RCS 6080 Medical and Psychosocial Aspects of Rehabilitation Counseling Spinal Cord Injury Anatomy of the Spine Vertebrae Body
Lamina Towards the back Boney arch surrounds spinal canal Spinous process Front section, shaped like drum Supports weight Boney process from arch
Points of attachment for muscles and ligaments Discs Cushions between vertebrae Anatomy of the Spine Vertebrae: 7 Cervical 12 Thoracic
Larger boney structures to support added wgt 5 Sacral Chest region, allows mostly for rotation 5 Lumbar Flexion, extension, bending and turning of
head Fused together Coccyx Anatomy of the Cord Cervical Cord
C1-C2: C3-4: Phrenic nucleus C4: Deltoids C4-5: Biceps C6: Wrist extensors C7: Triceps C8: Wrist extensors C8-T1: Hand muscles Anatomy of the Cord Thoracic Cord Lumbarsacral
Intercostal muscles and associated dermatones Starts at T9 and continues to L2 Innervates hips, legs, buttocks and anal region Cauda Equina (horses tail) Spinal cord ends at L2 Tip called conus, below conus a spray of spinal roots Dermatomes/Sensory Level
Dermatome: patch of skin innervated by a given spinal cord level C2 to C4. The C2 dermatome Myotomes/Motor Level Myotome: Spinal nerve roots which innervates
muscles groups Most muscles are innervated by more than one root ASIA Impairment Scale ASIA A: Complete: no motor or sensory function is preserved in the sacral segments S4-S5 ASIA B: Incomplete: sensory but NOT motor
function is preserved below the neurological level and includes the sacral segments ASIA C: Incomplete: motor function is preserved below the neurological level and more than half of key muscles below the neurological level have a muscle grade <3 ASIA D: Incomplete: motor function is preserved w/ muscle grade > 3 ASIA E: Normal Definition of Disability Tetraplegia (preferred to quadriplegia)
Refers to impairment or loss of motor/ sensory function in cervical segments of the spinal cord Impairment of function in arms, trunk, legs and pelvic organs ASIA Scale vs quadriparesis Definition of Disability Paraplegia
Refers to impairment or loss of motor/ sensory function in thoracic, lumbar or sacral segments of the spinal cord Arm function spared Possible impairment of function in trunk, legs and pelvic organs ASIA Scale vs paraparesis Clinical Syndromes Central Cord Syndrome:
lesion occurring almost exclusively in the cervical region Sacral sensory sparing Weakness > UE vs LE Brown-Sequard Syndrome: Lesion that produces ipsilateral, proprioceptive and motor loss and contralateral loss of sensitivity to pain and temp Clinical Syndromes Anterior Cord Syndrome:
Lesion that produces variable loss of motor function and of sensitivity while preserving proprioception Cauda Equina Syndrome: Injury to the lumbosacral nerve roots w/ in the neurocanal resulting in areflexive bladder, bowel and lower limbs Achievement of Functional Goals
Age Body type Comorbidities Prior athletic sense Fatigue level
Type of stabilization HX HO/POA Spasticity Psychosocial factors Nutrition Functional Outcomes Motor/sensory recovery Ability to perform or direct ADLs Social reintegration Quality of life
Functional Outcomes LEVEL C1-C3 Limited head/neck movement Rotate/flex neck (sternocleidomastoid) Extend neck (cervical paraspinals) Speech and swallowing (neck accessories)
Total paralysis of trunk,UE and LE LEVEL: C1-3 ADLs 24 hr care needs Able to direct care needs
Ventilator dependent Impaired communication Dependent for all care needs Mobility Power wheelchair Hoyer lift LEVEL: C1-C3 Equipment Needs
Adapted computer Bedside/portable ventilator Suction machine Specialty bed Hoyer Reclining shower chair Functional Outcomes LEVEL: C4
Head and neck control (cerv paraspinals) Shoulder shrug (upper traps) Inspiration(diaphragm) Lack of shoulder control (deltoids) Paralysis of trunk, UE and LE Inability to cough, low respiratory reserve LEVEL: C4
ADLs 24 hr care needs Able to direct care needs May or may not be vent dependent Improved communication Assisted cough Dependent for all care needs Mobility
Power wheelchair Hoyer lift LEVEL: C4 Equipment Needs Adapted computer Bedside/portable ventilator as
needed Suction machine Specialty bed Hoyer Reclining shower chair Functional Outcomes LEVEL: C5
Shoulder control (deltoids) Elbow flexion (biceps/elbow flexors) Supinate hands (brachialis and brachioradialis) Lack elbow extension and hand pronation Paralysis of trunk and LE LEVEL: C5 10hrs personal care need 6 hrs homemaking assistance ADLs
Set-up/equipment: eating, drinking, face wash and teeth Assisted cough Dependent for bowel, bladder and lower body hygiene Dependent for bed mobility and transfers LEVEL: C5 Mobility
Hoyer or stand pivot Power wheelchair w/ hand controls Manual wheelchair Drive motor vehicle w/ hand controls Equipment Needs Power and manual wheelchairs Adaptive splints/braces Page turners/computer adaptations
Functional Outcomes LEVEL: C6 Wrist extension (extensor carpi ulnaris and extensor carpi radialis longus/brevis) Arm across chest (clavicular pectrocialis) Lack elbow extension (triceps) Lack wrist flexion Lack hand control Paralysis of trunk and LE
LEVEL: C6 6 hrs personal care needs 4hrs homemaking assistance ADLs Assisted cough Set-up for feeding, bathing and dressing
Independent pressure relief, turns and skin assessment May be independent for bowel/bladder care LEVEL: C6 Mobility Independent slide board transfer Manual wheelchair Drive with adaptive equipment Functional Outcomes LEVEL: C7
Elbow flexion and extension (biceps/triceps) Arm toward body (sternal pectoralis) Lack finger function Lack trunk stability LEVEL: C7 6hrs personal care needs
2hrs homemaking assistance ADLs More effective cough Fewer adaptive aids Independent w/ all ADLs May need adaptive aids for bowel care LEVEL: C7 Mobility
Manual wheelchair Transfers without adaptive equipment Functional Outcomes LEVEL: C8-T1 Increased finger and hand strength
Finger flexion (flexor digitorum) Finger extension (extensor communis) Thumb movement (policus longis brevis) Separate fingers (introssi separates) LEVEL: C8-T1 ADLs
4hrs personal care needs 2hrs homemaking assistance Independent w/ or w/o assistive devices Assist w/ complex meal prep and home management Mobility Manual wheelchair Functional Outcomes LEVEL: T2-T6
Normal motor function of head, neck, shoulders, arms, hands and fingers Increased use of intercostals Increase trunk control (erector spinae) LEVEL: T2-T6 ADLs
3hrs personal care needs/homemaking Independent in personal care Mobility Manual wheelchair May have limited walking with extensive bracing Drive with hand controls Functional Outcomes LEVEL: T7-T12
Added motor function Increased abdominal control Increased trunk stability LEVEL: T7-T12 ADLs
2 hrs personal care needs/homemaking Independent Improved cough Improved balance control Mobility Manual wheelchair May have limited walking with bracing Driving with hand controls Functional Outcomes LEVEL: L2-L5
Added motor function in hips and knees L2 Hip flexors (iliopsas) L3 Knee extensors (quadriceps) L4 Ankle dorsiflexors (tibialis anterior) L 5 Long toe extensors (ext hallucis longus) LEVEL: L2-L5 ADLs
May need 1hr personal care/homemaking Independent Mobility Manual wheelchair May walk short distance with braces and assistive devices Driving with hand controls
Functional Outcomes LEVEL: S1-S5 Ankle plantar flexors (gastrocnemius) Various degrees of bowel, bladder and sexual function Lower level equals greater function LEVEL: S1-S5
ADLs No personal or homemaker needs Independent Mobility Increased ability to walk with less adaptive/supportive devices Manual w/c for distance Functional Outcomes
Achieving maximum functional outcomes provides the opportunity to reach the highest level of independence and quality of life Spinal Cord Injury Epidemiology 30-40 million per year 10,000 new cases per year Etiology
Motor vehicle accident: 44.5% Falls: 18.1% Violence: 16.6% (and increasing) Spinal Cord Injury Classification
Paraplegia/Tetraplegia ASIA Impairment Scale ASIA Motor/Sensory FIM functional limitations Acute Care Management Immediate spinal immobilization Methylprednisolone within 8 hours of injury Spinal Cord Injury Economic Consequences
Between $7.3 billion and $8.3 billion per year A person with a high cervical injury at age 25 incurs lifetime costs of more than $3 million Rehabilitation Treatment Systematic, intensive, coordinated team approach Spinal Cord Injury Potential Complications
Deep venous thrombosis (47-100%) Pulmonary embolism (3-15%) Pressure ulcers (25% annual incidence) Pneumonia Autonomic dysreflexia (usually above T6) Spasticity (78%) and Spasms (95%) Heterotopic ossification (16-53%) Gastrointestinal complications (e.g., impactions 33%) Spinal Cord Injury
Potential Complications Urinary tract infections Chronic pain (69%, severe 33%) Overuse syndrome (35-68%) Post-traumatic syringomyelia (1-5%) Additional Resources and Information from the Web
American Spinal Cord Injury Association ( www.asia-spinalinjury.org) TIRR Spinal Cord Injury Research Program ( www.tirr.org/research/?page=54) Spinal Cord Injury Information Network ( www.spinalcord.uab.edu/show.asp?durki =19679 ) American Paraplegia Society ( www.apssci.org) Additional Resources and Information from the Web
National Spinal Cord Injury Association ( www.spinalcord.org) Christopher & Dana Reeve Paralysis Resource Center (www.paralysis.org) Paralyzed Veterans of America ( www.pva.org) American Association of Spinal Cord Injury Psychologists and Social Workers (www.aascipsw.org)
