创伤性脊髓损伤物理治疗.ppt

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1、1,Physical Therapy for Adults with Traumatic Spinal Cord Injury,Acknowledgement:International educators for the China Self-Directed Learning Modules,MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury,2,Traumatic Spinal Cord Injury(SCI),Majority of traumatic SCI occurs in young adult malesTraumatic

2、 spinal cord injury is a non-progressive pathologyMotor and sensory function on both right and left sides is determined by the level of injuryA 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 Injur

3、y,MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury,4,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 sever

4、ity of impairment from A to EA is complete spinal cord injury with no motor or sensory function below the levelE 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 Injury,ASIA Impairment Scale,MODU

5、LE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury,6,Traumatic Spinal Cord Injury,DefinitionsParaplegia is defined as an impairment or loss of motor and/or sensory function of all or part of the trunk and both lower extremitiesTetraplegia is defined as an impairment or loss of motor and/or sensory fun

6、ction in both upper extremities in addition to trunk and both lower extremities;respiration is often affected,MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury,7,Spinal Cord Anatomy,Spine has 8 cervical,12 thoracic,5 lumbar,5 sacral,and 1 coccygeal spinal nerves(levels)Spinal cord ends around L1

7、vertebral levelThe 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 fun

8、ction of the lower extremitiesThe sacral spinal levels control the sensory function of the back of lower extremity and buttocks,bowel and bladder control,and sexual function,MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury,8,Symptoms of Spinal Cord Injury,Motor impairmentParalysis or weakness of

9、 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 Injury,Dermatomes,MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury,10,Symptoms of Spinal Cord Injury,Autonomic dysrefle

10、xiaOften 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 areaPatient shows flushed face,pounding headache,very high blood pressure,sweating above the level of injury

11、,piloerection,slow pulse,and nasal obstruction(nasal voice)Autonomic dysreflexia is a medical emergency,MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury,Piloerection or goosebumps on a human arm http:/,11,Symptoms of Spinal Cord Injury,Autonomic dysreflexia is managed in the following wayDont le

12、t the patient lie downPosition the patient in sittingCheck the catheter or tube for blockageCheck the feet positions for twisted ankles or pinched toesEmpty leg bag for urine if it is fullObtain immediate medical help,MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury,12,Symptoms of Spinal Cord In

13、jury,SpasticityMost common in patients with cervical and thoracic level injuriesOccurs below the level of lesion after the spinal shock periodPoor venous return below the level of lesion that may result in orthostatic hypotensionBradycardiaImpaired body temperature controlUnable to regulate body tem

14、perature in response to environmental changes(stay under sun)Impaired ability to sweat below the level of lesionImpaired respiratory functionDecreased tidal volume and vital capacityImpaired cough,MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury,13,Symptoms of Spinal Cord Injury,Bladder and bowe

15、l dysfunction for those patients with S2-4 involvementIf not managed properly,patient will have urinary tract infections and ultimately kidney failureMust drink sufficient fluid and eat a high fiber dietMost patients can be trained to manage their bladder and bowel problems,including a schedule to v

16、oid(every 4 hours)and to move bowel(once a day or once every other day)Sexual dysfunction,MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury,14,Symptoms of Spinal Cord Injury,Secondary complicationsPressure soresDeep vein thrombosisPain ContractureHeterotopic ossificationOsteoporosis,MODULE C4/CSD

17、LM/2013/NR Traumatic Spinal Cord Injury,15,Prognosis,After stabilizing the spinal(vertebral column)injury,the patient should begin a comprehensive rehabilitation programLife expectancy is related to the severity of impairmentIndividuals with spinal cord injury classified between the*ASIA A to C leve

18、ls and those with tetraplegia have shorter life expectanciesRef:American Spinal Cord Injury Association(ASIA)Classification,MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury,16,MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury,17,Medical Management,Emergency careKeep the neck and trunk stabili

19、zed(use a cervical collar and back board)during transportation Surgery to stabilize fractureOften involves immobilization after the surgery(Halo device for cervical spine and body cast/jacket for thoracic or lumbar spine)Drugs To manage spasticity and painTo manage infections,MODULE C4/CSDLM/2013/NR

20、 Traumatic Spinal Cord Injury,18,Physical Therapists Concerns,Patients with traumatic spinal cord injury often develop pneumonia,urinary tract infection,and pressure soresPhysical therapists must teach patientsWays to achieve a productive coughProper bladder management programDaily skin inspection,M

21、ODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury,19,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,2

22、0,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,21,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,22,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

23、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,23,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 Injury,有效长度的指屈肌腱才能允许患者有功能性抓握,M

24、ODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury,25,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 Injury,容易产生压疮部位,MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury,27,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

25、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,28,物理治疗检查评估,评估患者出院计划和家庭生活辅助用品使用FIM量表或其他合适量表*Ref:=889,MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury,MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury,30,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/

26、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,31,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,32,物理治疗师的干预

27、,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,33,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 Trau

28、matic Spinal Cord Injury,Assisted Cough,MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury,35,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,36,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

29、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 Injury,侧倾Side Lean,撑起Push Up,前倾Forward Lean,MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury,38,Skin Care,If the patient develops an ulcer,the patient should be referred to a wound care specialist to facilitate healing and

30、to prevent infectionPatient 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 healed,MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury,39,Early Strengthening and Range of Motion Exerc

31、ises,Strengthen all innervated musclesWatch for substitutionFor example,patient may use shoulder external rotators to substitute for elbow extensorsDo not stretchFinger flexors to protect tenodesisLower trunk muscles so that patient can lean on ligaments for sittingStretch Hamstrings-to assure a str

32、aight leg raise to 100 degrees Hip flexors to assure patient has 10 degrees of hip extensionAnkle plantar flexors to assure patient has 10 degrees of dorsiflexion,MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury,40,Sitting,Patient usually experiences postural hypotension in sitting or standingIn

33、itially,bring the patient to sitting slowlyUse an abdominal binder and elastic(pressure)stockings to assist venous returnGradually elevate the head and upper trunk in bedMay also use a tilt-in-place wheelchair with elevating leg rests or a tilt tableBiomechanical principles for mat activitiesHead-hi

34、ps relationshipUnweight the body part first before moving itUse momentum,MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury,41,Sitting,Be aware that the patient is using very small muscles(in upper extremities)to move a heavy load(the whole body)Protect patients shoulders and wrists from Day 1 of

35、physical therapy-patients with chronic spinal cord injury often experience shoulder problemsFor 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

36、 mat activitiesPatient need to learn the new center of mass for functional movements,MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury,42,Sitting,After the patient can tolerate sitting in the upright position,the patient can begin mat activities that may includeRolling from supine to proneProne p

37、ositionProne on elbowsProne to supineSupine to long sittingScooting side to side in long sittingScooting up and down in long sitting,MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury,Long sitting,lean on upper extremities,shoulders in extension and external rotation,and elbows extended,MODULE C4/

38、CSDLM/2013/NR Traumatic Spinal Cord Injury,Moving sideways in long sitting,MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury,45,Sitting Balance Training,Patient learns to use trunk ligamentsPatient in long sitting on matLift one arm firstLift both arms Catch a ball with both armsPatient sits on a

39、 bench with feet flat on the floor and thenLift one armLift both armsTry to catch a ball,MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury,46,Transfer Mat to Wheelchair,TetraplegiaUsually needs a sliding boardParaplegiaOften may do without a sliding boardPark wheelchair at 45 degree angle to the

40、mat and lock the wheelsRemove arm rest and leg rest next to matUse momentum to assist transferPush down on supporting surface with both arms and at the same time twist head and trunk away from wheelchairPatient with lower extremity spasticity can bear weight on legs to ease weight on upper extremiti

41、es,MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury,Patient with paraplegia transferring from mat to wheelchair at the same height,MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury,Patient with paraplegia transferring from mat to wheelchair to a higher surface,MODULE C4/CSDLM/2013/NR Traumati

42、c Spinal Cord Injury,Patient assisted sliding board transfer:#1-therapist assists the patient;#2-patient place left hand on sliding board,MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury,50,Standing,Standing program is good for the skeletal system and the cardiovascular systemCheck patients bloo

43、d pressure in sitting firstPatient may need abdominal binder and elastic stockingsStart in parallel barsPatient may need lower extremity orthotics and/or spinal orthoticPatient first presses down on parallel bars,lifts one arm,and then lifts both arms,MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord In

44、jury,51,Walking,Must determine if walking is a reasonable goalFor patients with a spinal cord injury,walking consumes a tremendous amount of energyPatients have strong upper extremity muscles,no contractures,and strong motivation are candidates for walking trainingMost patients are not going to be c

45、ommunity ambulators Potential gait patternsSwing toSwing throughFour pointTwo point,MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury,52,Walking,Patients 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 gaitPatie

46、nts 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 trainingRef:Uustal H.and

47、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 Injury,53,Wheelchair,Patients with a high cervical level injury may have difficulty sitting upright,due to postural hypoten

48、sion,and will need a wheelchair with a reclining backrest,MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury,54,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 tuberosi

49、ties.For patients who manually propel wheelchairs,lightweight and durability are two main considerations.,MODULE C4/CSDLM/2013/NR Traumatic Spinal Cord Injury,55,Wheelchair Propulsion Techniques,Use a semicircular patternLet the hand fall below the push rim during recoveryTake a long,smooth propulsi

50、ve stroke that the patient grasps and pushes as much of the push rim as possibleMinimize the cadence and peak forces applied-slow,long pushesManual wheelchair users often develop shoulder and wrist problems due to repetitive usePrevent these injuries by teaching the patient correct and biomechanical