创伤性脊髓损伤物理治疗.ppt

1,PhysicalTherapyforAdultswithTraumaticSpinalCordInjury,Acknowledgement:InternationaleducatorsfortheChinaSelf-DirectedLearningModules,MODULEC4/CSDLM/2019/NRTraumaticSpinalCordInjury,2,TraumaticSpinalCordInjury(SCI),MajorityoftraumaticSCIoccursinyoungadultmalesTraumaticspinalcordinjuryisanon-progressivepathologyMotorandsensoryfunctiononbothrightandleftsidesisdeterminedbythelevelofinjuryApatientwithC6levelinjuryhasintactmotorandsensoryfunctionbilaterallyatandabovetheC6level,MODULEC4/CSDLM/2019/NRTraumaticSpinalCordInjury,MODULEC4/CSDLM/2019/NRTraumaticSpinalCordInjury,4,TraumaticSpinalCordInjury,BasedontheInternationalStandardsforNeurologicalClassificationofSpinalCordInjury(publishedbytheAmericanSpinalInjuryAssociation,ASIA),patientscanbegroupedinfivecategoriesdependingontheseverityofimpairmentfromAtoEAiscompletespinalcordinjurywithnomotororsensoryfunctionbelowthelevelEisnormaleventhoughpatientmayhaveinitiallyexhibitedsymptomsofspinalcordinjury,butisnownormal,MODULEC4/CSDLM/2019/NRTraumaticSpinalCordInjury,ASIAImpairmentScale,MODULEC4/CSDLM/2019/NRTraumaticSpinalCordInjury,6,TraumaticSpinalCordInjury,DefinitionsParaplegiaisdefinedasanimpairmentorlossofmotorand/orsensoryfunctionofallorpartofthetrunkandbothlowerextremitiesTetraplegiaisdefinedasanimpairmentorlossofmotorand/orsensoryfunctioninbothupperextremitiesinadditiontotrunkandbothlowerextremities;respirationisoftenaffected,MODULEC4/CSDLM/2019/NRTraumaticSpinalCordInjury,7,SpinalCordAnatomy,Spinehas8cervical,12thoracic,5lumbar,5sacral,and1coccygealspinalnerves(levels)SpinalcordendsaroundL1vertebrallevelThecervicalspinallevelscontrolsensoryandmotorfunctionofhead/neckandupperextremitiesandthediaphragm(phrenicnerve,C3-5)ThethoracicspinallevelscontrolchestandabdominalmusclesandsensoryfunctionofthetrunkThelumbarspinallevelscontrolmotorandsensoryfunctionofthelowerextremitiesThesacralspinallevelscontrolthesensoryfunctionofthebackoflowerextremityandbuttocks,bowelandbladdercontrol,andsexualfunction,MODULEC4/CSDLM/2019/NRTraumaticSpinalCordInjury,8,SymptomsofSpinalCordInjury,MotorimpairmentParalysisorweaknessofaffectedmuscles(followingthemyotomes)SensoryimpairmentLossorimpairedsensationofaffectedareas(followingthedermatomes),MODULEC4/CSDLM/2019/NRTraumaticSpinalCordInjury,Dermatomes,MODULEC4/CSDLM/2019/NRTraumaticSpinalCordInjury,10,SymptomsofSpinalCordInjury,AutonomicdysreflexiaOftenoccursinpatientswithhighlevelspinalcordinjury(lesionlevelaboveT5)Causedbydistendedbladder,distendedrectum,blockedcatheter,orotherstimuliaboutthesacralinnervatedareaPatientshowsflushedface,poundingheadache,veryhighbloodpressure,sweatingabovethelevelofinjury,piloerection,slowpulse,andnasalobstruction(nasalvoice)Autonomicdysreflexiaisamedicalemergency,MODULEC4/CSDLM/2019/NRTraumaticSpinalCordInjury,P/wiki/Goose_bumps,11,SymptomsofSpinalCordInjury,AutonomicdysreflexiaismanagedinthefollowingwayDontletthepatientliedownPositionthepatientinsittingCheckthecatheterortubeforblockageCheckthefeetpositionsfortwistedanklesorpinchedtoesEmptylegbagforurineifitisfullObtainimmediatemedicalhelp,MODULEC4/CSDLM/2019/NRTraumaticSpinalCordInjury,12,SymptomsofSpinalCordInjury,SpasticityMostcommoninpatientswithcervicalandthoraciclevelinjuriesOccursbelowtheleveloflesionafterthespinalshockperiodPoorvenousreturnbelowtheleveloflesionthatmayresultinorthostatichypotensionBradycardiaImpairedbodytemperaturecontrolUnabletoregulatebodytemperatureinresponsetoenvironmentalchanges(stayundersun)ImpairedabilitytosweatbelowtheleveloflesionImpairedrespiratoryfunctionDecreasedtidalvolumeandvitalcapacityImpairedcough,MODULEC4/CSDLM/2019/NRTraumaticSpinalCordInjury,13,SymptomsofSpinalCordInjury,BladderandboweldysfunctionforthosepatientswithS2-4involvementIfnotmanagedproperly,patientwillhaveurinarytractinfectionsandultimatelykidneyfailureMustdrinksufficientfluidandeatahighfiberdietMostpatientscanbetrainedtomanagetheirbladderandbowelproblems,includingascheduletovoid(every4hours)andtomovebowel(onceadayoronceeveryotherday)Sexualdysfunction,MODULEC4/CSDLM/2019/NRTraumaticSpinalCordInjury,14,SymptomsofSpinalCordInjury,SecondarycomplicationsPressuresoresDeepveinthrombosisPainContractureHeterotopicossificationOsteoporosis,MODULEC4/CSDLM/2019/NRTraumaticSpinalCordInjury,15,Prognosis,Afterstabilizingthespinal(vertebralcolumn)injury,thepatientshouldbeginacomprehensiverehabilitationprogramLifeexpectancyisrelatedtotheseverityofimpairmentIndividualswithspinalcordinjuryclassifiedbetweenthe*ASIAAtoClevelsandthosewithtetraplegiahaveshorterlifeexpectanciesRef:AmericanSpinalCordInjuryAssociation(ASIA)C/elearning/ISNCSCI_Exam_Sheet_r4.pdf,MODULEC4/CSDLM/2019/NRTraumaticSpinalCordInjury,16,MODULEC4/CSDLM/2019/NRTraumaticSpinalCordInjury,17,MedicalManagement,EmergencycareKeeptheneckandtrunkstabilized(useacervicalcollarandbackboard)duringtransportationSurgerytostabilizefractureOfteninvolvesimmobilizationafterthesurgery(Halodeviceforcervicalspineandbodycast/jacketforthoracicorlumbarspine)DrugsTomanagespasticityandpainTomanageinfections,MODULEC4/CSDLM/2019/NRTraumaticSpinalCordInjury,18,PhysicalTherapistsConcerns,Patientswithtraumaticspinalcordinjuryoftendeveloppneumonia,urinarytractinfection,andpressuresoresPhysicaltherapistsmustteachpatientsWaystoachieveaproductivecoughProperbladdermanagementprogramDailyskininspection,MODULEC4/CSDLM/2019/NRTraumaticSpinalCordInjury,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,MODULEC4/CSDLM/2019/NRTraumaticSpinalCordInjury,20,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,MODULEC4/CSDLM/2019/NRTraumaticSpinalCordInjury,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,MODULEC4/CSDLM/2019/NRTraumaticSpinalCordInjury,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,MODULEC4/CSDLM/2019/NRTraumaticSpinalCordInjury,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),MODULEC4/CSDLM/2019/NRTraumaticSpinalCordInjury,有效长度的指屈肌腱才能允许患者有功能性抓握,MODULEC4/CSDLM/2019/NRTraumaticSpinalCordInjury,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）,MODULEC4/CSDLM/2019/NRTraumaticSpinalCordInjury,容易产生压疮部位,MODULEC4/CSDLM/2019/NRTraumaticSpinalCordInjury,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？功能性技能翻身坐起床-轮椅转移站立步行-取决于损伤程度,MODULEC4/CSDLM/2019/NRTraumaticSpinalCordInjury,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:/lists/rehabmeasures/dispform.aspx?id=889,MODULEC4/CSDLM/2019/NRTraumaticSpinalCordInjury,MODULEC4/CSDLM/2019/NRTraumaticSpinalCordInjury,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/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,MODULEC4/CSDLM/2019/NRTraumaticSpinalCordInjury,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,MODULEC4/CSDLM/2019/NRTraumaticSpinalCordInjury,32,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,MODULEC4/CSDLM/2019/NRTraumaticSpinalCordInjury,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,MODULEC4/CSDLM/2019/NRTraumaticSpinalCordInjury,AssistedCough,MODULEC4/CSDLM/2019/NRTraumaticSpinalCordInjury,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,MODULEC4/CSDLM/2019/NRTraumaticSpinalCordInjury,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分钟缓解下受压部位的压力(独自或者依靠帮助)撑起侧倾前倾,MODULEC4/CSDLM/2019/NRTraumaticSpinalCordInjury,侧倾SideLean,撑起PushUp,前倾ForwardLean,MODULEC4/CSDLM/2019/NRTraumaticSpinalCordInjury,38,SkinCare,Ifthepatientdevelopsanulcer,thepatientshouldbereferredtoawoundcarespecialisttofacilitatehealingandtopreventinfectionPatientshouldnotputpressureontheulceruntilitishealed-forexample,apatientwitharightgreatertrochanterulcercannotlieontherightsideuntilthewoundishealed,MODULEC4/CSDLM/2019/NRTraumaticSpinalCordInjury,39,EarlyStrengtheningandRangeofMotionExercises,StrengthenallinnervatedmusclesWatchforsubstitutionForexample,patientmayuseshoulderexternalrotatorstosubstituteforelbowextensorsDonotstretchFingerflexorstoprotecttenodesisLowertrunkmusclessothatpatientcanleanonligamentsforsittingStretchHamstrings-toassureastraightlegraiseto100degreesHipflexorstoassurepatienthas10degreesofhipextensionAnkleplantarflexorstoassurepatienthas10degreesofdorsiflexion,MODULEC4/CSDLM/2019/NRTraumaticSpinalCordInjury,40,Sitting,PatientusuallyexperiencesposturalhypotensioninsittingorstandingInitially,bringthepatienttosittingslowlyUseanabdominalbinderandelastic(pressure)stockingstoassistvenousreturnGraduallyelevatetheheadanduppertrunkinbedMayalsouseatilt-in-placewheelchairwithelevatinglegrestsoratilttableBiomechanicalprinciplesformatactivitiesHead-hipsrelationshipUnweightthebodypartfirstbeforemovingitUsemomentum,MODULEC4/CSDLM/2019/NRTraumaticSpinalCordInjury,41,Sitting,Beawarethatthepatientisusingverysmallmuscles(inupperextremities)tomoveaheavyload(thewholebody)ProtectpatientsshouldersandwristsfromDay1ofphysicaltherapy-patientswithchronicspinalcordinjuryoftenexperienceshoulderproblemsForscootingsidewaysorupanddowninbed(oronmat),patientsneedtoclearbuttocksfromthesupportingsurfaceinordertomove-hence,patientswithshortarmsandalongtrunkwillneedpush-upblocksformatactivitiesPatientneedtolearnthenewcenterofmassforfunctionalmovements,MODULEC4/CSDLM/2019/NRTraumaticSpinalCordInjury,42,Sitting,Afterthepatientcantoleratesittingintheuprightposition,thepatientcanbeginmatactivitiesthatmayincludeRollingfromsupinetopronePronepositionProneonelbowsPronetosupineSupinetolongsittingScootingsidetosideinlongsittingScootingupanddowninlongsitting,MODULEC4/CSDLM/2019/NRTraumaticSpinalCordInjury,Longsitting,leanonupperextremities,shouldersinextensionandexternalrotation,andelbowsextended,MODULEC4/CSDLM/2019/NRTraumaticSpinalCordInjury,Movingsidewaysinlongsitting,MODULEC4/CSDLM/2019/NRTraumaticSpinalCordInjury,45,SittingBalanceTraining,PatientlearnstousetrunkligamentsPatientinlongsittingonmatLiftonearmfirstLiftbotharmsCatchaballwithbotharmsPatientsitsonabenchwithfeetflatonthefloorandthenLiftonearmLiftbotharmsTrytocatchaball,MODULEC4/CSDLM/2019/NRTraumaticSpinalCordInjury,46,TransferMattoWheelchair,TetraplegiaUsuallyneedsaslidingboardParaplegiaOftenmaydowithoutaslidingboardParkwheelchairat45degreeangletothematandlockthewheelsRemovearmrestandlegrestnexttomatUsemomentumtoassisttransferPushdownonsupportingsurfacewithbotharmsandatthesametimetwistheadandtrunkawayfromwheelchairPatientwithlowerextremityspasticitycanbearweightonlegstoeaseweightonupperextremities,MODULEC4/CSDLM/2019/NRTraumaticSpinalCordInjury,Patientwithparaplegiatransferringfrommattowheelchairatthesameheight,MODULEC4/CSDLM/2019/NRTraumaticSpinalCordInjury,Patientwithparaplegiatransferringfrommattowheelchairtoahighersurface,MODULEC4/CSDLM/2019/NRTraumaticSpinalCordInjury,Patientassistedslidingboardtransfer:#1-therapistassiststhepatient;#2-patientplacelefthandonslidingboard,MODULEC4/CSDLM/2019/NRTraumaticSpinalCordInjury,50,Standing,StandingprogramisgoodfortheskeletalsystemandthecardiovascularsystemCheckpatientsbloodpressureinsittingfirstPatientmayneedabdominalbinderandelasticstockingsStartinparallelbarsPatientmayneedlowerextremityorthoticsand/orspinalorthoticPatientfirstpressesdownonparallelbars,liftsonearm,andthenliftsbotharms,MODULEC4/CSDLM/2019/NRTraumaticSpinalCordInjury,51,Walking,MustdetermineifwalkingisareasonablegoalForpatientswithaspinalcordinjury,walkingconsumesatremendousamountofenergyPatientshavestrongupperextremitymuscles,nocontractures,andstrongmotivationarecandidatesforwalkingtrainingMostpatientsarenotgoingtobecommunityambulatorsPotentialgaitpatternsSwingtoSwingthroughFourpointTwopoint,MODULEC4/CSDLM/2019/NRTraumaticSpinalCordInjury,52,Walking,PatientswithaT12abovelevelwillneedbilateralkneeandankleorthoses(e.g.CraigScottorthoses)towalkusingaswingthroughorswingtogaitPatientswithaT12orbelowlevelwillneedbilateralkneeandankleorthosesandcanwalkwithareciprocalgaitpattern(fourpointortwopoint)PatientswithanL4-5levelorbelowwillneedanklefootlorthosestowalkreciprocallyandarebestcandidatesforreciprocalgaitt