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Rehabilitation Conditions

Speech Impairment

Speech Impairment (adult)


Definition


Speech impairment may be any of several speech problems, particularly the following:

  • Dysarthria is difficult, poorly pronounced speech, such as slurring.
  • Aphasia is a problem with expressing or understanding written or spoken language.

Dysarthria is occasionally confused with aphasia. It is important to distinguish between a difficulty in pronunciation of words, as opposed to a problem with the production of language, as these have different causes.

Alternative Names


Language impairment; Impairment of speech; Inability to speak; Aphasia; Dysarthria; Slurred speech

Considerations


DYSARTHRIA

Dysarthria is generally apparent in daily conversation where there is difficulty expressing certain sounds or words. This condition may be caused by taking excess medications such as narcotics, phenytoin, or carbamazepine. Alcohol intoxication causes dysarthria.

Degenerative neurological (nervous system) disorders affecting the cerebellum, basal ganglia, or brainstem (all are important parts of the brain) can also cause dysarthria. Stroke that affects the brainstem or cerebellar regions can also cause dysarthria. Any facial weakness, such as Bell's palsy or tongue weakness, can cause dysarthria.

APHASIA

Aphasia is loss of communication skills that were previously learned. It commonly occurs following strokes, or in people with brain tumors or degenerative diseases that affect the language areas of the brain. This term does not apply to children who have never developed communication skills.

In some cases of aphasia, the problem eventually corrects itself, but in others the condition is irreversible.

Causes


DYSARTHRIA

  • Poorly fitting dentures
  • Alcohol intoxication
  • Side effects of medications that act on the central nervous system
  • Degenerative neurological disorders, such as Parkinson disease or Huntington disease (more common in dysarthria than aphasia)
  • Stroke
  • Transient ischemic attack (TIA)
  • Head trauma
  • Other dementias

APHASIA

  • Head trauma
  • Alzheimer's disease
  • Stroke
  • Transient ischemic attack (TIA)
  • Brain tumor (more common in aphasia than dysarthria)
  • Other dementias

Home Care


For dysarthria, speaking slowly is encouraged, and the use of hand gestures, when necessary, is recommended. Family and friends need to provide plenty of time for those afflicted with the disorder to express themselves. Medications that are causing the problem should be stopped, if possible. Use of alcohol should be minimized.

For aphasia, family members may need to provide frequent orientation reminders, such as what day it is, because disorientation and confusion often follow the onset of aphasia.

A relaxed, calm environment where external stimuli are kept to a minimum is important.

Speak in a normal tone of voice (this condition is not a hearing or emotional problem), use simple phrases to avoid misunderstandings, and don't assume that the affected person understands. Frustration, profanity, and depression are typical responses in people suffering from aphasia.

Provide communication aids, if possible, depending on the particular person and condition.

When to Contact a Medical Professional


  • If impairment or loss of communication comes on suddenly, call your health care provider immediately.
  • If there is any unexplained impairment of speech or written language, call your provider.

What to Expect at Your Office Visit


The health care provider will take a medical history and perform a physical examination. The medical history may require the assistance of family or friends.

Medical history questions documenting speech impairment may include the following:

  • When did it develop?
  • Did it develop suddenly?
  • Is there a problem with clearly pronouncing words (dysarthria)?
  • Is there a problem understanding speech?
  • Is there a problem expressing thoughts through speech?
  • Is there a problem understanding writing?
  • Is there a problem expressing thoughts through writing?
  • Has there been a recent head injury?
  • Are there problems with dentures?
  • What medications are used?
  • Is there recent or former heavy alcohol use?
  • What other symptoms are also present?

The physical examination will include a detailed evaluation of brain function.

Diagnostic tests that may be performed include the following:

  • CT scan of the head
  • MRI of the head
  • EEG
  • X-rays of the skull
  • Blood tests
  • Urine tests
  • Lumbar puncture
  • MR angiography
  • Cerebral angiography

The health care provider may provide a referral to a speech pathologist, and in some cases, to a social worker.

 

Review Date: 9/7/2006
Reviewed By: Kenneth Gross, M.D., Neurology, North Miami, FL. Review provided by VeriMed Healthcare Network.
A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org). URAC's accreditation program is an independent audit to verify that A.D.A.M. follows rigorous standards of quality and accountability. A.D.A.M. is among the first to achieve this important distinction for online health information and services. Learn more about A.D.A.M.'s editorial policy, editorial process and privacy policy. A.D.A.M. is also a founding member of Hi-Ethics and subscribes to the principles of the Health on the Net Foundation (www.hon.ch).
The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. © 1997- 2008 A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.
adam.com

Stroke

Stroke


Definition


A stroke is an interruption of the blood supply to any part of the brain. A stroke is sometimes called a "brain attack."

Alternative Names


Cerebrovascular disease; CVA; Cerebral infarction; Cerebral hemorrhage; Ischemic stroke; Stroke - ischemic

Causes


Every 45 seconds, someone in the United States has a stroke. A stroke can happen when:

  • A blood vessel carrying blood to the brain is blocked by a blood clot. This is called an ischemic stroke.
  • A blood vessel breaks open, causing blood to leak into the brain. This is a hemorrhagic stroke.

If blood flow is stopped for longer than a few seconds, the brain cannot get blood and oxygen. Brain cells can die, causing permanent damage.

ISCHEMIC STROKE

This is the most common type of stroke. Usually this type of stroke results from clogged arteries, a condition called atherosclerosis. (See stroke secondary to atherosclerosis.) Fatty deposits collect on the wall of the arteries, forming a sticky substance called plaque. Over time, the plaque builds up. Often, the plaque causes the blood to flow abnormally, which can cause the blood to clot. There are two types of clots:

  • A clot that stays in place in the brain is called a cerebral thrombus.
  • A clot that breaks loose and moves through the bloodstream to the brain is called a cerebral embolism.

Another important cause of cerebral embolisms is a type of arrhythmia called atrial fibrillation. Other causes of ischemic stroke include endocarditis, an abnormal heart valve, and having a mechanical heart valve. A clot can form on a heart valve, break off, and travel to the brain. For this reason, those with mechanical or abnormal heart valves often must take blood thinners.

HEMORRHAGIC STROKE

A second major cause of stroke is bleeding in the brain hemorrhagic stroke. This can occur when small blood vessels in the brain become weak and burst. Some people have defects in the blood vessels of the brain that make this more likely. The flow of blood after the blood vessel ruptures damages brain cells.

STROKE RISKS

High blood pressure is the number one reason that you might have a stroke. The risk of stroke is also increased by age, family history of stroke, smoking, diabetes, high cholesterol, and heart disease.

Certain medications increase the chances of clot formation, and therefore your chances for a stroke. Birth control pills can cause blood clots, especially in woman who smoke and who are older than 35.

Men have more strokes than women. But, women have a risk of stroke during pregnancy and the weeks immediately after pregnancy.

Cocaine use, alcohol abuse, head injury, and bleeding disorders increase the risk of bleeding into the brain.

See also:

  • Stroke secondary to carotid dissection (bleeding from the carotid arteries)
  • Stroke secondary to carotid stenosis (narrowing of the carotid arteries)
  • Stroke secondary to cocaine use
  • Stroke secondary to FMD (fibromuscular dysplasia)
  • Stroke secondary to syphilis
  • Hemorrhagic stroke
  • Arteriovenous malformation (AVM)

Symptoms


The symptoms of stroke depend on what part of the brain is damaged. In some cases, a person may not even be aware that he or she has had a stroke.

Usually, a SUDDEN development of one or more of the following indicates a stroke:

  • Weakness or paralysis of an arm, leg, side of the face, or any part of the body
  • Numbness, tingling, decreased sensation
  • Vision changes
  • Slurred speech, inability to speak or understand speech, difficulty reading or writing
  • Swallowing difficulties or drooling
  • Loss of memory
  • Vertigo (spinning sensation)
  • Loss of balance or coordination
  • Personality changes
  • Mood changes (depression, apathy)
  • Drowsiness, lethargy, or loss of consciousness
  • Uncontrollable eye movements or eyelid drooping

If one or more of these symptoms is present for less than 24 hours, it may be a transient ischemic attack (TIA). A TIA is a temporary loss of brain function and a warning sign for a possible future stroke.

Exams and Tests


In diagnosing a stroke, knowing how the symptoms developed is important. The symptoms may be severe at the beginning of the stroke, or they may progress or fluctuate for the first day or two (stroke in evolution). Once there is no further deterioration, the stroke is considered completed.

During the exam, your doctor will look for specific neurologic, motor, and sensory deficits. These often correspond closely to the location of the injury in the brain. An examination may show changes in vision or visual fields, abnormal reflexes, abnormal eye movements, muscle weakness, decreased sensation, and other changes. A "bruit" (an abnormal sound heard with the stethoscope) may be heard over the carotid arteries of the neck. There may be signs of atrial fibrillation.

Tests are performed to determine the type, location, and cause of the stroke and to rule out other disorders that may be responsible for the symptoms. These tests include:

  • Head CT or head MRI -- used to determine if the stroke was caused by bleeding (hemorrhage) or other lesions and to define the location and extent of the stroke.
  • ECG (electrocardiogram) -- used to diagnose underlying heart disorders.
  • Echocardiogram -- used if the cause may be an embolus (blood clot) from the heart.
  • Carotid duplex (a type of ultrasound) -- used if the cause may be carotid artery stenosis (narrowing of the major blood vessels supplying blood to the brain).
  • Heart monitor -- worn while in the hospital or as an outpatient to determine if a heart arrhythmia (like atrial fibrillation) may be responsible for your stroke.
  • Cerebral (head) angiography -- may be done so that the doctor can identify the blood vessel responsible for the stroke. Mainly used if surgery is being considered.
  • Blood work may be done to exclude immune conditions or abnormal clotting of the blood that can lead to clot formation.

Treatment


A stroke is a medical emergency. Physicians have begun to call it a "brain attack" to stress that getting treatment immediately can save lives and reduce disability. Treatment varies, depending on the severity and cause of the stroke. For virtually all strokes, hospitalization is required, possibly including intensive care and life support.

The goal is to get the person to the emergency room immediately, determine if he or she is having a bleeding stroke or a stroke from a blood clot, and start therapy -- all within 3 hours of when the stroke began.

IMMEDIATE TREATMENT

Thrombolytic medicine, such as tPA, breaks up blood clots and can restore blood flow to the damaged area. People who receive this medicine are more likely to have less long-term impairment. However, there are strict criteria for who can receive thrombolytics. The most important is that the person be examined and treated by a specialized stroke team within 3 hours of when the symptoms start. If the stroke is caused by bleeding rather than clotting, this treatment can make the damage worse -- so care is needed to diagnose the cause before giving treatment.

In other circumstances, blood thinners such as heparin and Coumadin are used to treat strokes. Aspirin may also be used.

Other medications may be needed to control associated symptoms. Pain killers may be needed to control severe headache. Medicine may be needed to control high blood pressure.

Nutrients and fluids may be necessary, especially if the person has swallowing difficulties. The nutrients and fluids may be given through an intravenous tube (IV) or a feeding tube in the stomach (gastrostomy tube). Swallowing difficulties may be temporary or permanent.

For hemorrhagic stroke, surgery is often required to remove pooled blood from the brain and to repair damaged blood vessels.

LONG-TERM TREATMENT

The goal of long-term treatment is to recover as much function as possible and prevent future strokes. Depending on the symptoms, rehabilitation includes speech therapy, occupational therapy, and physical therapy. The recovery time differs from person to person.

Certain therapies, such as repositioning and range-of-motion exercises, are intended to prevent complications related to stroke, like infections and bed sores. People should stay active within their physical limitations. Sometimes, urinary catheterization or bladder/bowel control programs may be needed to control incontinence.

The person's safety must be considered. Some people with stroke appear to have no awareness of their surroundings on the affected side. Others show indifference or lack of judgment, which increases the need for safety precautions. For these people, friends and family members should repeatedly reinforce important information, like name, age, date, time, and where they live, to help the person stay oriented.

Caregivers may need to show the person pictures, repeatedly demonstrate how to perform tasks, or use other communication strategies, depending on the type and extent of the language problems.

In-home care, boarding homes, adult day care, or convalescent homes may be required to provide a safe environment, control aggressive or agitated behavior, and meet medical needs.

Behavior modification may be helpful for some people in controlling unacceptable or dangerous behaviors.

Family counseling may help in coping with the changes required for home care. Visiting nurses or aides, volunteer services, homemakers, adult protective services, and other community resources may be helpful.

Legal advice may be appropriate. Advance directives, power of attorney, and other legal actions may make it easier to make ethical decisions regarding the care of a person who has had a stroke.

Support Groups


Additional support and resources are available from the American Stroke Association -- www.strokeassociation.org.

Outlook (Prognosis)


The long-term outcome from a stroke depends on the extent of damage to the brain, the presence of any associated medical problems, and the likelihood of recurring strokes.

Of those who survive a stroke, many have long-term disabilities, but about 10% of those who have had a stroke recover most or all function. Fifty percent are able to be at home with medical assistance while 40% become residents of a long-term care facility like a nursing home.

Possible Complications


  • Problems due to loss of mobility (joint contractures, pressure sores)
  • Permanent loss of movement or sensation of a part of the body
  • Bone fractures
  • Muscle spasticity
  • Permanent loss of brain functions
  • Reduced communication or social interaction
  • Reduced ability to function or care for self
  • Decreased life span
  • Side effects of medications
  • Aspiration
  • Malnutrition

When to Contact a Medical Professional


Call your local emergency number (such as 911) if someone has symptoms of a stroke. Stroke requires immediate treatment!

Prevention


To help prevent a stroke:

  • Get screened for high blood pressure every 1 - 2 years, especially if you have a family history of high blood pressure.
  • Have your cholesterol checked. If you are high risk, your LDL "bad" cholesterol should be lower than 100 mg/dL. Your doctor may recommend you try to reduce your LDL cholesterol to as low as 70 mg/dL.
  • If you have high blood pressure, diabetes, high cholesterol, and heart disease, make sure you follow your doctor's treatment recommendations.
  • Follow a low-fat diet.
  • Quit smoking.
  • Exercise regularly -- 30 minutes a day if you are not overweight; 60 - 90 minutes a day if you are overweight.
  • Do not drink more than 1 to 2 alcoholic drinks a day.

Aspirin therapy (81mg a day or 100mg every other day) is now recommended for stroke prevention in women under 65 as long as the benefits outweigh the risks. It should be considered for women over age 65 only if their blood pressure is controlled and the benefit is greater than the risk of gastrointestinal bleeding and brain hemorrhage. Ask your doctor if aspirin is right for you.

Your doctor may also recommend that you take aspirin or another blood thinner if you have had a TIA or stroke in the past, or if you currently have a heart arrhythmia (like atrial fibrillation), mechanical heart valve, congestive heart failure, or risk factors for stroke.

Carotid endarterectomy (removal of plaque from the carotid arteries) may help prevent new strokes from occurring in people with large blockage in their blood vessels.

References


American Heart Association. Heart Disease and Stroke Statistics -- 2005 Update. Dallas, Texas: American Heart Association; 2005.

Goldman L, Ausiello D, eds. Cecil Textbook of Medicine, 22nd ed. Philadelphia, Pa: Saunders; 2004.

Marx JA, Hockberger RS, Walls RM, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 5th ed. St. Louis, Mo: Mosby; 2002.

Mosca L, Banka CL, Benjamin EJ, et al. Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women: 2007 Update. Circulation. 2007; Published online before print February 19, 2007.

Wolff T, Miller T. Evidence for the reaffirmation of the U.S. Preventive Services Task Force recommendation on screening for high blood pressure. Ann Intern Med. 2007;147(11): 787-91.

 

Review Date: 3/21/2008
Reviewed By: A.D.A.M. Editorial Team: David Zieve, MD, MHA, Greg Juhn, MTPW, David R. Eltz, Kelli A. Stacy, ELS. Previously reviewed by Larry A. Weinrauch, MD, Assistant Professor of Medicine, Harvard Medical School, and Private practice specializing in Cardiovascular Disease, Watertown, MA. Review provided by VeriMed Healthcare Network (3/15/2007).
A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org). URAC's accreditation program is an independent audit to verify that A.D.A.M. follows rigorous standards of quality and accountability. A.D.A.M. is among the first to achieve this important distinction for online health information and services. Learn more about A.D.A.M.'s editorial policy, editorial process and privacy policy. A.D.A.M. is also a founding member of Hi-Ethics and subscribes to the principles of the Health on the Net Foundation (www.hon.ch).
The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. © 1997- 2008 A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.
adam.com

Brain / Head Injury

Head Injury


Definition


A head injury is any trauma that leads to injury of the scalp, skull, or brain. The injuries can range from a minor bump on the skull to serious brain injury.

Head injury is classified as either closed or open (penetrating).

  • A closed head injury means you received a hard blow to the head from striking an object.
  • An open, or penetrating, head injury means you were hit with an object that broke the skull and entered the brain. This usually happens when you move at high speed, such as going through the windshield during a car accident. It can also happen from a gunshot to the head.

There are several types of brain injuries. Two common types of head injuries are:

  • Concussion, the most common type of traumatic brain injury
  • Contusion, which is a bruise on the brain

See also:

  • Subarachnoid hemorrhage
  • Subdural hematoma

Alternative Names


Brain injury; Head trauma; Contusion

Considerations


Every year, millions of people sustain a head injury. Most of these injuries are minor because the skull provides the brain with considerable protection. The symptoms of minor head injuries usually go away on their own. More than half a million head injuries a year, however, are severe enough to require hospitalization.

Learning to recognize a serious head injury, and implementing basic first aid, can make the difference in saving someone's life.

In patients who have suffered a severe head injury, there is often one or more other organ systems injured. For example, a head injury is sometimes accompanied by a spinal injury.

Causes


Common causes of head injury include traffic accidents, falls, physical assault, and accidents at home, work, outdoors, or while playing sports.

Some head injuries result in prolonged or non-reversible brain damage. This can occur as a result of bleeding inside the brain or forces that damage the brain directly. These more serious head injuries may cause:

  • Changes in personality, emotions, or mental abilities
  • Speech and language problems
  • Loss of sensation, hearing, vision, taste, or smell
  • Seizures
  • Paralysis
  • Coma

Symptoms


The signs of a head injury can occur immediately or develop slowly over several hours. Even if the skull is not fractured, the brain can bang against the inside of the skull and be bruised. (This is called a concussion.) The head may look fine, but complications could result from bleeding inside the skull.

When encountering a person who just had a head injury, try to find out what happened. If he or she cannot tell you, look for clues and ask witnesses. In any serious head trauma, always assume the spinal cord is also injured.

The following symptoms suggest a more serious head injury -- other than a concussion or contusion -- and require emergency medical treatment:

  • Loss of consciousness, confusion, or drowsiness
  • Low breathing rate or drop in blood pressure
  • Convulsions
  • Fracture in the skull or face, facial bruising, swelling at the site of the injury, or scalp wound
  • Fluid drainage from nose, mouth, or ears (may be clear or bloody)
  • Severe headache
  • Initial improvement followed by worsening symptoms
  • Irritability (especially in children), personality changes, or unusual behavior
  • Restlessness, clumsiness, lack of coordination
  • Slurred speech or blurred vision
  • Inability to move one or more limbs
  • Stiff neck or vomiting
  • Pupil changes
  • Inability to hear, see, taste, or smell

First Aid


Get medical help immediately if the person:

  • Becomes unusually drowsy
  • Develops a severe headache or stiff neck
  • Vomits more than once
  • Loses consciousness (even if brief)
  • Behaves abnormally

For a moderate to severe head injury, take the following steps:

  1. Call 911.
  2. Check the person's airway, breathing, and circulation. If necessary, begin rescue breathing and CPR.
  3. If the person's breathing and heart rate are normal but the person is unconscious, treat as if there is a spinal injury. Stabilize the head and neck by placing your hands on both sides of the person's head, keeping the head in line with the spine and preventing movement. Wait for medical help.
  4. Stop any bleeding by firmly pressing a clean cloth on the wound. If the injury is serious, be careful not to move the person's head. If blood soaks through the cloth, DO NOT remove it. Place another cloth over the first one.
  5. If you suspect a skull fracture, DO NOT apply direct pressure to the bleeding site, and DO NOT remove any debris from the wound. Cover the wound with sterile gauze dressing.
  6. If the person is vomiting, roll the head, neck, and body as one unit to prevent choking. This still protects the spine, which you must always assume is injured in the case of a head injury. (Children often vomit ONCE after a head injury. This may not be a problem, but call a doctor for further guidance.)
  7. Apply ice packs to swollen areas.

For a mild head injury, no specific treatment may be needed. However, closely watch the person for any concerning symptoms over the next 24 hours. The symptoms of a serious head injury can be delayed. While the person is sleeping, wake him or her every 2 to 3 hours and ask simple questions to check alertness, such as "What is your name?"

If a child begins to play or run immediately after getting a bump on the head, serious injury is unlikely. However, as with anyone with a head injury, closely watch the child for 24 hours after the incident.

Over-the-counter pain medicine (like acetaminophen or ibuprofen) may be used for a mild headache. DO NOT take aspirin, because it can increase the risk of bleeding.

DO NOT

  • DO NOT wash a head wound that is deep or bleeding a lot.
  • DO NOT remove any object sticking out of a wound.
  • DO NOT move the person unless absolutely necessary.
  • DO NOT shake the person if he or she seems dazed.
  • DO NOT remove a helmet if you suspect a serious head injury.
  • DO NOT pick up a fallen child with any sign of head injury.
  • DO NOT drink alcohol within 48 hours of a serious head injury.

When to Contact a Medical Professional


Call 911 if:

  • There is severe head or facial bleeding.
  • The person is confused, drowsy, lethargic, or unconscious.
  • The person stops breathing.
  • You suspect a serious head or neck injury or the person develops any symptoms of a serious head injury.

Prevention

  • Always use safety equipment during activities that could result in head injury. These include seat belts, bicycle or motorcycle helmets, and hard hats.
  • Obey traffic signals when riding a bicycle. Be predictable so that other drivers will be able to determine your course.
  • Be visible. DO NOT ride a bicycle at night.
  • Use age-appropriate car seats or boosters for babies and young children.
  • Make sure that children have a safe area in which to play.
  • Supervise children of any age.
  • DO NOT drink and drive, and DO NOT allow yourself to be driven by someone who you know or suspect has been drinking alcohol.

References


Marx JA, Hockberger RS, Walls RM, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 5th ed. St. Louis, Mo: Mosby; 2002.

DeLee JC, Drez, Jr., D, Miller MD, eds. DeLee and Drez’s Orthopaedic Sports Medicine. 2nd ed. Philadelphia, Pa: Saunders; 2003.

Goetz CG, Pappert EJ. Textbook of Clinical Neurology. 2nd ed. Philadelphia, Pa: Saunders; 2003:1130-1134.

 

Review Date: 1/8/2007
Reviewed By: Eric Perez, MD, Department of Emergency Medicine, St. Luke's-Roosevelt Hospital Center, New York, NY. Review provided by VeriMed Healthcare Network.
A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org). URAC's accreditation program is an independent audit to verify that A.D.A.M. follows rigorous standards of quality and accountability. A.D.A.M. is among the first to achieve this important distinction for online health information and services. Learn more about A.D.A.M.'s editorial policy, editorial process and privacy policy. A.D.A.M. is also a founding member of Hi-Ethics and subscribes to the principles of the Health on the Net Foundation (www.hon.ch).
The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. © 1997- 2008 A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.
adam.com

Spinal Injury

Spinal injury


Definition


Your spinal cord contains the nerves that carry messages between your brain and body. The cord passes through your neck and back. A spinal cord injury is very serious because it can cause paralysis below the site of the injury.

Alternative Names


Neck injury

Considerations


When someone has a spinal injury, additional movement may cause further damage to the nerves in the cord and can sometimes mean the difference between life and death.

If you think someone could possibly have a spinal injury, DO NOT move the injured person even a little bit, unless it is absolutely necessary (like getting someone out of a burning car).

If you are in doubt about whether a person has a spinal injury, assume that he or she DOES have one.

Causes

  • Bullet or stab wound
  • Direct trauma to the face, neck, head, or back (e.g., car accidents)
  • Diving accident
  • Electric shock
  • Extreme twisting of the trunk
  • Sports injury (landing on head)
  • Major blow to the head or chest, car accident, fall from a great height

Symptoms


  • Head held in unusual position
  • Numbness or tingling that radiates down an arm or leg
  • Weakness
  • Difficulty walking
  • Paralysis of arms or legs
  • No bladder or bowel control
  • Shock (pale, clammy skin; bluish lips and fingernails; acting dazed or semi-conscious)
  • Unconscious
  • Stiff neck, headache, or neck pain

First Aid


The main goal is to keep the person immobile and safe until medical help arrives.

  1. You or someone else should call 911.
  2. Hold the person's head and neck in the position in which they were found. DO NOT attempt to reposition the neck. Do not allow the neck to bend or twist.
IF THE PERSON IS UNRESPONSIVE
  1. Check the person's breathing and circulation. If necessary, begin rescue breathing and CPR.
  2. DO NOT tilt the head back when attempting to open the airway. Instead, place your fingers on the jaw on each side of the head. Lift the jaw forward.

IF YOU NEED TO ROLL THE PERSON

Do not roll the person over unless the person is vomiting or choking on blood, or you need to check for breathing.

  1. Two people are needed.
  2. One person should be stationed at the head, the other at the person's side.
  3. Keep the person's head, neck, and back in line with each other while you roll him or her onto one side.

DO NOT

  • DO NOT bend, twist, or lift the person's head or body.
  • DO NOT attempt to move the person before medical help arrives unless it is absolutely necessary.
  • DO NOT remove a helmet if a spinal injury is suspected.

When to Contact a Medical Professional


Call you local emergency number (such as 911) if there has been any injury that affects the neck or spinal cord. Keep the person absolutely immobile. Unless there is urgent danger, keep the person in the position where he or she was found.

Prevention

  • Wear seat belts.
  • Avoid drinking alcohol and driving.
  • Avoid diving into pools, lakes, rivers and surf, particularly if you cannot determine the depth of the water, or if the water is not clear.
  • Avoid motorcycles and all-terrain vehicles.
  • Avoid "spearing" (tackling or diving into a person with your head).

References


Marx JA, Hockberger RS, Walls RM, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 5th ed. St. Louis, Mo: Mosby; 2002.

Townsend, Jr., CM, ed. Sabiston Textbook of Surgery. 17th ed. Philadelphia, Pa: Elsevier; 2004:498-502,1952.

DeLee JC, Drez, Jr., D, Miller MD, eds. DeLee and Drez’s Orthopaedic Sports Medicine. 2nd ed. Philadelphia, Pa: Saunders; 2003:798,837.

 

Review Date: 7/25/2007
Reviewed By: Andrew L. Chen, M.D., M.S., Orthopedist, The Alpine Clinic, Littleton, NH. Review provided by VeriMed Healthcare Network.
A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org). URAC's accreditation program is an independent audit to verify that A.D.A.M. follows rigorous standards of quality and accountability. A.D.A.M. is among the first to achieve this important distinction for online health information and services. Learn more about A.D.A.M.'s editorial policy, editorial process and privacy policy. A.D.A.M. is also a founding member of Hi-Ethics and subscribes to the principles of the Health on the Net Foundation (www.hon.ch).
The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. © 1997- 2008 A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.
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Joint Replacement

Knee joint replacement


Definition


Knee joint replacement is surgery to replace a painful damaged or diseased knee joint with an artificial joint (prosthesis).

Alternative Names


Total knee replacement; Knee arthroplasty; Knee replacement - total 

Description


The operation is done while you are asleep and without pain (general anesthesia). The orthopedic surgeon makes a cut over the affected knee. The knee cap (patella) is moved out of the way, and the ends of the thigh bone (femur) and shin bone (tibia) are cut to fit the prosthesis. The undersurface of the knee cap is cut to allow the surgeon to place an artificial piece.

The two parts of the prosthesis are placed onto the ends of the femur, the tibia, and the undersurface of the patella using a special bone cement. Usually, metal is used on the end of the femur, and plastic is used on the tibia and patella, for the new knee surface. However, surgeons are now using newer surfaces, including metal on metal, ceramic on ceramic, or ceramic on plastic.

In some cases, a mini-incision may be used to avoid cutting the tendon on the front of the knee. This may allow for faster, less painful recovery, but it has risks because of the difficulty of the surgery and the lack of a clear view for the surgeon.

A foley catheter may be inserted during surgery to monitor the function of your kidneys and hydration level. This will be removed on the second or third day after surgery. You will be encouraged to try to walk to the bathroom with help.

Why the Procedure is Performed

Knee joint replacement may be recommended for:

  • Knee pain that hasn't responded to other therapy (including medication, injections, and physical therapy for 6 months or more)
  • Knee pain that limits or prevents activities
  • Arthritis of the knee
  • Decreased knee function caused by arthritis
  • Inability to sleep through the night because of knee pain
  • Some tumors involving the knee

Knee joint replacement is usually not recommended for:

  • Current knee infection
  • Poor skin cover around the knee
  • Paralysis of the muscles in the front of the thigh (quadriceps)
  • Severe peripheral vascular disease or neuropathy that affect the knee
  • Severe mental dysfunction
  • Terminal disease (for example, cancer that has spread)
  • Morbid obesity (over 300 pounds)

Risks


The risks of this surgery include:

  • Blood clots in the legs (deep vein thrombosis or DVT)
  • DVT that breaks loose and goes to the lungs (embolus)
  • Pneumonia
  • Infection requiring removal of the joint
  • Loosening of the prosthesis
  • Displacement of the prosthesis

People who have a prosthetic device (such as an artificial joint) need to carefully protect against infection. You should carry a medical identification card indicating that you have a prosthetic device. Also, always tell your health care provider about your prosthetic knee joint. You should take antibiotics before any dental work or any invasive procedure.

Outlook (Prognosis)


The results of a total knee replacement are often excellent. The operation relieves pain in most patients, and most need no help walking after recovery. Most prostheses last 10 to 15 years, some as long as 20 years, before loosening and needing another surgery.

Recovery


After surgery, you will have a large dressing on the knee area. A small drainage tube will be placed during surgery to help drain excess fluids from the joint area.

You will also have an IV in place to provide fluids until you are able to drink. Special stockings are placed on your legs to reduce your risk of getting blood clots, which are more common after leg surgery.

Your doctor will prescribe pain medicines and, possibly, antibiotics to prevent infection.

You will stay in the hospital for 3-5 days, but the total recovery period varies from 2-3 months to a year.

You will be encouraged to start moving and walking as early as the first day after surgery. You will be helped out of bed to a chair on the first day after surgery. When in bed, bend and straighten your ankles often to prevent blood clots.

Some surgeons recommend using a continuous passive motion (CPM) machine that will bend the knee for you while you're in bed. Over time, the rate and amount of bending will increase. Always keep your leg in the CPM device when in bed. This device helps speed recovery, and reduces pain, bleeding, and infection.

Some patients need a short stay in a rehabilitation hospital to become safely independent in their daily activities. You might need to use crutches or a walker for a few weeks or even months after surgery.

The physical therapy started in the hospital will continue after you've gone home until your strength and motion return. Avoid contact sports, but you should be able to do low impact activities, such as swimming and golf, after you fully recover from surgery.

 

Review Date: 8/6/2007
Reviewed By: Thomas N. Joseph, MD, Private Practice specializing in Orthopaedics, subspecialty Foot and Ankle, Camden Bone Joint, Camden, SC. Review provided by VeriMed Healthcare Network.
A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org). URAC's accreditation program is an independent audit to verify that A.D.A.M. follows rigorous standards of quality and accountability. A.D.A.M. is among the first to achieve this important distinction for online health information and services. Learn more about A.D.A.M.'s editorial policy, editorial process and privacy policy. A.D.A.M. is also a founding member of Hi-Ethics and subscribes to the principles of the Health on the Net Foundation (www.hon.ch).
The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. © 1997- 2008 A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.
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Spinal Cord Trauma

Spinal cord trauma


Definition


Spinal cord trauma is damage to the spinal cord. It may result from direct injury to the cord itself or indirectly from damage to surrounding bones, soft tissues, and blood vessels.

Alternative Names


Spinal cord injury; Compression of spinal cord

Causes


Spinal cord trauma can be caused by any number of injuries to the spine. They can result from motor vehicle accidents, falls, sports injuries (particularly diving into shallow water), industrial accidents, gunshot wounds, assault, and others.

A minor injury can cause spinal cord trauma if the spine is weakened (such as from rheumatoid arthritis or osteoporosis) or if the spinal canal protecting the spinal cord has become too narrow (spinal stenosis) due to the normal aging process.

Direct injury, such as cuts, can occur to the spinal cord, particularly if the bones or the disks have been damaged. Fragments of bone (from fractured vertebrae, for example) or fragments of metal (such as from a traffic accident) can cut or damage the spinal cord.

Direct damage can also occur if the spinal cord is pulled, pressed sideways, or compressed. This may occur if the head, neck, or back are twisted abnormally during an accident or injury.

Bleeding, fluid accumulation, and swelling can occur inside the spinal cord or outside the spinal cord (but within the spinal canal). The accumulation of blood or fluid can compress the spinal cord and damage it.

Most spinal cord trauma occurs to young, healthy individuals. Males between ages 15 and 35 are most commonly affected. The death rate tends to be higher in young children with spinal injuries.

Risk factors include participating in risky physical activities, not wearing protective gear during work or play, or diving into shallow water.

Older people with weakened spines (from osteoporosis) may be more likely to have a spinal cord injury. Patients who have other medical problems that make them prone to falling from weakness or clumsiness (from stroke, for example) may also be more susceptible.

Symptoms


Symptoms vary somewhat depending on the location of the injury. Spinal cord injury results in varying degrees of weakness and sensory loss at and below the injury. The pattern depends on whether the entire cord is injured (complete) or only partially (incomplete).

The spinal cord doesn't go below the 1st lumbar vertebra, so injuries at and below this level do not cause spinal cord injury. However, they may cause "cauda equina syndrome" -- injury to the nerve roots in this area.

CERVICAL (NEAR THE NECK) INJURIES

When spinal cord injuries occur near the neck, varying degrees of symptoms can affect both the arms and the legs:

  • Weakness, paralysis
  • Breathing difficulties (from paralysis of the breathing muscles)
  • Spasticity (increased muscle tone)
  • Sensory changes
  • Numbness
  • Pain
  • Loss of normal bowel and bladder control (such as constipation, incontinence, bladder spasms)

THORACIC (CHEST-LEVEL) INJURIES

When spinal injuries occur at chest level, varying degrees of symptoms can affect the legs:

  • Weakness, paralysis
  • Breathing difficulties (from paralysis of the breathing muscles)
  • Spasticity (increased muscle tone)
  • Sensory changes
  • Numbness
  • Pain
  • Loss of normal bowel and bladder control (such as constipation, incontinence, bladder spasms)

Injuries to the cervical or high thoracic cord may also result in blood pressure problems, abnormal sweating, and trouble maintaining regular body temperature.

Exams and Tests


Spinal cord injury is a medical emergency requiring immediate attention.

The health care provider will perform a physical exam, including a neurological exam. This will help identify the exact location of the injury, if it is not already known. Some of the person's reflexes may be abnormal or absent. Once swelling goes down, some reflexes may slowly recover.

The following tests may be ordered:

  • Spine x-rays may show fracture or damage to the bones of the spine.
  • A CT scan or MRI of the spine may show the location and extent of the damage and reveal problems such as blood clots (hematomas).
  • Myelogram (an x-ray of the spine after injection of dye) may be necessary in rare cases.
  • Somatosensory evoked potential (SSEP) testing or magnetic stimulation may show if nerve signals can pass through the spinal cord.

Treatment


A spinal cord trauma is a medical emergency requiring immediate treatment to reduce the long-term effects. The time between the injury and treatment is a critical factor affecting the eventual outcome.

Corticosteroids, such as dexamethasone or methylprednisolone, are used to reduce swelling that may damage the spinal cord. If spinal cord compression is caused by a mass (such as a hematoma or bony fragment) that can be removed or brought down before there is total destruction of the nerves of the spine, paralysis may in some cases be reduced or relieved. Ideally, corticosteroids should begin as soon as possible after the injury.

Surgery may be necessary. This may include surgery to remove fluid or tissue that presses on the spinal cord (decompression laminectomy). Surgery may be needed to remove bone fragments, disk fragments, or foreign objects or to stabilize fractured vertebrae (by fusion of the bones or insertion of hardware).

Bedrest may be needed to allow the bones of the spine, which bears most of the weight of the body, to heal.

Anatomic realignment is important. Spinal traction may reduce dislocation and/or may be used to immobilize the spine. The skull may be immobilized with tongs (metal braces placed in the skull and attached to traction weights or to a harness on the body).

Treatment will address muscle spasms, care of the skin, and bowel and bladder dysfunction.

Extensive physical therapy, occupational therapy, and other rehabilitation interventions are often required after the acute injury has healed. Rehabilitation assists the person in coping with disability that results from spinal cord trauma.

Spasticity can be reduced by many oral medications, medications that are injected into the spinal canal, or injections of botulinum toxins into the muscles. It is important to treat pain with analgesics, muscle relaxants, or physical therapy modalities.

Support Groups


For organizations that provide support and additional information, see spinal injury resources.

Outlook (Prognosis)


Paralysis and loss of sensation of part of the body are common. This includes total paralysis or numbness and varying degrees of movement or sensation loss. Death is possible, particularly if there is paralysis of the breathing muscles.

How well a person does depend on the level of injury. Injuries near the top of the spine result in more extensive disability than injuries low in the spine.

Recovery of some movement or sensation within 1 week usually means the person will eventually recover most function, although this may take 6 months or more. Losses that remain after 6 months are more likely to be permanent.

Possible Complications

  • Paralysis (paraplegia, quadriplegia)
  • Loss of sensation
  • Loss of bladder control
  • Increased risk of urinary tract infections
  • Increased risk of chronic bilateral obstructive nephropathy
  • Loss of bowel control
  • Loss of sexual functioning (male impotence)
  • Paralysis of breathing muscles
  • Increased risk of injury to numb areas of the body
  • Pain
  • Complications of immobility:
    • Deep vein thrombosis
    • Pulmonary infections
    • Skin breakdown
    • Contractures
  • Shock
  • Blood pressure changes - can be extreme
  • Muscle spasticity

When to Contact a Medical Professional


Call your health care provider if injury to the back or neck occurs. Call 911 if there is any loss of movement or sensation. This is a medical emergency!

Management of spinal cord injury begins at the site of an accident with paramedics trained in immobilizing the injured spine to prevent further damage to the nervous system. Someone suspected of having a spinal cord injury should NOT be moved without immobilization unless there is an immediate threat.

Prevention


Safety practices during work and recreation can prevent many spinal cord injuries. Use proper protective equipment if an injury is possible.

Diving into shallow water is a major cause of spinal cord trauma. Check the depth of water before diving, and look for rocks or other possible obstructions.

Football and sledding injuries often involve sharp blows or abnormal twisting and bending of the back or neck and can result in spinal cord trauma. Use caution when sledding and inspect the area for obstacles. Use appropriate techniques and equipment when playing football or other contact sports.

Falls while climbing at work or during recreation can result in spinal cord injuries. Defensive driving and wearing seat belts greatly reduces the risk of serious injury if there is an automobile accident.

 

Review Date: 7/14/2006
Reviewed By: J.A. Lee, M.D., Division of Surgery, UCSF, San Francisco, CA. Review provided by VeriMed Healthcare Network.
A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org). URAC's accreditation program is an independent audit to verify that A.D.A.M. follows rigorous standards of quality and accountability. A.D.A.M. is among the first to achieve this important distinction for online health information and services. Learn more about A.D.A.M.'s editorial policy, editorial process and privacy policy. A.D.A.M. is also a founding member of Hi-Ethics and subscribes to the principles of the Health on the Net Foundation (www.hon.ch).
The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. © 1997- 2008 A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.
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