CLIN ED 2 | 2nd SG
Topics:
SCI
Movement DO (PD, MS)
LMN (GBS ++)
SCI
Definition Spinal cord injuries typically are
divided into two broad functional
categories: tetraplegia and
paraplegia. Tetraplegia refers to
complete paralysis of all four
extremities and trunk, including
the respiratory muscles, and
results from lesions of the cervical
cord. Paraplegia refers to
complete paralysis of all or part of
the trunk and both lower
extremities (LEs), resulting from
lesions of the thoracic or lumbar
spinal cord or cauda equina.
(Sullivan)
Incidence -highest for persons 16 to 30 y/o
-current average age at onset is
40.2 years
-More than 80% of all SCI occurs in
males
(Braddom)
Etiology Traumatic:
MVA  Falls  Violence/GSW 
Sports
Non Traumatic:
Disease or pathologic influence
Cardinal
Features
Clinical Spinal Shock
Manifestations Motor and Sensory Impairments
Autonomic Dysreflexia
CV Impairments
Postural Hypotension
Impaired Temp Control
Respiratory Impairments
Spasticity
Endorsement Notes
Discharge Summary
Incident Report
PD MS LMN
A chronic and progressive Autoimmune disease characterized by inflammation, ALS = aka Lou Gehrig’s Dse (both UMN and LMN)
disorder of the central nervous demyelination and gliosis of the central nervous -rapidly progressive neurodegenerative dse
system affecting the basal ganglia system. -destruction of motor neurons in the primary motor cortex (BA 4&6), brain stem and SC
with motor and “Great Crippler of Young Adults” (specifically AHC)
non-motor symptoms. -demyelinating -men, 40-60 y/o
Onset is insidious with slow rate -affected white matter (myelin sheaths) -cardinal sign: weakness
of progression. -pseudobulbar affect, common CN affected: CN 5, 7, 9, 10, 12, onufrowicz nucleus/ onuf’s =
-neurodegenerative seen in ventral S2; fxn in control of bladder, ext sphincter of anus), spinocerebellar tract =
-affected grey matter (BG, sensation for balance, sensory problems
substantia nigra, pars compacta
++) Sporadic ALS = western pacific region
-UMN presentation (loss of dexterity or feeling of stiffness in the limbs, weakness,
spasticity) + LMN presentation (mm weakness, atrophy, fasciculations and muscle
cramping anywhere in the body)
-pseudobulbar affect, common CN affected: CN 5, 7, 9, 10, 12, onufrowicz nucleus/ onuf’s =
-2nd most common -common age 20-40 y/o seen in ventral S2; fxn in control of bladder, ext sphincter of anus), spinocerebellar tract =
neurodegenerative DO among -Female > Males (2:1 to 3:1) sensation for balance, sensory problems
elderly people >65 y/o -White and African-Am > Asians
-Men > Women (1.2 to 1.5 times) -Extreme hemispheres before 15y/o Sporadic Progressive LS = onset: spinal and bulbar region
-Age onset: 50-60 y/o -5th decade of life
*Young onset PD = 21-40 y/o -most common presenting sign: spasticity
*Juvenile onset PD = <21 y/o
Primary Parkinsonism Idiopathic Spinal Muscular Atrophy = selective destruction of AHC
=most common; idiopathic; True Type Synonyms Dse Onset Natural Hx
Parkinson’s Disease; aka Paralysis Autoimmune = viral infections (epstein barr, canine SMA I Wernig Before 6 -Unable to sit
Agitans; classified into TP (tremor distemper, human herpesvirus 6, chlamydia -worse (dies before 2 y/o) Hoffman mos indep
predominant) and PIGD (postural pneumonia) -tongue fasciculation Acute -Poor survival
instab gait disturbance) Infantile
Genetic predisposition = human leukocyte antigen +++ SMA II Wernig Before 18 -Sits indep
Secondary Parkinsonism -proximal weakness > Hoffman mos -No indep amb
=post infectious distal Chronic -Over 50%
=toxic (Manganese = Mn) -joint dse (severe Infantile survive to mid 20s
=drug induced (neuroleptic progressive scolio)
drugs++) SMA III Kugelberg- After 18 mos -Amb indep
=metabolic (calcium metabolism -proximal weakness > Welander -N survival
probs) distal Chronic
-hand tremors, tongue Juvenile
fasci, areflexia
Parkinsons Plus Syndrome
=affect substantia nigra SMA IV Adult Onset Mid 30s -N survival
=(-) Apomorphine Test
Hereditary Sensory Motor Neuropathy = hallmark presentation of peroneal and distal leg
PTRB SIN
Postural instability Scanning speech/dysarthria atrophy, weakness, sensory loss and areflexia
Tremors (4-6 hz; initial sx) Intention tremor HSMN I – Charcot Marie Tooth Dse (Ia – chromosome 17;
Rigidity (1 of the clinical hallmark) Nystagmus Ib – chromosome 1) *inverted Champaign bottle leg appearance
Bradykinesia/akinesia (least === Charcot’s Triad HSMN II – lesser hypertrophic change in myelin, w more neuronal or axonal involvement
than those seen in CMT type 1
specific and most disabling)
*HSMN 1 = more severe = slow NCV
Motor Planning (start hesitation, Sensation (paresthesia, pain, trigeminal neuralgia,
*HSMN 2 = axonal feature = abN EMG
micrographia, freezing episodes, paroxysmal limb pain, hyperpathia, HA)
HSMN III = Degerine Sottas Dse
hypomimia; uniplanar Visual changes (optic neuritis, scotoma, marcus gunn,
HSMN IV = Refsum’s Dse; hearing loss; dec phytanic acid
movements) nystagmus, diplopia)
HSMN V = spinocerebellar degeneration = balance problems
Motor Learning (procedural Spasticity
HSMN VI = w optic nerve atrophy = loss of vision
learning) Balance and Coordination (dyssynergia,
HSMN VII = w retinitis pigmentosa = inflammation ng retina
Gait (festinatong, shuffling) dysdiadochokinesia)
 Bladder & Bowel Dysfunction
Sexual Dysfunction
Subjective Informant!!!
Objective OI = *dry skin and nails below the
level of the lesion
Myotomes
Dermatomes = LT & PP
Test deep sensations and anal
sensation also
MMT = mm grade 8-12 mos after
SCI = plateau ng grade; will not get
better na; ratio: maintenance of
mm strength
Reflexes = hyperreflexia below level
of lesion; hypo if very recent ang
injury
-Superficial reflexes (abdominal,
cremasteric, bulbocavernosus,
anocutaneous)
*cremasteric = touch
anteromedial thigh of male
Sensation (paresthesia and pain,
proprioceptive deficits, postural
stress syndrome, akathisia)
Speech, Voice, Swallowing
(dyspahia, sialorrhea, mutism,
hypokinetic dysarthria)
Cognitive Fxn & Behavior
(depression, dysthymic behavior,
dementia, bradyphrenia)
Autonomic Nervous System
(seborrhea, seborrheic dermatitis,
GI dysfxn, sexual dysfxn)
Cardiopulmo Fxn (orthostatic
hypotension, airway obstruction,
restrictive lung dysfxn)
Deformities (striatal hand/toe)
CN Affectation (3,7,9, marcus
gunn pupil, Argyll-robertson
pupil; blepharospasm,
blepharoclonus; hypomimia)
Informant!!!
+Htn
Sinimet = meds
Palp = RIGIDITY!!!
NA > Basal Ganglia > …
BG – aki/brady/hypokinesia,
athetosis, chorea, dystonia,
hemiballismus, rigidity, resting
tremor
Sensory > Combine Cortical > 2pt
discri and stereognosis = if intact,
other combined cortical are intact
too
Cognition (impaired attention, concentration, memory,
executive fxn, slow info processing)
Affection (euphoria, depression, bipolar affective
disorder)
Autonomic (bladder and bowel dysfxn, sexual dysfxn)
TYPES:
E. Benign = pt remaind fully fxnal 15 yrs after onset
F. Malignant = aka Marburg Dse; rapid onset within
short time after onset
HPI =Kailan attack, saan lesion, kailan improve, kailan
attack ulit? (double vision  tingling  weakness 
balance problems)
Medications (corticosteroids), previous PT
Migration? Before 15y/o
Lifestyle = detailed activities, ilan hrs/day
Palp = SPASTICITY!!!!!
NA > Cerebellum > …
Cerebellum – asthenia, dysarthria, dysdiadochokinesia,
dys/hyper/hypometria, rebound phenomenon,
intention tremor, asy/dyssynergia, gait disorders
Polio
-condition w damage to the AHC of the SC, caused by the polio virus (Picorna Virus) =
enteric/GI virus (fecal oral route)
-clinical presentations include: fever, malaise, myalgia, sore throat and gastrointestinal
upset
-asymmetric weakness and atrophy affecting the legs>arms or bulbar mm progress to
flaccid paralysis
Myasthenia Gravis Lambert- Eaton Myasthenic Syndrome
(LEMS) / Eaton-Lambert/ Lambert-Eaton
Syndrome
Post synaptic Pre synaptic
Dec ACH receptors Dec ACH
Initially w strength, then decreases 2nd wind phenomenon = lumalakas
females (2-3/ 2:1) males (4:1)
Associated w thymoma 75% of the time Often associated w bronchogenic
carcinoma
-Ptosis and diplopia = initial s/sx -Proximal weakness or fatigue
-Slurring speech (slow and imprecise) -Dry mouth
-Fluctuating bulbar paralysis -Sexual dysfxn
-Weakness is proximal > distal -Areflexia
-Smooth and cardiac mm -Occasional bulbar sign
Acute Demyelinating Inflammatory Polyneuropathy/GBS
-post infection demyelination of peripheral nerves; breakdown of blood-nerve barrier; hx
of preceding viral infection, immunization, surgery or dse affecting the immune system
-weakness, hypotonia, areflexia (involves the extremities)
*Miller Fisher Syndrome: areflexia, ataxia, opthalmo plegia
Chronic Inflammatory Demyelinating Polyneuropathy
-T-cell mediated autoimmune peripheral neuropathy (motor & sensory)
-cramps & fasciculations in the UE
CC: weakness, sensory def, loss on dermatomal distribution, neurologic deficit, balance
probs, diff amb/breathing, loss of fxn on a specific part of body, autonomic dysfxn
Riluzole = ALS pt (dec sx, but not to cure)
Aspirin or Gabapentin = GBS for pain (ask when taken and mg?)
Home/Work Env = adaptive equipment to modify ADLs
Psych = family support
DTR
-myostatic reflexes: jaw, biceps, brachioradialis, triceps, finger flexors,
hamstrings, quadriceps, Achilles
-superficial reflexes: plantar, abdominal reflexes
Sensory Testing
-distal to proximal using knowledge of the dermatomal and peripheral nerve
innervation
-exteroreceptors: pain, temp, light touch, pressure
-deep sensation: proprioception, kinesthesia, vibration
-cortical sensation: tactile localization, double simultaneous simulation, two
point discrimination, texture recognition, graphesthesia, barognosis,
stereognosis
Two Point Discrimination Normal Values and Discrimination
Distances Required for Certain Tasks
Normal = <6mm Winding a watch = 6mm
Fair = 6-10mm Sewing = 6-8mm
Poor = 11-15mm Handling precision tools = 12mm
Protective = 1 point Gross tool handling = >15mm
perceived
 *bulbocavernosus = pink bulb
of penis/tug catheter  anal
wink
*anocutaneous = stroke
perianal area  anal wink
*(+) abdominal reflex =
N; hindi nag deviate
Tools ASIA Impairment Scale
A Complete: no motor or
sensory function is
preserved in the sacral
segments S4-S5
B Incomplete: sensory but
no motor function is
preserved below the
neurological level and
extends through the
sacral segments S4-S5
C Incomplete: motor
function is preserved
below the neurological
level, and majority of key
muscles below the
neurological level have a
muscle grade less than 3
D Incomplete: motor
function is preserved
below the neurological
level, and majority of key
muscles below the
neurological level have a
muscle grade greater
than or equal to 3
E Normal: motor and
sensory functions are
normal
Case Disc and Subjective: -establish cord
Case Pre syndrome
comments: Sensory Assessment – complete
(superficial & deep)
-introduce sensations to face
- test dermatomes affected
-compare w the face
-pracs: test on level of lesions, 3
segments above and below, both
sides
MMT
FA -assess bed mob, STS, transfers
-ilapit w/c to bed if mag ttransfer
-hawak sa legs kasi mag bbuckle
*GA – depends on level of lesion; if
pt is amb
*ROM – if di pwede GA
Palpatioin
-check swelling, edema sa LE cos
laging nasa w/c
Endorsement Notes
Anesthetic = 0 points
perceived
FA: ALS AQ = PEACE (Physical mobility, Eating and drinking, ADLs, Communication,
Emotional reactions)
Hoehn-Yahr Classification of Kurtzke Expanded Disability Status Scale ALS – El Escorial Criteria for the Diagnosis of ALS
Disability *printed copy
1 Unilateral (if present)
Minimal or absent McDonald Criteria of the International Panel on Dx of
2 Bilateral or midline MS
involvement Attack Lesion Additional
Balance not impaired 2/+ 2/+ None
3 Can live indep, some 2/+ 1 Dissemination in
forms of employment space
Impaired righting 1 2 Dissemination in
reflexes time
Unsteadiness when 1 1 Dissemination in
turning or rising from space and time
chair 0 1 year of disease
4 All sx present and progression and at
severe lease 2 out of 3
Standing and walking criteria
w assistance
5 Confined in bed and Clinically definite MS = 2 attack 2 lesion
w/c Clinically probable = 2 attack 1 lesion / 1 attack 2 lesions
Possible MS = 1 attack 1 lesion
FA – Parkinsons Disease  Better to do cerebrum first. San kayo ngayon, sino Complains: weakness, areflexia, hypotonic
Questionnaire kasama niyo, ano oras kayo pumunta dito? Ano -rapidly progressive, so 2wks na expect na nag ascend weakness na
kinanin niyo for breakfast. -HPI: hindi nag sasabay fever and tingling sensation. Mauuna dapat infection and then
 Phys Env sa school. Stairs or elev. How frequent later on develop tingling sensation
lifestyle. Ano sched sa school. Distance room to other -out pt so dapat full blown GBS
places. -sensory assessment: introduce modality first then test na (What? Where? Quantify)
 Dapat may frequent rest period kahit di pa niya
nararamdaman yung pagod. pag LMN, no more Neuro 1&2. Separate na Sensory and Reflex.
 CN. Always ALWAYS introduce the modality first
before assessing kahit na common yung amoy (CN1).
“Ito po amoy ng coffee, ng orange”
 Careful sa instructions esp CN 2346
“Steady yung head po. Yung mata lang po gagalaw.”
“Tingin lang po kayo sakin, sabihin niyo po if may
nakikita pa kayo or wala na” From wide to narrow
 MMT. Stabilization!!!
 6MWT wag hintayin na mapagod bago magpa rest
Discharge Summary Incident Report
Why do we need to write endorsement notes? -notes that recap the entire rehab program and progress. It should -administrative document, not part if the medical record
-to entrust a pt or delegate the care of the pt to another therapist include factors that have influenced the program throughout, ie: -one of the systems used to identify and report pt and visitor
in situations that the therapist-in-charge cannot attend to the pt injury, problems, progress, objective measurements and test, related occurrences is the hospital/healthcare set up
-to properly turnover care of the pt to a therapist disposition -reportable incidents:
--days off 1 error in the care of pt (may cancer pero di nila sinabi)
--absences 2 destruction or lost machines (replace what you broke)
--end of rotation (PT interns) 3 sexual harassments (pwedeng words, no touching)
--resignation 4 incongruence w the policies and procedures of the center

Common Precautions Include: Reasons for d/c Purpose:

-cardiac conditions -goals established were achieved -identify and provide notification of incidents or events that have
-sensory -pt has not improved, and no other Rx has been indicated occurred involving pts, visitors, staff, equipment, facilities or
-surgical (C/I to post op) -pt is non compliant grounds
-osteoporosis and fx (careful w poundage) -pt has transferred to another facility -immediately investigate the circumstances of the incident = NOT
-balance (when you do transfers, exercises in standing) -pt refuses further Rx A FAULT FINDING ACTIVITY (not subjective, no personal
-brief background of pt’s personality (type a?) -physiatrist recommends termination of Rx opinions and emotions. Should be objective, all facts)
-attitude towards tx -if necessary, institute corrective action to prevent similar
-preferred tx strategies occurrences in the future
-plan of tx
--according to performance of sequence
--parameters, modifications
Example: Example: Example
Endorsement Notes (March 12, 2009) Date (02/07/19) PT D/C Summary Incident Report
This is the case of <pt’s initials>, <age>, <htn/dm>, <handedness>,
Name: B.I (Full name) Schedule: 3x/wk (MWF) <gender>, who was refered for PT evaluation & mx 2˚ to c/o _____ c Date of Report
(10:30-12:00nn) Room: highmat area MD Dx of ____. To Whom It May Concern (Staff/chief PT)
Age: 60 yo PT respectfully suggest that pt be formally d/c from rehab This is to report about the incident that happened last (date and
Gender: Male services d/t ____. time), regarding our pt (initials) dx c (dx), (age, +/- Htn/DM,
MD Dx: Primary PD Pt was seen and treated <# of Rx sessions>, <reg/irreg>, <# of handedness, gender) who was referred for PT eval and mx 2o to
Precaution: Falls, Fx & orthostatic hypotension Rx/wk> since IE <date>. (complains) and it treated (schedule) c the following PT Mx:
>Problems on IE: 1
I am respectfully endorsing BL (full name), a 60 yo male pt who is in 1 (Narrate Incident)
stage 4 HYC. Most of the tx is done passively and w diff in 2 -describe exactly what happened
communication. Pt is friendly. >Goals Achieved: -include:
1 person involved (staff, therapist, pt, visitor, witness, etc)
Present PT Mx: 2 materials or equipment involved
1 Cont/Pulsed US x 1.5 w/cm2 x 1 MHz x 5mins each on B anterior >Problems upon D/C: -exclude:
shoulder (done in supine position) 1 personal views as to why incident happened
2 GPS of B shoulder flex x 15SH x 3 reps to dec tightness 2 sarcasms and unnecessary comments
3 Rhythmic initiation on all 4s x 10 reps in all planes to maintain jpint >Present PT Rx: (Actions Taken)
integrity (planes/pattern) 1 -immediately after the incident, what has been done (sent to md,
4 Bed mob training from supine  sidelying x 3reps to inc indep in 2 bp)
bed mob >HEP c special instructions given: -what interventions were given?
5 Standing balance and tolerance inside // bars c mod +1 assist x 1 -discontinued therapy session? Continued after a rest period?
10mins to improve standing tolerance (weight shift side/AP, head 2 (Present Status)
turning, reaching within/beyond reach) (heel raise, toe raise) -as of press time…
<signature> -include follow up with hospitals and referrals
Name of Intern <designation> Sign of intern over printed name
UST PT Intern Designation
Name of Clinical Supervisor Countersigned by clinical supervisor over printed name