Concorde Career College
Physical Therapist Assistant
PTA 150: Fundamentals of Treatment II
Day 13 & 14
Spinal Cord Injury
Concorde Career College
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
Concorde Career College
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
Concorde Career College
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
Concorde Career College
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
Concorde Career College
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
Concorde Career College
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
Concorde Career College
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
Concorde Career College
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
Concorde Career College
ASIA Impairment Scale
Concorde Career College
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
Concorde Career College
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
Concorde Career College
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
Concorde Career College
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
Concorde Career College
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
Concorde Career College
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
Concorde Career College
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
Concorde Career College
TLSO
Concorde Career College
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
Concorde Career College
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
Concorde Career College
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
Concorde Career College
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
Concorde Career College
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
Concorde Career College
Spinal Cord Lesion
Level &
Functional Outcomes
Refer to O’Sullivan, Table 23.6, page 961
Concorde Career College
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
Concorde Career College
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
Concorde Career College
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
Concorde Career College
Hand Rim Projections
Joystick
Concorde Career College
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
Concorde Career College
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
Concorde Career College
C7
Continued
 Ambulation: Spinal Orthoses,
Long leg braces, Pelvic Band
 Drag to gait
Concorde Career College
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
Concorde Career College
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
Concorde Career College
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
Concorde Career College
Concorde Career College
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
Concorde Career College
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
Concorde Career College
PT Examination
 Respiratory Examination
 Integumentary examination
 Sensation
 Tone and DTR
 MMT
 ROM
 Functional Status
Concorde Career College
SCI – Outcome Measures
 Functional Independence Measure (FIM)
 Wheelchair Skills Test
(O’Sullivan, pg 966)
 Examining walking ability:
 SCI Functional Ambulation Inventory SCI-FAI
(O’Sullivan, pg 967)
 Walking Index for Spinal Cord Injury (WISCI)
Concorde Career College
Physical Therapy Intervention
 Respiratory Management
 Diaphragmatic breathing
 Glossopharyngeal breathing
 Assisted coughing
 Abdominal support
 Stretching pectorals and chest wall muscles
 Postural draining
Concorde Career College
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
Concorde Career College
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
Concorde Career College
Physical Therapy Interventions
 Orientation to vertical position
 Mat/Bed Exercises
Achievement of stability within a posture
⇓
Controlled mobility
⇓
Skill in functional use
Concorde Career College
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
Concorde Career College
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
Concorde Career College
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
Concorde Career College
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 patient’s pelvis
 PNF patterns – UE D1 Flexion, D2 Extension
Concorde Career College
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!
Concorde Career College
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
Concorde Career College
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
Concorde Career College
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:
1. Using abdominals if sufficient strength
2. Wedging hands under hips, hooking thumbs into
belt loops and pull up while lateral weight shifting
3. Can be done from sidelying, lower elbow
positioned first and then roll supine extending the
opposite arm and landing on the elbow
Concorde Career College
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
Concorde Career College
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 patient’s supinated
forearms just above the wrists, patient pulls to sitting
and then lowers back to the mat
 May also use a trapeze bar
Concorde Career College
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
Concorde Career College
Physical Therapy Interventions
 How to get to a sitting position
Start in supine-on-elbows, shift weight from side-toside, 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
2. 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
1.
Concorde Career College
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
Concorde Career College
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
Concorde Career College
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
Concorde Career College
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
Concorde Career College
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)
Concorde Career College
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
Concorde Career College
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
Concorde Career College
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)
Concorde Career College
Wheelchair that transitions
to standing position
Standing Frame
Concorde Career College
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
Concorde Career College
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
Concorde Career College
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
Concorde Career College
Ambulation after SCI: Videos
 http://www.youtube.com/watch?v=AQDCFMYGuGQ
 http://www.youtube.com/watch?v=Ff3QUler05A
T3 injury with RGOs
 http://www.youtube.com/watch?v=jJvxYQklHfs
 http://www.youtube.com/watch?v=r3F_a_jqDmw
 http://www.youtube.com/watch?v=BhWZajGXtPk
Concorde Career College
Physical Therapy Interventions
 Fall & Recovery training
 Locomotor Training
 Means of intensely practicing the distinct and specific
task of walking (O’Sullivan, 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
Concorde Career College
Body Weight Support Systems
Concorde Career College
Ambulation after SCI: Videos
 http://www.youtube.com/watch?v=AWj9O-oMFyo
 http://www.youtube.com/user/ryanclausing?blend=
24&ob=5#p/u/0/E5s9uetONYw
Concorde Career College
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
Concorde Career College
Areas Susceptible to Pressure
Supine
Sidelying
Prone
 Occiput
 Ears
 Scapulae
 Shoulders
 Vertebrae
 Iliac Crest
 Elbows
 Male genital region
 Sacrum
 Patella
 Coccyx
 Dorsum of feet
•
•
•
•
•
•
•
 Heels
O’Sullivan, pg. 957 Table 23.5
Concorde Career College
Ears
Shoulders
Greater Trochanter
Head of Fibula
Knees
Lateral Malleolus
Medial Malleolus
Physical Therapy Interventions
 Reinforcement of Self Care Activities
 Grooming, Bathing, Dressing, Feeding,
 Recreation, Sports
 Energy Conservation
 Cardiovascular training
 Aquatic Exercises
 Patient and Family Education
Concorde Career College
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?
Concorde Career College
References
 Physical Rehabilitation, 5th ed., Susan B. O’Sullivan 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.
Concorde Career College
Peripheral Nerve System
Disorders
PTA 150: Fundamentals of Treatment II
Day 12
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
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
Terminology
 Neuropathies
 Myopathy
 Polyneuropathy
 Mononeuropathy
 Radiculopathy
 Causalgia
 Entrapment syndrome
Major Pathologies
 Bell’s palsy – swelling/inflammation of facial nerve
(CN VII)
 Usually caused by a viral infection
 S&S: facial droop, weakened taste, sound sensitivity,
weak facial expressions
 Trigeminal neuralgia - compression of trigeminal
nerve (CN V)
 AKA tic douloureux
 S&S: episodes of intense pain (like electric shock) in
the face
Major Pathologies
 Poliomyelitis
 Viral infection
 S&S: 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
 S&S: 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
Major Pathologies
 Guillian-Barre Syndrome
 Associated with autoimmune attack; often occurs
after recovery from an infectious disease
 Demyelinating LMN motor: cranial and peripheral
nerves
 S&S: 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
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
 S&S: fluctuating weakness, usually affects eye
movements first, more noticeable in proximal
muscles, dysphagia, gagging, muscle function better
after rest, fatigue, double vision
Major Pathologies
 Complex regional pain syndrome - vasomotor
dysfunction to chronic sensory stimulus
 S&S: 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
Radicular pathology
 Foraminal stenosis - intervertebral foramen is
narrowed by something such as osteophytes (bone
spurs)
 Structural
 Functional
• Postural
• Activity dependent – overhead work – computer use
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
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
 S&S: numbness, tingling, pain, clumsiness with hand
activity, weak grip, swelling
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
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
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
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
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
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
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
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
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
Questions
References
Physical Rehabilitation, 5th ed., Susan B. O’Sullivan
and Thomas J. Schmitz, 2007; F.A. Davis,
Company. Chapter 13