Lecture 6: Impairment and Disability

Question 1

Describe the difference between impairment and disability

Answer 1

Impairment relates to physiological deficit.

Disability relates to functional deficit.

Question 2

How can we examine and assess impairment?

Answer 2

Impairment is rated using neurological examination and assessment scales such as ASIA, Frankel or Fugl-Meyer.

Question 3

How can we examine and assess disability?

Answer 3

Measures such as Functional independence measure (FIM) or Quadriplegia index of function (QIF) assess quality of life and ability to perform typical daily activities.

Question 4

What is the importance of functional measures (3)?

Answer 4

Functional measures are used to:
* select appropriate therapy or assistive systems
* assess progress during the rehabilitation process
* predict long-term outcomes

Question 5

Describe how sensory impairment can be assessed?

• Discuss how it is assessed
• Discuss how it is scored
• Discuss max score

Answer 5

Sensory impairment can be assessed by examining each of the 28 dermatomes on each side of patient’s body (total 56). It checks spinal roots from C2 to S4/5.

Within each dermatome, sensitivity to pain and light touch must be assessed. The 2 modalities belong to separate tracts (spinothalamic vs dorsal column medial lemniscus).

Pain: pin prick
Light touch: cotton

3 point scale:
0: absent
1: impaired - partial or altered appreciation (Due to dermatome overlap there is some sensation but it is reduced if only a single root is damaged.), including hyperaesthesia (excessive sensation )
2: normal
NT: not testable

112 possible points for pain (both left and right sides) and 112 points for light touch (both sides) for a total of 224.

Question 6

Describe how motor impairment can be assessed?

• Discuss how it is assessed
• Discuss how it is scored
• Discuss max score

Answer 6

Motor examination is performed by testing key muscles in 10 paired myotomes. It’s a manual motor examination where the patient produces force against examiner’s added resistance (ex: hand).

The strength of each muscle is graded on a 6-point ASIA scale (American Spinal
Injury Association classification):
0 = total paralysis
5 = total movement, full ROM against full resistance

In addition, the external anal sphincter is tested for presence or absence of tonic contraction. This information is used for determining the completeness of injury and not for score

Max score per side: 50
Total score both sides: 100

Question 7

By convention, when a muscle’s grade is at least 3, it is considered to have intact innervation by the more _____ of the innervating spinal segments.

Answer 7

rostral

Question 8

List the myotomes

Answer 8

C5 - elbow flexion (biceps, brachialis)
C6 - wrist extensors (extensor carpi radialis longus and brevis)
C7 - elbow extensors (triceps)
C8 - finger flexors (flexor digitorum profundus) to the middle finger
T1 - small finger abductors (abductor digiti minimi)

L2 - hip flexor (iliopsoas)
L3 - knee extensor (quadriceps)
L4 - ankle dorsiflexor (tibialis anterior)
L5 - long toe extensor (extensor hallucis longus)
S1 - ankle plantarflexors (gastrocnemius, soleus)

S4-5 - voluntary anal contraction (yes/no)

Question 9

What action and muscle(s) are responsible for: C5

Answer 9

Elbow flexion (biceps, brachialis)

Question 10

What action and muscle(s) are responsible for: C6

Answer 10

C6 - wrist extensors (extensor carpi radialis longus and brevis)

Question 11

What action and muscle(s) are responsible for: C7

Answer 11

C7 - elbow extensors (triceps)

Question 12

What action and muscle(s) are responsible for: C8

Answer 12

C8 - finger flexors (flexor digitorum profundus) to the middle finger

Question 13

What action and muscle(s) are responsible for: T1

Answer 13

T1 - small finger abductors (abductor digiti minimi)

Question 14

What action and muscle(s) are responsible for: L2

Answer 14

L2 - hip flexor (iliopsoas)

Question 15

What action and muscle(s) are responsible for: L3

Answer 15

L3 - knee extensor (quadriceps)

Question 16

What action and muscle(s) are responsible for: L4

Answer 16

L4 - ankle dorsiflexor (tibialis anterior)

Question 17

What action and muscle(s) are responsible for: L5

Answer 17

L5 - long toe extensor (extensor hallucis longus)

Question 18

What action and muscle(s) are responsible for: S1

Answer 18

S1 - ankle plantarflexors (gastrocnemius, soleus)

Question 19

What action is responsible for: S4-5

Answer 19

voluntary anal contraction

Question 20

Describe the difference between a physiotherapist’s and a neurologist’s definition of motor level

Answer 20

Physiotherapist: If no activity is found in the C7 key muscle, the C6 key muscle is graded 3 and the C5 key muscle is graded 5, then the “motor level” for the tested
side of the body is C6. The motor level is the last level with full active ROM against gravity.

Neurologist would say motor level is C5. The motor level is the last segment that is unharmed

Question 21

What myotomes can’t be tested by manual muscle examination?

What is assumed about these areas?

Answer 21

C1-C4; T2-L2, S2-S5

Motor level is presumed to be the same as sensory level.

If you know there is damaged to a sensory root, T5 for example, then you suspect the ventral root of T5 is also damaged (assumption since you can’t test it independently)

Question 22

Describe the American Spinal Injury Association (ASIA) Impairment Scale

Answer 22

The ASIA scale grades the degree of impairment as follows:

ASIA A: complete. No voluntary anal contraction or anal sensation (S4-S5 sensory score is 0)

all other ASIA categories are considered incomplete

ASIA B: Sensory but not motor function is preserved below the neurological level and includes sacral segments S4-S5.

ASIA C: Motor function is preserved below the neurological level, and more than half of key muscles below the neurological level have a muscle grade less than 3.

ASIA D: Motor function is preserved below the neurological level, and at least half of key muscles below the neurological level have a muscle grade greater than or equal to 3.

ASIA E: Sensory function and motor function are normal.

Main use: track pt’s changes overtime - progression or regression in paralysis?

Question 23

Describe The Functional Independence Measure (FIM) of Disability

• Discuss how it is scored
• Discuss max score

Answer 23

Classification Standards for
Sensory-Motor Disability in Paraplegia or Tetraplegia

• focuses on 6 areas of functioning: self-care, sphincter control, mobility, locomotion, communication and social cognition.
• Within each area, 2 or more specific activities or items are evaluated (18 items in total). For example, the self-care area comprises 6 activity items (eating, grooming, bathing, dressing-upper body, dressing lower body, and using toilet).

7 point scale for 18 items total:
7 - complete independence
1 - total assistance

The FIM total score, summed across all items (maximum score = 126) estimates the cost of disability in terms of safety issues and of dependence on others and on technological devices.

Question 24

What are some of the cautions of using FIM?

Answer 24

• designed for general disabled population - not specifically SCI
• poor validity
• poor reliability for communication and social cognition
• poor sensitivity for self care functioning changes in tetraplegic subjects that are in rehab

Question 25

Discuss The Quadriplegia Index of Function (QIF)

Answer 25

The QIF is a functional assessment instrument designed specifically for use with quadriplegic persons. The QIF consists of two parts with specific activities to be assessed by the evaluator and an assessment of human services. Part 1: The QIF assessment considers the performance ability of a subject; not their daily behavior. Not all gender related activities are assessed. 5 Point scale (4 - completely independent; 0 - completely dependent) 9 categories: transfers, grooming, bathing, feeding, dressing, wheelchair mobility, bed activities, bladder care, bowel care 2nd part: level of understanding of personal care variables; thus, cognitive independence is included in the scoring. The questionnaire part relates to skin care, diet and nutrition, medication and equipment used for daily activities. It also addresses physical and other plausible conditions such as autonomic dysreflexia, respiratory and other infections, deep vein thrombosis and other complications that follow tetraplegia. The final part of the questionnaire deals with human services that are available to the subject and addresses the social and economic aspects of living with SCI.

Question 26

Discuss why there is a sigmoidal curve observed in the Swedish Study that reviewed the validity of The Spinal Cord Index of Function (SIF)

Answer 26

Lowest score is 9 (1s in all categories) Maximum score is 54 (6 points in each category) Plateau occurs because there is a limit of the values. Additionally, patient's reach their personal limit in recovery.