Tetraplegia

Definition/Description

Tetraplegia is paralysis caused by injury to the cervical spinal cord. This can result in partial or total loss of sensation and movement in the extremities and trunk [1]. Injuries above grade C4 usually result in shortness of breath. [2]

Epidemiology /Etiology

In the United States, an estimated 230,000 people become quadriplegic or paraplegic each year. [3][4] Eighty percent of cases of tetraplegia are in men, and almost sixty percent of cases are caused by traffic accidents. Nearly 50% of patients are between the ages of 18 and 25 The time of the accident. The most commonly affected levels are C4 – C7. Half of the patients had an average of 3 sessions of physical therapy per week. [5]

Characteristics/Clinical Presentation

Patients with tetraplegia have different clinical presentations depending on the extent of the injury. In general, all patients have motor and sensory deficits in the arms, trunk and legs. [1] The spinal cord may be crushed (eg, due to compressive forces caused by translation of vertebrae or segments) or tear (for example, trauma to multiple tissues due to extreme tension caused by extreme movements of the spine). If it is torn, it may have a better prognosis. When the spinal cord is compressed, emergency decompression should be done within 2-3 hours, otherwise the prognosis will be worsened. [6] In the case of high tetraplegic injuries (above C3), patients may develop locked-in syndrome. This means that he or she knows everything but cannot communicate, or that communication is limited to vertical eye movements and blinking. [7]

The most common complications are:[3][8]

• Respiratory problems such as atelectasis, hypersecretion, bronchospasm, pulmonary edema, and pneumonia.
• Pulmonary thromboembolism and other emboli (blood clots).
• urinary and pulmonary infections
• pressure sores
• spastic muscles
• loss of bladder and bowel control
• pain

Differential Diagnosis

The American Spinal Injury Association (ASIA) classification does not exclude other disorders in the differential diagnosis. Frankel or ASIA classification: only class A is paraplegic or quadriplegic. We can distinguish between quadriplegia and paraplegia and quadriplegia and quadriparesis. we say If paralysis is incomplete, quadriplegia. The difference between quadriplegia and paraplegia is the level affected, we say that everything above the T1 level falls under the category of quadriplegia. Below C8 up to cauda equina paraplegia [9]

Diagnostic Procedures

Early and accurate diagnosis of spinal and cervical spine lesions is important. To identify the damaged part of the spinal cord imaging studies such as computed tomography (CT) and magnetic resonance imaging can be used. Sometimes a CT or MRI scan is used with contrast to ensure an accurate diagnosis. When infections of the rectum occur blood tests and/or rectal taps are performed to analyze blood and/or rectal fluid.[10] [11] .

Examination

The initial evaluation of individuals with acute spinal cord injury should include a thorough historical physical and neurological examination to determine the nature of the injury as accurately as possible. Physical examination should include assessment of breathing and cough effectiveness. The the most common abnormal breathing patterns are isolated breaths within the lungs and chest wall contraction during inspiration.[8]Neuroanalysis is more specific in the physical and cognitive assessment of tetraplegia include:

• International Standard Neurological Classification of Spinal Cord Injuries (ISCSCI) .
• Electrophysiological measures: stimulated muscle testing strength-duration (SD) test evoked-potential test nerve conduction velocity (NCV) test and needle and dynamic electromyography (EMG) test
  These motor and sensory tests can be used to assess muscle strength and sensation.
  For the upper extremity assessment of tetraplegia, the Sollerman Hand Function Test Competence Upper Extremity Apparatus (CUE), the Motor Capacity Scale, and the Tetraplegic Hand Activity Questionnaire are useful tools. At least one or a combination of these tools should be used Assess hand function and gather evidence for interventions. [12]

In a systematic review, Julio C. Furlan et al. They collected eight different outcome measures for assessing disability in the SCI population:[13]

• Functional Independence Measure (FIM)
• Spinal Cord Injury Measure
• Spinal Cord Injury Walking Index (WISCI)
• Quadriplegia Index of Function (QIF)
• Modified Barthel Index (MBI)
• Timed Up & Go (TUG)
• 6-min walk test (6MWT)
• 10-m walk test (10MWT)

Medical Management

Medical management of quadriplegia may be to treat the cause and may use invasive techniques to relieve pressure or attempt to repair the damage. Most of these technologies are still experimental (such as the use of stem cells). [14] More commonly, treatments aim at Function restored. The ability to use the upper extremities has a major impact on the patient’s independence (independent transfers using wheelchair decompression maneuvers, etc.). Thus, strategies such as diverting the teres minor motor branch for triceps reinnervation and A biceps-to-triceps transfer for elbow extension can improve patient function. Most physicians consider these procedures beneficial, but unfortunately they are not usually used because the risk/benefit ratio remains unknown. Known literature includes small case reports. [15] [16] [17] Patients who lose the ability to breathe spontaneously and are ventilated through a tracheostomy are more likely to develop respiratory infection and/or disease. A better technique is to use a diaphragm pacing system, which paces the diaphragm by electrically stimulating the phrenic nerve. The technique has promising results, but more trials are needed to assess the impact on patients. [18]

Physical Therapy Management

As noted above, the ability to use the upper body is considered critical to regaining independence. A review of several studies suggests that different training techniques may improve arm and hand function after cervical spinal cord injury leading to quadriplegia. there is some evidence This suggests that task-specific training (and functional electrical stimulation if grasping function is too weak) is ideal for improving hand function. Almost all studies show improvements in arm and hand function and/or activity levels. Therefore, physical therapists should set individual goals for each patient and use a specific (appropriate) training program to achieve success. [19][20][1] If the surgeon and physician decide to use the procedure described above, the task of the physical therapist will be to strengthen the muscles and teach the patient individual control of the muscles.

In addition, lack of physical activity is often accompanied by chronic spinal cord injury, which should be one of the key issues that should be addressed by physical therapists. Innovative techniques such as cycling using functional electrical stimulation of the lower extremities [21] treadmill gait and Electrical stimulation during gait is used to restore/maintain muscle mass in the legs, strengthen bones, and obtain many other benefits from physical activity (cardiovascular). [22][23] Hypotension and orthostatic hypotension are frequent in these patients; patients should be instructed Get up gradually and slowly (from a lying or sitting position). Circuit exercises before standing may help stimulate blood flow. In addition, a special diet (enough water and salt) and regular exercise regimens should be given to prevent hypotension.

For respiratory problems that may arise from secretion removal techniques in tetraplegia, an expiratory flow device is recommended and it is recommended to improve the various components of the cough (vital flow rate maximal respiratory pressure). intermittent positive pressure Breathing (IPPB) can be used to treat or prevent atelectasis. Inspiratory muscle training using a threshold trainer at low loads increases respiratory muscle strength in quadriplegic patients, research suggests. Efficacy for quadriplegia has not been proven, but it is It is suggested that this will help COPD patients to breathe. [twenty four]

Clinical Bottom Line

Patients with tetraplegia have different clinical presentations depending on the extent of the injury. Cervical spinal cord injuries can result in partial or complete loss of sensation and movement in the extremities and trunk. [25] Early and accurate diagnosis of spinal and cervical spondylosis The spinal cord of a quadriplegic is very important. The initial evaluation of a patient with acute SCI should include a complete history, physical examination and neurologic examination (CT scan) to determine the extent of injury as accurately as possible. A physical assessment should include Assess breathing patterns and cough effectiveness. A physical therapist should set individual goals for each patient and use a specific (appropriate) training program to achieve success. [26] Physical inactivity often accompanies chronic spinal cord injury and should be one of the Points a physical therapist should address. If breathing problems develop, appropriate treatment should be instituted (see Physiotherapy Management).