|Where is injury for incomplete tetra/paraplegia?
||Above the neck
|Where is injury for complete tetra/paraplegia?
||Below brachial plexus
|Where are most frequent levels of injury? Why?
||C5 with C4, C6, T12 following in frequency
C5-7, T4-7, T10-L2
*Mostly C5 bc it is apex of lordosis, also involvement at C4 & C6.
T12 bc transitional vertebra– from kyphosis to lordosis
|Which ASIA patients are most likely to be employed?
||Those with Asia D (least involved)
|Employment: Do pts who are employed tend to work F/t? Which jobs do they return to if they return w/in one year? Who has greater likelihood of returning to work?
||Full time; Return to same job; Younger, male, white, more formal education, higher IQ
|What influences return to work?
||Type of injury, Support at work & home, Position/Type of work
|Philosophy of Rehab
||restoration thru personal health services of handicapped ppl to the fullest physical, mental social & economic usefulness of which they are capable, including ordinary treatment treatment in special rehab centers.
|The Team Approach
||Members: PT, OT, Speech, Vocational Rehab, Nurse, Physiatrist, Psychologist, Social Worker
|Achievement of Goals
||1. Evaluate (at baseline, see what they can do) 2. Develop a program (based on pt's goals) 3. Motivate & Direct (encourage, be a cheerleader)
|Individual Vertebrae: Structure
||2 Lamina + 2 Pedicles form transverse processes; Vertebral arches (?) form spinous processes
|Where are discs found?
||Bt C2/C3 –>L5/S1
|Where are ligaments found?
||Bt vertebral bodies
|What are the ligaments of the spinal column?
||Anterior Longitudinal Ligament;
Posterior Longitudinal Ligament;
Ligamentum Flavum (bt Lamina);
Supraspinous Ligament (tip of spinous processes);
Interspinous Ligament (bt spin processes);
Intertransverse Ligament (bt trans proces
|Where does spinal cord go from & to?
||Medulla spinalis- caudal continuation of brain. Exits occiput from foramen magnum–>L1L2. No cord at L4L5 so we do spinal tap here
|Spinal Nerve Roots- talk about them
Anterior root: ventral-efferent;
posterior root: dorsal- afferent.
Some "paired spinal segment" of nerve roots exit horizontally, some more obliquely (almost vertical) at bottom
|What are Meninges layers & where is CSF housed?
Arachnoid mater- subarachnoid space houses CSF;
|How long is spinal cord? How much does it weigh?
||45 cm in males & 42 cm in females; ~30 grams.
|Inner organization of vertebra
||Gray vs white matter; Columns anterior, posterior & two lateral & tracts. (know which column each tract is in)
|What does nerve room come out of?
||Nerve root comes out from correct segment. Cord segment of spinal cord does not match bone it sits on- difference bt neurological cord segment & its location compared to the bone it sits on.
|Anatomical Relationships bt the Spinal Cord & the Vertebral Column
||Cd seg: Vert Bdies: Spin Proc:
C8 LowC6/UprC7 C6
T6 LowT3/UprT4 T3
T12 T9 T8
L5 T11 T10
S T12/L1 T12
|Rules for Anatomical Relationships bt the Spinal Cord & the Vertebral Column
||Cord comes out above same # vertebra, then switches at C7/T1 bc there is a C8 nerve root
Grays: Rough rule of 2- add 2 to spin process for C2-T10. (Tip of T9 process is at T12), then add 3. Close from C1-C4.. difference gets greater as u go down cord.
|How can cord function without cortical input? What system does not need cortical input?
||afferent/efferent nerve form loop- independent. Pt can maintain functions w/o cortical input. Bladder is system like this. Form isolated cord below level of lesion (?)
|Major Motor tracts
||Lateral corticospinal (Ips): voluntary mvt- precise mvts of distal limbs
Ventral corticospinal (Con): voluntary mvt of axial mm (not very signif).
Rubrospinal (Ips): voluntary mvt of UE, esp precise mvts of extremities.
Vestibulospinal (Bil): Posture/B
|Last Major Motor tract
||Lateral & Medial Reticulospinals (Ips): Posture, balance, modulation of spinal reflexes, axial & proximal limb motions; in performance of motor tasks, comlements actions driven by corticospinals
||Anterolateral system: Spinothalamic, spinoreticular & Spinotetal tracts (Contra): Pain, temp & crude touch
Dorsal column (Ips): Proprioception, vibratory sense, deep touch & discriminative touch
|Last 2 Major Sensory Tracts
||Dorsal Spinocerebellar (Ips): Unconscious proprioception from trunk & LE
Ventral spinocerebellar (Bil): Unconscious proprioception from trunk & LE
|How many pairs of spinal nerves from each section? (thor, lumbar, cerv)
||Cerv: 8, Thoracic: 12, Lumbar: 5.
|Anterior spinal artery
||Runs along anterior fissure until it gets to thoracic spine- here, gives rise to sulcal (supply center of cord) & pial (supply lateral cord) arteries.
|Lateral spinal arteries
||A set. Comes from b/t lateral artery b/t C2 & T2.
|Segmental Radicular arteries
||Continuation of anterior spinal artery below T4. Have connection to intercostal artery from Aorta. Largest component of this is Adam Kiewicz: supplies anterior part b/t C8-T4. Responsible for Thoracic & Lumbar spine.
|Posterior spinal arteries
||From posterior nerve roots- supply posterior horn. Start inter-cranially & descend all the way down.
||Comes from anterior median fissure. Arises from anterior spinal artery & supplies center of cord: supplies ___ (most) of gray matter & inner 1/2 of white matter.
||Comes from anterior & posterior spinal arteries & supplies outer part of white matter. Supplies posterior horns: inner & outer part of lateral column.
|Fracture dislocation – importance
||Often the etiology of SCI- causes large bleeds. Capillary network is more dense in gray than in white matter.
|How do u conduct examination of joint?
||Subjective, Observation & palpation (posture & limb posturing), Active mvt testing (quick tests), Resistive tests, Passive mvt testing, Special tests/other tests (neuro), Palpation: specific
|How do u conduct active mvt testing at shoulder complex?
||Clear jts above & below, Quick tests (tests the shoulder complex)- if these reveal no problems, do Quick tests w/overpressure, Scapular motions, GH jt motions, Elbow flexion & extension
|How do u conduct passive mvt testing at shoulder complex?
||Clera jts above & below, Passive ROM = physiologic motions (shoulder jt, ST jt, GH jt), Joint Mobility Testing = accessory mvt (ST jt, SC jt, AC jt, GH jt)
|How do u conduct Resistive testing at shoulder complex?
||Muscles for scapular motions, muscles for GH jt motions, muscles for elbow motions
|What is purpose of special tests? What do u test?
||Orthopaedic & neuro: tests designed to stress certain structures
|How do u take subjective of shoulder complex?
||Hx of present illness (why here? what about shoulder bothers u? ever bothered u before?), Dominant arm (R or L), Neck/thorax prob (upper back/neck refers pn), Systems review – search for referred pn, Job/sport- simulate offending mvts, PMH, PSH, Sochx
|What are major things to ask during subjective?
||Area- where pn?
Onset- when start?
Nature- what feel like (burn/pinch)?
What about job/sport interacts w/this prob?
How long pn last (irritability)- show me w/good arm what creates prob
What can't u do? (****)
|Referred pn- red flag example & how do u intervene?
||Pt says they have shoulder pn that comes on w/climbing steps only – send to dr to get cardiogram *CV may have probs
|Examination: Observation of shoulder complex
||Posture: attitude of arm, body posture/habits, willing to mv?, atrophy or hypertrophy (imbalanced mm), note edema-jt could get inflamed then mv down to elbow, symmetry (1 blade much higher). If bad attitude no willing to mv- have TLC- massage to decr. pn
|Examination: Palpation of shoulder complex
||Palpate: temperature, edema, atrophy, tenderness (capsule, tendon, bursa, etc), analyze alignment & pos'n- is blade dropped? msr w/tape msr- document "at rest pos'n, scap angle at level of T7." use this as baseline to document changes.
|How to conduct examination of shoulder complex: active mvt testing
||incl jts above & below affected jt. Neck: tell pt to look up to sky, then L, then R. then overpressure- but no overpressure this semester.
Quick tests: apply overpressure if no limitation- Flexion, Abdn, Hand behind back, Hand behind head, Rotator cuff.
|What to look for during examination of shoulder complex: active mvt testing
||Symmetry, painful arcs ("pn started at 45–>120, then went away"), willingness to mv, pain
|What does painful arc help u determine?
||Where probs are
|What motions to test during examination of shoulder complex: active mvt testing
||C-spine, scapular elev/depression, scapular upward & downward rotation, scapular ad/abduction, GH physiologic motions, elbow flex/extension
|How to apply overpressure during flexion of shoulder
||Stabilize scapula, put hand on distal humerus, apply overpressure (stresses ligaments to the max). If no pn, u clear this motion, so this wouldn't fall into ur goals unless goal is to maintain ROM.
|What motions to do Resisted (Active) Mvt Testing on for pt w/prob in shoulder complex
||Scapular, glenohumeral, elbow. For hypermobile joints: if looking for end-range cardinal sign (pn at end-range in shoulder) then u can apply overpressure to hypermobile jt (otherwise, don't)
|What to include in passive mvt testing
||Test joints above & below affected jt. Passive physiologic motion & goniometry. Joint mobility testing: remember good body mechanics, relax (pt and PT), get pt feedback
|What end-feel is normal for shoulder complex?
||Capsular at 120. Before 120 is not normal. Empty is ROM limited by pain.
|What are the 3 things u are assessing with passive mvt testing?
||Arc of mvt (goniometer – preset it to estimated range so u aren't fiddling with it), End-feel, Quality (if u feel hitches or muscle spasm)
|What should do u for a stiffer joint during passive mvt testing?
||Alternate hand-placement- gravity doesn't help as much- PT has to perform motion.
|What mvts do u passively test for Scapulothoracic jt? Which direction is pt lying?
||Elevation/depression, Ab/adduction, Up/downward rotation, "distraction" (sidelying)
|What mvts do u passively test for Sternoclavicular jt? Which direction is pt lying? What mvts are u testing?
||Cephalad & caudad glide, A-P glide (pt supine) Accessory mvts
|What mvts do u passively test for Acromioclavicular jt? Which direction is pt lying? What mvts are u testing?
||A-P glide, P-A glide (pt supine) Accessory mvts
|What is the concept of hand-placement when passively testing SC joint, ST joint & AC jt?
||Stabilize scapula, control distal same arm as pt, After 90 use opp arm as pt. Note whether GH motion stops at 120.
|What mvts do u passively test for Glenohumeral jt? Which direction is pt lying? What mvts are u testing?
||Lateral distraction of head of humerus, anterior glide, posterior glide, ER of head of humerus, IR of head of humerus, longitudinal mvt in neutral, inferior glide (pt supine) Accessory mvts
|Hand Placements- Caution with:
||Tender areas (pt will tell u where they are), Unstable bony segments (ie recent fractures, ORIF), *Osteoporosis (u can still test but use no force?
|What mvts do u assess/mobilize(?) for Scapulothoracic jt?
||Elevation/depression, Protraction/retraction, Ab/adduction, Lifting scapula
|What is correct hand placement/body mechanics for scapulothoracic mobilization?
||Pt sidelying. One hand's web-space on inferior angle, other hand on superior border. Stabilize upper arm w/your forearm- lock ur elbows & mv your legs.
|What mvts do u assess/mobilize for Sternoclavicular jt?
||Inferior glide to increase elevation, Superior glide to increase depresion, A-P glide to increase retraction, P-A glide to increase protraction,