacral innervated area Patient shows flushed face, pounding headache, very high blood pressure, sweating above the level of injury, piloerection, slow pulse, and nasal obstruction (nasal voice) Autonomic dysreflexia is a medical emergencyMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjuryPiloerection or goosebumps on a human arm http://en.wikipedia.org/wiki/Goose_bumps Symptoms of Spinal Cord InjurySymptoms of Spinal Cord InjuryAutonomic dysreflexia is managed in the following way Don’t let the patient lie down Position the patient in sitting Check the catheter or tube for blockage Check the feet positions for twisted ankles or pinched toes Empty leg bag for urine if it is full Obtain immediate medical help MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjurySymptoms of Spinal Cord InjurySymptoms of Spinal Cord InjurySpasticity Most common in patients with cervical and thoracic level injuries Occurs below the level of lesion after the spinal shock period Poor venous return below the level of lesion that may result in orthostatic hypotension Bradycardia Impaired body temperature control Unable to regulate body temperature in response to environmental changes (stay under sun) Impaired ability to sweat below the level of lesion Impaired respiratory function Decreased tidal volume and vital capacity Impaired cough MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjurySymptoms of Spinal Cord InjurySymptoms of Spinal Cord InjuryBladder and bowel dysfunction for those patients with S2-4 involvement If not managed properly, patient will have urinary tract infections and ultimately kidney failure Must drink sufficient fluid and eat a high fiber diet Most patients can be trained to manage their bladder and bowel problems, including a schedule to void (every 4 hours) and to move bowel (once a day or once every other day) Sexual dysfunctionMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjurySymptoms of Spinal Cord InjurySymptoms of Spinal Cord InjurySecondary complications Pressure sores Deep vein thrombosis Pain Contracture Heterotopic ossification Osteoporosis MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjuryPrognosisPrognosisAfter stabilizing the spinal (vertebral column) injury, the patient should begin a comprehensive rehabilitation program Life expectancy is related to the severity of impairment Individuals with spinal cord injury classified between the *ASIA A to C levels and those with tetraplegia have shorter life expectancies Ref: American Spinal Cord Injury Association (ASIA) Classification http://www.asia-spinalinjury.org/elearning/ISNCSCI_Exam_Sheet_r4.pdf MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjurynullMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjuryMedical ManagementMedical ManagementEmergency care Keep the neck and trunk stabilized (use a cervical collar and back board) during transportation Surgery to stabilize fracture Often involves immobilization after the surgery (Halo device for cervical spine and body cast/jacket for thoracic or lumbar spine) Drugs To manage spasticity and pain To manage infectionsMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjuryPhysical Therapist’s ConcernsPhysical Therapist’s ConcernsPatients with traumatic spinal cord injury often develop pneumonia, urinary tract infection, and pressure sores Physical therapists must teach patients Ways to achieve a productive cough Proper bladder management program Daily skin inspection MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury物理治疗检查评估物理治疗检查评估确保脊髓损伤的位置是固定好的 病人可能存在其他损伤部位 确保病人在医学上是稳定的 关注生命体征 评估患者末梢循环情况，特备注意足部（桡动脉与足上动脉对比） 评估呼吸功能（肺活量） 吸气时相关肌肉 - 膈肌(膈神经, C3-5), 肋间外肌和辅助呼吸肌(T1-11), 腹肌 呼气时相关肌肉 - 腹肌, 肋间内肌, 膈肌 辅助呼吸肌对呼吸的影响 - 分别检查坐位、卧位下的情况 判断患者是否有呼吸机依赖MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury物理治疗检查评估物理治疗检查评估评估是否能够产生有效的咳嗽 咳嗽需要声门和呼吸肌的协调运动 评估 会话情况(发声情况) 评估 言语功能 患者可能在事故后存在脑外损伤，所以其言语功能可能受到损害 评估 感觉功能 基于感觉评估结果 遵循ASIA量表 MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury物理治疗检查评估物理治疗检查评估评估 肌力 基于肌力评估结果 使用MMT检查10块关键肌 MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury物理治疗检查评估物理治疗检查评估评估 肌张力 检查损伤节段以下的痉挛情况 颈髓或高位胸髓损伤患者常有痉挛 评估 运动范围 踝关节必须能背屈达一半以确保可以站立 腘绳肌必须有足够长度才能确保能穿裤子 (伸膝起码达110度 ) 髋关节后伸必须达到10度才能确保步行 必须要有全范围的肩关节后伸、外旋、内收，肘关节伸，前臂旋后，腕关节的背伸来确保能坐起 MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury物理治疗检查评估物理治疗检查评估肌腱的检查 查看指屈肌腱是否紧张短缩 当病人伸腕时，手指会有自动的屈曲(功能性抓握) MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injurynull有效长度的指屈肌腱才能允许患者有功能性抓握MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury物理治疗检查评估物理治疗检查评估评估 皮肤完整性 是否发红 局部温度升高、肿胀 开放性伤口 对于长期坐在轮椅上患者必须检查： 双侧坐骨结节 骶骨 尾骨 对皮肤易产生压疮部位要尤为关注（下一张幻灯片） MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injurynull容易产生压疮部位MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury物理治疗检查评估物理治疗检查评估直肠和膀胱功能 患者能否自己管理大小便或者自己通过辅助用品来清洁？ 功能性技能 翻身 坐起 床-轮椅转移 站立 步行-取决于损伤程度 MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury物理治疗检查评估物理治疗检查评估评估患者出院和家庭生活辅助用品 使用FIM量表或其他合适量表 * Ref: http://www.rehabmeasures.org/lists/rehabmeasures/dispform.aspx?id=889 MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjurynullMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury创伤性脊髓损伤患者一般管理规则创伤性脊髓损伤患者一般管理规则持续监测生命体征和循环情况来防止体位性低血压 强化损伤平面以上的肌肉力量 教会患者头部/躯干和上肢对于功能性活动的关系 患者积极寻找新的方式来达到完成功能性活动的目的 患者有体温自我调节障碍--当病人训练时保持治疗区域舒适MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury物理治疗师干预的目标物理治疗师干预的目标患者功能上独立 高位颈段损伤患者应当教会其直接照顾者 腰段和低胸段损伤的患者以独自转移为目标 慢性脊髓损伤患者，不管损伤平面在哪，都应选择轮椅来作为移动的主要工具来节省体力 患者应知道所有技能来预防压疮的发生与发展MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury物理治疗师的干预物理治疗师的干预呼吸功能管理 皮肤护理 早期肌力训练和关节活动度训练 床上运动 转移 坐起及坐位时活动 站立及站立时活动 步行 MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury呼吸功能管理呼吸功能管理如果可以，安静状态下使用腹式呼吸模式 深呼吸训练 吞咽呼吸 – 使用声门来吞咽一口空气到肺里面，以此增加吸气量。对于呼吸机依赖的患者可能有用 胸壁活动 在坐位下考虑腹肌的支持 (举例, 用一根绳索) 来改善静脉回流和增加血容量 体位引流，叩诊，振动排痰，吸痰 人工辅助咳嗽 治疗师或者患者把手放在上腹部 咳嗽随着手向上向内的压力同时快速进行MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjurynullAssisted CoughMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury呼吸功能管理呼吸功能管理高位颈段损伤患者( C3 及以上) 将依赖呼吸机进行呼吸 C3-5 损伤患者可能要在夜间睡眠时使用呼吸机 MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury皮肤护理皮肤护理患者（或护工）应该检查有压疮倾向的皮肤区域，至少一天一次 高位颈段损伤患者应当两小时翻身一次 轮椅应该有恰当的压力缓冲垫 骨盆应该放置在中立对称的位置上 在轮椅上患者应该每15分钟缓解下受压部位的压力(独自或者依靠帮助) 撑起 侧倾 前倾MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injurynull侧倾Side Lean撑起Push Up前倾Forward LeanMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjurySkin CareSkin CareIf the patient develops an ulcer, the patient should be referred to a wound care specialist to facilitate healing and to prevent infection Patient should not put pressure on the ulcer until it is healed - for example, a patient with a right greater trochanter ulcer cannot lie on the right side until the wound is healedMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjuryEarly Strengthening and Range of Motion ExercisesEarly Strengthening and Range of Motion ExercisesStrengthen all innervated muscles Watch for substitution For example, patient may use shoulder external rotators to substitute for elbow extensors Do not stretch Finger flexors to protect tenodesis Lower trunk muscles so that patient can lean on ligaments for sitting Stretch Hamstrings - to assure a straight leg raise to 100 degrees Hip flexors – to assure patient has 10 degrees of hip extension Ankle plantar flexors – to assure patient has 10 degrees of dorsiflexion MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjurySitting Sitting Patient usually experiences postural hypotension in sitting or standing Initially, bring the patient to sitting slowly Use an abdominal binder and elastic (pressure) stockings to assist venous return Gradually elevate the head and upper trunk in bed May also use a tilt-in-place wheelchair with elevating leg rests or a tilt table Biomechanical principles for mat activities Head-hips relationship Unweight the body part first before moving it Use momentum MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjurySittingSittingBe aware that the patient is using very small muscles (in upper extremities) to move a heavy load (the whole body) Protect patient’s shoulders and wrists from Day 1 of physical therapy - patients with chronic spinal cord injury often experience shoulder problems For scooting sideways or up and down in bed (or on mat), patients need to clear buttocks from the supporting surface in order to move - hence, patients with short arms and a long trunk will need push-up blocks for mat activities Patient need to learn the new center of mass for functional movementsMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjurySitting Sitting After the patient can tolerate sitting in the upright position, the patient can begin mat activities that may include Rolling from supine to prone Prone position Prone on elbows Prone to supine Supine to long sitting Scooting side to side in long sitting Scooting up and down in long sitting MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjurynullLong sitting, lean on upper extremities, shoulders in extension and external rotation, and elbows extended MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjurynullMoving sideways in long sittingMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjurySitting – Balance TrainingSitting – Balance TrainingPatient learns to use trunk ligaments Patient in long sitting on mat Lift one arm first Lift both arms Catch a ball with both arms Patient sits on a bench with feet flat on the floor and then Lift one arm Lift both arms Try to catch a ball MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjuryTransfer Mat to WheelchairTransfer Mat to WheelchairTetraplegia Usually needs a sliding board Paraplegia Often may do without a sliding board Park wheelchair at 45 degree angle to the mat and lock the wheels Remove arm rest and leg rest next to mat Use momentum to assist transfer Push down on supporting surface with both arms and at the same time twist head and trunk away from wheelchair Patient with lower extremity spasticity can bear weight on legs to ease weight on upper extremitiesMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjurynullPatient with paraplegia transferring from mat to wheelchair at the same heightMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjurynullPatient with paraplegia transferring from mat to wheelchair to a higher surface MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjurynullPatient assisted sliding board transfer: #1 - therapist assists the patient; #2 - patient place left hand on sliding boardMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjuryStandingStandingStanding program is good for the skeletal system and the cardiovascular system Check patient’s blood pressure in sitting first Patient may need abdominal binder and elastic stockings Start in parallel bars Patient may need lower extremity orthotics and/or spinal orthotic Patient first presses down on parallel bars, lifts one arm, and then lifts both armsMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjuryWalkingWalkingMust determine if walking is a reasonable goal For patients with a spinal cord injury, walking consumes a tremendous amount of energy Patients have strong upper extremity muscles, no contractures, and strong motivation are candidates for walking training Most patients are not going to be community ambulators Potential gait patterns Swing to Swing through Four point Two pointMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjuryWalkingWalkingPatients with a T12 above level will need bilateral knee and ankle orthoses (e.g. Craig Scott orthoses) to walk using a swing through or swing to gait Patients with a T12 or below level will need bilateral knee and ankle orthoses and can walk with a reciprocal gait pattern (four point or two point) Patients with an L4-5 level or below will need ankle foot lorthoses to walk reciprocally and are best candidates for reciprocal gait training Ref: Uustal H. and Baerga E Orthotics in Physical Medicine and Rehabilitation Board Review Cuccurullo S, Editor. New York: Demos Medical Publishing; 2004 MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjuryWheelchair Wheelchair Patients with a high cervical level injury may have difficulty sitting upright, due to postural hypotension, and will need a wheelchair with a reclining backrestMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjuryWheelchair Wheelchair Wheelchair should be fitted for each patient. It is not one size fits all patients. Patient should have a proper cushion providing sufficient pressure relief to ischial tuberosities. For patients who manually propel wheelchairs, lightweight and durability are two main considerations. MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjuryWheelchair Propulsion Techniques Wheelchair Propulsion Techniques Use a semicircular pattern Let the hand fall below the push rim during recovery Take a long, smooth propulsive stroke that the patient grasps and pushes as much of the push rim as possible Minimize the cadence and peak forces applied - slow, long pushes Manual wheelchair users often develop shoulder and wrist problems due to repetitive use Prevent these injuries by teaching the patient correct and biomechanically efficient propulsion techniques Reduce shoulder forces and moments during propulsion (protect shoulders) Use of all upper extremity muscles for propulsion (shoulder, elbow, wrist, and fingers)MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord InjurynullSemi-circular method of propulsionMODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury