A PROJECT Entitled “REHABILITATION IN PARAPLEGIA” Submitted To The Department Of Physiotherapy I.T.S PARAMEDICAL COLLEGE Affiliated To CHAUDHARY CHARAN SINGH UNIVERSITY, MERRUT In The Partial Fulfillment of Degree Of BACHELOR OF PHYSIOTHERAPY Guide Submitted By
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A PROJECT
Entitled
“REHABILITATION IN PARAPLEGIA”
Submitted To
The Department Of Physiotherapy
I.T.S PARAMEDICAL COLLEGE
Affiliated To
CHAUDHARY CHARAN SINGH UNIVERSITY, MERRUT
In The Partial Fulfillment of Degree Of
BACHELOR OF PHYSIOTHERAPY
Guide Submitted By Dr Shubhra Narang Vishakha puri
March 2010
CERTIFICATE
This is to certify that the project work entitled “REHABILITATION IN PARAPLEGIA” by VISHAKHA PURI BPT 2006-2010 Batch , Enroll No._____________has been completed in the partial fulfillment for the degree of Bachelor of Physiotherapy from C.C.S. University, Meerut, U.P., India. I recommend him/her for the award of BPT Degree.
DR.C.S.RAM
DIRECTOR
DEPT. OF PHYSIOTHERAPY
I.T.S PARAMEDICAL COLLEGE
CERTIFICATE
This is to certify that the project work entitled “REHABILITATION IN PARAPLEGIA” is conducted by VISHAKHA PURI in the partial fulfillment for the degree of Bachelor of Physiotherapy under my guidance and supervision .
GUIDE
Dr SHUBHRA NARANG
MPT NEUROLOGY
(i)
CERTIFICATE OF ORIGINALITY
I hereby declare that the project work entitled “REHABILITATION IN PARAPLEGIA ”
embodies the original work by me . This work in part or full has not been submitted to any
other university for award of degree. I shall not publish the contents of this project in part
or full without the written consent of my guide and college.
VISHAKHA PURI
B.P.T 2006-2010 Batch
Enroll. No. ________
(ii)
ACKNOWLEDGEMENT
I would like to express my sincerest gratitude to the following individuals without whom this study would have been unattainable.
I offer my sincerest gratitude to Dr. Shubhra Narang (M.P.T) whose guidance constructive concel , unmatchable suggestions and unstinted encouragement enlightened me throughout the project.
I express my heartiest gratitude to Dr. C.S. Ram , H.O.D , Department Of Physiotherapy , I.T.S Paramedical college for kindly permitting us to pursue research work.
I am thankful to Dr. M Thangaraj , Dr. Stuti Sehgal , Dr. Tanu Shrivastava , Dr. Kanika Govil , Dr. Ekta for their constant inspiration and support in pursuing the study .
I would like to thank my colleagues Ashish gautam , Pooja sinha , Priyenka tyagi and Yukti sharma for their co-operation in my project .
Remarkable co-operation and dedication by the subjects laid milestone for the success of project completion.
And finally thanks to all those who have contributed directly and indirectly towards this study.
VISHAKHA PURI
(iii)
DEDICATED
TO
MY PARENTS
AND
ALL MY FACULTY
(iv)
TABLE OF CONTENTS
Certificate ( Guide) iCertificate Of Originality ii
Acknowledgement iii
Dedication iv
List of figures v-vi
List of Tables vii
1) INTRODUCTION
Anatomy – The basis of injury classification
Epidemiology
Mechanism of injury
Designation of lesion level
2) TYPES OF LESIONS IN SPINAL CORD
Complete injury
Incomplete injury a) Central cord syndrome b) Anterior cord syndrome c) Brown sequard syndrome d) Posterior cord syndrome e) Cauda equine syndrome f ) Sacral sparing
Stages after spinal cord injury a) Stage of spinal shock b) Stage of reflex activity c) Stage of reflex failure
3) CLINICAL MANIFESTATIONS
Direct Impairments a) Autonomic dysreflexia b) Impaired temperature regulation c) Orthostatic hypotension d) Bladder dysfunction e) Bowel dysfunction
Indirect impairments a) Pressure sores b) Deep venous thrombosis c) Contractures d) Heterotopic ossification e) Pain
4) HOSPITAL MANAGEMENT
Prehospital management
Immediate management of patient with spinal cord injury a) transfer from the site of emergency b) assessment of ABCDE c) neurological status examination d) skin inspection e) temperature examination f) bladder function
Investigations
Fracture stabilization
Pharmacological management
5) REHABILITATIVE MANAGEMENT
Acute phase rehabiltation
Active phase rehabilitation
Transition phase of rehabilitation
( 6 ) BIBLIOGRAPHY
(7 ) APPENDICES
Appendix A
Appendix B
Appendix C
Appendix D
LIST OF FIGURES
Figure 1) : Etiology of spinal cord injury
Figure 2) : Types of thoracolumbar fractures
Figure 3) : Central cord syndrome
Figure 4) : Anterior cord syndrome
Figure 5) : Brown sequard syndrome
Figure 6) : Cauda equine syndrome
Figure 7) : Stage of spinal shock
Figure 8) : Autonomic dysreflexia
Figure 9) : Pressure sore
Figure10) : Deep venous thrombosis
Figure11) : Heterotopic ossification
(a) Hip
(b) Knee
Figure12) : Harrington rod
Figure13) : Jewett brace
Figure14) : Phenol peripheral nerve block
Figure15) : Negative pressure vacuum technique
Figure 16) : Elastic support stockings
Figure 17) : Tilt table
Figure 18) : Rolling
Figure 19) : Supine to long sitting position
Figure 20) : Prone on elbow position
Figure21) : Prone on hand position
Figure22) : Quadruped position
Figure23) : Kneeling position
(v)
Figure24) : Push up weight shift
Figure25) : Bed to wheelchair transfer
Figure26) : Wheelchair to bed transfer
Figure27) : Wheelchair to car transfer
Figure28) : Car to wheelchair transfer
Figure29) : Wheelchair to toilet transfer
Figure30) : Toilet to wheelchair transfer
Figure 31) : Wheelchair to bath seat transfer
Figure 32) : Bathseat to wheelchair transfer
Figure 33 ) : Oswestry standing frame
Figure34) : Orthosis prescribed in case of paraplegics
a) Knee ankle foot orthosis
b) Scott craig orthosis
Figure35) : Standing from wheelchair with crutches
a) Forward technique
b) Sideway technique
c) Backward technique
Figure 36) : Crutch balancing
Figure 37) : Ambulation activities with crutches
a) Swing to gait
b) Swing through gait
c) Four point gait
Figure38) : Partial body weight support treadmill
Figure39) : Functional electrical stimulation
(vi)
LIST OF TABLES
Table 1 : Etiology
Table 2 : Mechanism of injury
Table 3 : Pharmacological management of spasticity
Table 4 : Pharmacological management of pain
Table 5 : Correlation of complete injury levels and orthosis prescription
ABBREVIATIONS USED
LMN - Lower motor neuron UMN - Upper motor neuron SCI - Spinal cord injury DVT - Deep vein thrombosis PaO2 - Partial pressure of oxygen BP - Blood pressure CT Scan-Computed tomographic scan MRI - Magnetic resonance imaging IM - Intramuscularly IV - Intravenously TENS - Transcutaneous electrical nerve stimulation KAFO - Knee ankle foot orthosis RGO - Reciprocal gait orthosis AFO - Ankle foot orthosis FES - Functional electrical stimulation Ft - Feet # - Fracture N - Normal I - Intact PT - Performance timeRep - Repetitions Sec - Seconds H - Hold Res - Resistance
(vii)
CHAPTER 1
INTRODUCTION
( SIMILARLY FOR OTHER CHAPTERS)
Spinal cord injury is a central neurological disorder1 . It occurs due to damage to neurological
components in spinal cord occurring as a result of primary or secondary effects of disease or trauma 2. Spinal cord injury is a low incidence , high cost disability requiring tremendous changes in an individuals
life style3 . Normal events of life driving a car, diving into lake or walking down stairs can suddenly
results in life changing injury with physical and lifestyle constraints that totally refigure the realities of
daily life .
SPINAL CORD INJURY ANATOMY – THE BASIS OF INJURY CLASSIFICATION
The term spinal column refers to the vertebral column bones and disc that collectively
encases and protects the soft tissue of the spinal cord .The spinal cord is made up of nerve tracts
carrying signal back and forth between the brain and rest of the body4 .
Address: Railway Road, New Defence Colony, Muradnagar, Ghaziabad
Chief Complaint: Patient complaints of Low back pain since 3-4 months with the pain on the left side of
buttocks.
History of Past Illness
A) History of Previous similar Problem: Same type of illness occurs 2 year back, but the intensity of
episode was less problematic then present.
Any Previous traumatic History: History of fall from the stairs 2 years back.
History of Present Illness:
A) Episode of illness: The illness started 8-9 years back. The episode is of recurrent low back pain
with aggravation of symptom since 3-4 months. This is second episode of illness.
B) Onset : (i) Pathological-
a) Sudden - N b) Gradual -Y
(ii) Traumatic-
Mechanism of injury-
C) Site of pain: Pain is in lower lumbar region and the left side of buttocks
D) Is there is any radiation of pain: Yes/No-
If yes: where it goes- It radiated form the lower back to the left side of buttocks till mid of
thigh.
E) Is any paraesthesia / numbness / tingling sensation:
F) Most preferred position of the patient: Lying in the supine position.
G) Sleeping position of the patient: Patient preferred to lie in the right side lying position.
H) Mattress used: Hard Surface
I) Any other history: No
Medical History
Diabetes Y/N√
Hypertension Y/N√
Yes
No
Y
No
Cardiac disease Y/N√
Cancer Y/N√
Tuberculosis Y/N√
Infection Y/N√
Repetitive Coughing Y/N√
Any other medical problem Y/N√
Drug History
Past drugs History: No
Present drug History: On Phase Medications - Analgesic
Allergic to any Drug: No
Surgical History
Any surgery: Hysterectomy has been done 5 years back.
Date of Surgery: Not known
Any complication after Surgery: No.
Bed stay after Surgery: 15 -20 days.
Occupational History: - Home maker.
Personal History:
Smoking: No
Alcohol: No
Dietary Habits: Regular
History of Constipation: No
Other Details:
Fever: N
Malaise: N
Any other joint problem: N
Any bladder/ bowel symptoms like incontinence or retention N
Any respiratory problem N
Symptoms suggestive of major neurological disturbances N
Frequency of episodes of pain: 1 attack before 8 years
2 attack before 2 years
3 attack before 3 months
Intensity (VAS) (On first visit) - 9 out of max. of 10
Type of Pain:
Superficial- X
Deep- √
Nature of Pain:
Sharp- X
Dull- √
Aggravating Factors:
Pain is aggravated by prolonged sitting, standing, and bending forward.
Relieving Factors:
Patient got relief after lying in right side lying position.
Does pain aggravates with coughing, sneezing: N
(But previously it was present)
On Observation:
Body type: Ectomorphic
Mesomorphic
Endomorphic
Gait: Patient walks with the lordotic posture and takes precautionary measures during walking
to avoid the jerk.
Assistive device: No
Attitude of patient: Normal Tense Bored
Lethargic Over anxious
X o
√
X
√
X X
XX
Spinal posture:
Standing: Patient was having protruded neck with excessive lumbar
Lordosis.
Lying: Patient lies in supine lying position and avoids bending forward
while getting up from bed.
Spinal curvature:
Lumbar spine: Normal lordosis
Excessive lordosis
Flat back
Scoliosis
Sway back
Thoracic spine: Normal Kyphosis
Excessive kyphosis
Scoliosis
Any Step off sign: No.
Any presence of tuft of hairs: No
Others: No
On Palpation
X
√ √
X
X
X
X
√
X
Muscle tone (Lumbar muscle): Tone Increased
Tenderness: Present
Site: Left PSIS and L3-L4 spinous process.
Odema: Absent
Swelling: Absent
On Examination:
MOVEMENTS:
JOINT MOVEMENTS ACTIVE PASSIVE
LUMBAR FLEXION P, TR P,TR
EXTENSION NP NP
SIDE FLEXION LEFT RIGHT LEFT RIGHT
NP P NP P
ROTATION LEFT RIGHT LEFT RIGHT
NP NP NP NP
P- PAINFUL
NP- NON PAINFUL
IR-INITIAL RANGE
MR- MID RANGE
TR- TERMINAL RANGE
RANGE OF MOTION:
JOINT MOVEMENTS ACTIVE PASSIVE
LUMBAR SPINE Flexion 0-74* 0-75*
Extension 0-18* 0-20*
Side Flexion RIGHT LEFT RIGHT LEFT
62-47 62-49 62-48 62-50
*- signifies taken from the inclinometer
END FEELS:-
Lumbar Flexion: Tissue Stretch
Lumbar Extension: Tissue Stretch
Lumbar Side Flexion: Right Tissue Stretch
Left Tissue Stretch
Lumbar Rotation: Right Tissue Stretch
Left Tissue Stretch
JOINT MOVEMENTS ACTIVE PASSIVE
Right Left Right Left
HIP JOINT Flexion 0-100 0-100 0-110 0-110
Extension 0-15 0-15 0-15 0-15
Abduction 0-35 0-35 0-40 0-40
Adduction 0-20 0-20 0-25 0-25
Internal Rotation 0-35 0-35 0-35 0-35
External Rotation 0-45 0-45 0-45 0-45
END FEELS:-
Hip Flexion: Right- Tissue Stretch
Left- Tissue Stretch
Hip Extension: Right- Tissue Stretch
Left- Tissue Stretch
Hip Abduction: Right- Tissue Stretch
Left- Tissue Stretch
Hip Adduction: Right- Tissue Stretch
Left- Tissue Stretch
MANUAL MUSCLE TESTING OF LUMBAR SPINE
1) Abdominals : 4
2) Lumbar Extensors : 4
MANUAL MUSCLE TESTINGOF HIP
1) Hip Flexors: Left- 4+
Right- 4+
2) Hip extensors: Left- 4+
Right- 4+
3) Hip Adductors: Left- 4+
Right- 4+
4) Hip abductors: Left- 4+
Right- 4+
5) Hip Internal rotators: Left – 4+
Right- 4+
6) Hip External Rotators: Left- 4+
Right- 4+
MUSCLE LENGTH TEST:
Hamstring test: Normal
Rectus femoris test/ Ely’s test: Normal
MYOTOMES:
Affected myotomes are: L3, L5
DERMATOMAL EXAMINATION:
Affected Dermatomes are: L3, L4, L5
SPECIAL TEST:
SLR: Negative for neural tissue
Slump test- Positive
Prone Knee Bending – Negative
Bowstring test – Positive
Valsalva maneuver- Negative
ANY OTHER FINDINGS:
PROVISIONAL DIAGNOSIS:
Lumbar PIVD (L3, L4, L5) WITH RADICULOPATHY
INVESTIGATIONS:
MRI FINDING:
MRI reveals: Disc Degeneration at L4-L5 levels
Diffuse Posterior disc herniations with extrusion at L5-S1
Diffuse Posterior herniations with annular tear at L4-L5 level
Disc bulge at L3-L4
DIAGNOSIS:
LUMBAR PIVD (L3- L4-L5) without radiculopathy to left buttocks.
PHYSIOTHERAPY TREATMENT:
Treatment A: (10 DAYS)
1) Hot pack for 15 minutes
2) Interferential Therapy- 10 minutes, Four pole vector 45 degree scan, square waveform
3) Traction: 20 Kg, intermittent traction with hold time 5seconds and relax time 20 second for the
duration of 10 minutes is given in straight leg position.
Treatment B: (Next 10 DAYS)
1) Hot pack for 15 minutes
2) Transcutaneous Electrical Nerve Stimulation- HI TENS, 2 channels, 1st at the nerve roots of L3,
L4, and L5. 2nd channel at the nerve course at left buttocks for 15 minutes
Treatment C: (Next 5 days)
1) Ultrasound at the L4-L5 level- pulsed 1.2W/cm2 for 5minute and at the left sacroiliac joint pulsed
0.8 W/cm2 for 5 minutes
2) Transcutaneous Electrical Nerve Stimulation- HI TENS, two channels, one at the nerve roots of
L3, L4, and L5. two channel at the nerve course at left buttocks for 15 minutes
HOME PROGRAM AND ERGONOMICS:
1) Patient is advised to use the lumbosacral orthosis to support the back during travelling.
2) Patient is advised for hot fomentation at home.
3) Patient is advised to lying in prone lying position for at least 15 minutes duration twice in
a day.
4) Patient is explained about the proper sitting, standing, lying, and lying to standing, doing
the household activities in a proper way.
5) Patient is advised to take rest and to avoid the forward bending as much as the patient can
avoid.
Exercises:
Protocol A:
Pelvic tilting
Hamstring Stretching
Spinal Rotation
Calf Stretching
Neck Raising
Knee Rolling
These exercises are advised to be done twice daily for the 10 seconds hold time and 10
repetitions.
Protocol B:
Lying in extension
Extension exercises
Back and Gluteal exercise
PROGRESS NOTE:
Pain Reduction Progress: Visual Analog Scale (VAS):
Dated:
0 5 10
No pain Mild Pain Severe Pain
4/3/10- 5 out of max 10
9/3/10- 3 out of max 10
17/3/10- 1out of max 10
The patient had the treatment A for 10 days continuous then the patient pain subsided to the lower lumbar
back and slightly to the left buttocks area. All the lumbar muscle spasm has been also reduced.
After 10 days the Treatment plan B started and continued for the 7 days. Now the pain was reduced to a
limit and patient was able to do her ADL’s. Along with the treatment plan B, the patient was advised to
start the exercise protocol A. But the patient had the slight tenderness at the lower lumbar spinous
process.
After that the treatment plan C was started for 5 days.
Pictures Of assessment:
Posture assessment:
Tenderness checking: Fig 1 & 2
Fig 1 Fig 2
Two tender points: Fig 3
Fig 3
Lumbar movement assessment:
Lumbar flexion and extension Fig 4 & 5
Fig 4 Fig 5
Measurement of lumbar range by inches tape (schobber’s test)
Measuring Lumbar Flexion: Fig 6
Fig 6 fig 7
Measuring Lumbar Movement by Inclinometer:
Fig 8 Fig 9
Special test:
PKB Fig 10 Slump Test Fig 11
SLR Test Fig 12
APPENDIX
ASSESSMENT SCALES
Scale For Assessment Of Spinal Cord injury
ASIA Scale Impairment Scale
Scale For Assessment Of Spasticity
Spasm Frequency Scale Modified Ashworth Scale
Scale for Assessment Of Pressure Sore Risk
Bradens scale
Scales For Assessment Of Activities of Daily Living
Barthel Index Scale Functional Independence Measure Scale
Scale For Assessment Of Ambulation
Walking Index Scale For Spinal Cord Injury
ASIA Scale ( Standard neurological classification of spinal cord injury )
Impairment Scale
A - Complete : No motor or sensory function is preserved in the sacral segment
S4 -S5 level
B - Incomplete : Sensory but not motor function is preserved below the neurological
level and includes the sacral segments S4- S5
C - Incomplete : Motor function is preserved below the neurological level and more
than half of the key muscles below the neurological level have a
muscle grade less than 3 .
D- Incomplete : Motor function is preserved below the neurological level and at least
half of the key muscles below the neurological level have a grade of 3
or more
E- Normal : Motor and sensory function is normal
SCALES FOR ASSESSING SPASTICITY
Spasticity Rating Scale
Spasm Frequency Scale
0 - No spasms
1 - One spasm or fewer per day
2 - Between one and five spasms per day
3 - Between five and nine spasms per day 4 -
Ten or more spasms per day
Modified Ashworth Scale
0 - No increase in muscle tone
1 - Slight increase in muscle tone, manifested by a catch and release or by minimal
resistance at the end range of motion when the part is moved in flexion /extension
abduction or adduction
1+ - Slight increase in muscle tone, manifested by a catch, followed by minimal
resistance throughout the remainder (less than half) of the ROM
2 - More marked increase in muscle tone through most of the ROM, but the affected
part is easily moved
3 - Considerable increase in muscle tone, passive movement is difficult
SCALE FOR ASSESSING PRESSURE SORE RISK
Braden Scale
Patients Name _____________________________________
Evaluators Name
Name________________________________ Date of Assessment
Sensory perception
Ability to respond meaningfully to pressure-related discomfort
Completely Limited
Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished .level of consciousness or sedation / limited ability to feel pain over most of body
Very Limited
Responds only to painful stimuli . Cannot communicate discomfort except by moaning or restlessness / has a sensory impairment which limits the ability to feel pain or discomfort over 2 of body.
Slightly Limited
Responds to verbal commands, but cannot always communicate discomfort or the need to be turned / has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities.
No Impairment
Responds to verbal commands . Has no sensory deficit which would limit ability to feel or voice pain or discomfort .
Moisture
Degree to which skin is exposed to moisture
Constantly Moist
Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned.
Very Moist
Skin is often, but not always moist .Linen must be changed at least once a shift.
Occasionally Moist
Skin is occasionally moist, requiring an extra linen change approximately once a day.
Rarely Moist
Skin is usually dry, linen only requires changing at routine intervals.
Activity
Degree of physical activity
Bed fast
Confined to bed.
Chair fast
Ability to walk severely limited or non-existent . Cannot bear own weight and/or must be assisted into chair or wheelchair.
Walks Occasionally
Walks occasionally during day, but for very short distances, with or without assistance . Spends majority of each shift in bed or chair
Walks Frequently
Walks outside room at least twice a day and inside room at least once every two hours during waking hours .
Mobility
Ability to change and control body position
Completely Immobile
Does not make even slight changes in body or extremity position without assistance
Very Limited
Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.
Slightly Limited
Makes frequent though slight changes in body or extremity position independently .
No Limitation
Makes major and frequent changes in position without assistance.
Nutrition
Usual food intake pattern
Very Poor
Never eats a complete meal . Rarely eats more than a of any food offered . Eats 2 servings or less of protein (meat or dairy products) per day . Takes fluids poorly . Does not take a liquid dietary supplement /or maintained on clear liquids or IV for more than 5 days.
Probably Inadequate
Rarely eats a complete meal and generally eats only about 2 of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement / receives less than optimum amount of liquid diet or tube feeding
Adequate
Eats over half of most meals . Eats a total of 4 servings of protein (meat, dairy products per day . Occasionally will refuse a meal, but will usually take a supplement when offered / is on a tube feeding or TPN regimen which probably meets most of nutritional needs
Excellent
Eats most of every meal . Never refuses a meal . Usually eats a total of 4 or more servings of meat and dairy products . Occasionally eats between meals . Does not require supplementation.
Friction and shear
Problem
Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance . Spasticity , contractures or agitation leads to almost constant friction.
Potential Problem
Moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair, restraints or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down.
No Apparent Problem
Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move . Maintains good position in bed or chair.
SCALES FOR ASSESSING ACTIVITIES OF DAILY LIVING
Functional Independence Measure ( FIM SCALE )
The Functional Independence Measure (FIM) scale assesses physical and cognitive disability.
Fim scale
Self-care
1. Eating
2. Grooming
3. Bathing/showering
4. Dressing upper body
5. Dressing lower body
6. Toileting
7. Swallowing
Sphincters
1. Bladder management
2. Bowel management
Mobility
1. Transfers : bed/chair/wheelchair
2. Transfers : toilet
3. Transfers : bathtub/shower
4. Transfers : car
5. Locomotion : walking/wheelchair
6. Locomotion : stairs
7. Community mobility
Barthel index
Activity Score
Feeding
0 - unable
5 - needs help cutting, spreading butter, etc., or requires modified diet