SCI management and expected outcomes Flashcards
OM - activity limitation
SCIM spinal cord independence measure self care resp and sphincter management mobility
FIM- functional independence measure
socio-cognitive skills
Barthel index
personal care
mobility
effect of injury level: tetraplegia
C1-4 preserved
SCM traps cervical paraspinal neck accessory muscle
imps - total ass with TF may achieve modified ass with power chair.
C5
+deltoids, biceps
no wrist or hand function may use trick extension for TF
C6
+ extensor carpi radialis longus, brevis
tenodesis grip for minimal hand function, can use trick extension for transfers
C7
+ triceps
tenodesis grip, minimal finger control
C8 - + flexor carpi radialis, finger flexors
full active wrist movement
limited fine hand function
T1
lumbricals, abductor pollicis
full fine hand function
Effect of injury level: paraplegia
T2-T9: full uper limb function
imp weak trunk, impaired sitting balance, possible swing to ambulation wiht HKAFO and ZF
T10 - L1 - + paraspinal and ab muscles
better sitting balance, possible swing to ambulation in HKAFO + ZF
L2 + hip flexors
reciprocal ambulation in long leg splints or KAFOs + crutches
L3
+ quads reciprocal ambulation in AFOs + crutches
L4
+ tibialis anterior
ambulation with crutches +/- AFOs
L5
+ long toe extensors
independent ambulation +/- AFOs, crutches
S1
independent +/- stick
critical levels of injury
C1-3 tetraplegia Ventilator dependent Upper limb paralysis Lower limb paralysis Can move head Fully dependent for all motor tasks and ADLs Can use assistive technology
C4 Can breathe independently Upper limb paralysis Lower limb paralysis Fully dependent for all motor tasks and ADLs Can use assistive technology
C5
Partial paralysis of upper limbs Lower limb paralysis
Can use hand-control power
wheelchair
Assistance with transfers Assistance with most ADLs Can use upper limbs to perform
simple tasks without fine hand control Potential trick elbow extension (limited by wrist)
C6
Potential to live independently if adequately equipped and set-up
May be able to transfer, roll, move from lying to sitting, dress, bathe and tend to personal hygiene
Can use manual wheelchair Can use power wheelchair Tenodesis grip
Trick elbow extension
C7
Active elbow extension
Rely on tenodesis grip for hand function Independent in ADLs and transfers
C8
Good hand function, not reliant on
tenodesis grip
Independent in ADLs and transfers
T1
Normal fine hand function at NLI T1 Very difficult to sit unsupported Independent in ADLs and transfers
Thoracic T2-12 paraplegia Normal hand function Varying degrees of trunk paralysis Varying cough efficacy Lower limb paralysis Potential ambulation with HKAFO
prognosis of incomplete injury
More difficult to predict
20-50% of ASIA B paraplegia recover the ability to walk by 1
year
85% of muscles that were Grade 1 or 2 at one month > Grade 3 by 1 year
26% of muscles that were Grade 0 at 1 month > Grade 3 by 1 year (Burns et al., 2012)
early functional goals
Tolerate sitting out of bed in an appropriately prescribed seating system for a specified time period
Maintain skin integrity
Able to verbalise skills that require help
Caregiver independence
initial focus
24 hour postural management
Readjustment of vasomotor control
Postural sensibility, balance re-education
Provision of seating, teach pressure relief
24 hour postural management
skin management
prevent contractures
vasomotor control
Before sitting out, tilt in bed to 30 degrees and gradual increase to 90 degrees
Deep breathing exercises and monitoring of vitals in each
position
Introduction of some leg hanging
10-15 minutes – 3 hours over 1 week
Progress to chair
stnading programme
Key Message: All patients with SCI should be assessed for the potential benefits of standing, as soon as they are physiologically stable and it is practically possible
Specific goals based on initial assessment and on-going evaluation
Suitable outcome measures
Target: 3 or more times a week, 30-60 minutes each time
benefits
Soft tissue Bladder/bowel Quality of life Bone health Exercise effects
precautions
Bone demineralisation Cardiovascular considerations Pain
Soft tissue considerations
wheelchair prescription
Considerations Good posture Ergonomic features that allow full use, full time Comfort Durability Aesthetics Attributes “Pushability”
Electric wheelchairs
high lesions
are heavier and bulkier controls
stability
outcome meausures Wheelchair Skills Test Ascend / descend incline Ascend / descend kerb Get through hinged door
Wheelchair Users Shoulder Pain Index Transfers
Mobility
Self-care General activities
wheelchair provision
lightweight customised
bucekt configuration
pressure relieving cushion
position changes educate patients on changing position regularly Why? Sitting pressure Postural issues Fatigue Discomfort
How?
Vertical lift unlikely to be long enough for benefit
Leaning forward 45° and lateral trunk leaning to 15° reduces pressure at the sitting surface
transfers and bed mobility
Sitting unsupported
Rolling
Moving from lying to sitting
Transferring
postural control and sitting balance
Back to basics of sitting balance re-education
Won’t manage COM outside BOS, no active righting reactions (only saving reactions)
Compensation for limited trunk control: Big BOS, ability to change BOS Using head and arms for momentum and orientation of COM over BOS Appropriate hamstring extensibility Develop upper limb strength
Consider the individual, task and environment
rolling
Used to dress, change position at night, pre-requisite for getting from lying to sitting
Rely on upper limbs and head to
generate momentum
Can be easier if ankles are crossed and body is stiffer
Difficult without triceps because of
tendency for elbow flexion
Unable to roll: can rely on bed rails or loops attached to the side of the bed; or assistance
lie to long sit
Essential for dressing and transferring Easy with triceps Triceps paralysis: more complex
vertical lift
Goals: relieve pressure, transfer, dress and move about the bed
Need to be able to perform with knees flexed and extended
3 components Elbow extension
Scapula depression Shoulder flexion
Vertical transfers possible for some people with SCI
Transfers
Performed with legs up or legs down
Advantages and disadvantages to both techniques Two commonly used strategies
Rotatory strategy
Translatory strategy
Critical aspects of transfers
Buttocks do not touch the wheels
Control of end of transfer / foot placement
Slideboards can be used for training or long-term
Hooking of the wrist for C6 tetraplegia
factors influencing transfers
body weight
extensibility of hamstrings
spine stiffness
spasticity
walking
~50% of SCI survivors will walk (Harvey, 2008)
Walking can be a functional, therapeutic or task-specific goal
People with tetraplegia can stand with frames, tilt-tables or
standing wheelchairs
People with thoracic paraplegia ambulate with walking aids*
People with motor incomplete lesions and lumbosacral
paraplegia
Most can walk for at least limited distances Usefulness of walking depends on extent of paralysis
walking with thoracic paraplegia
hip-knee-ankle-foot-orthosis. HKAFO
knee-ankle-foot-orthosis- KAFO
walking with partial paralyis of lower limbs
AFO
dictus splint
functional electrical stimulation
gait re-education
Conventional overground gait training
Orthoses
Aids
Therapist assistance
Electromechanical / robotic assisted (Lokomat)
Comparable to overground training in improving
walking speed and distance (Mehrholz et al 2017)
Less therapist assistance required
Functional electrical stimulation + exoskeleton / neuroprosthesis
Lab based walking
outcome measures for walking
Valid and Reliable in SCI 6 minute walk test 10 metre walk test Berg Balance Test Timed Up and Go Test Walking Index for Spinal Cord Injury (WISCI) II SCI Functional Ambulation Inventory SCI Functional Ambulation Profile
hand function
Hugely important to tetraplegia Outcome Measures
Handheld dynamometry
Capabilities of Upper Extremity Functioning Instrument
Graded and Redefined Assessment of Sensibility, Strength and Prehension (GRASSP)
9 Hole Peg Test
Box and Blocks
Action Research Arm Test
hand function
C4-8
T1
C4: Prevent complications, maintain range (low load sustained stretch)
C5: Strengthen biceps and deltoid, maintain length of paralysed muscles (aids, orthoses, splints, exercise)
C6, 7: Tenodesis grip: active wrist extension + passive tightening of finger
flexors for crude but very useful grip.
Essential point: Never stretch fingers and wrist into extension
C8: have active grip, limited fine hand function
T1 full function
treatment options
Task-specific training Splinting Orthoses Taping Strengthening Mobilisation techniques Functional electrical stimulation Close collaboration with occupational therapist
other treatment options
Reconstructive surgery: improve pinch, grip and elbow extension => improve ADL performance and quality of life in tetraplegia
Nerve transfer surgery to restore hand and upper limb function is emerging
Neuroprostheses have a positive impact on pinch and grip strength and ADL functions in C5-C6 complete tetraplegia (devices are expensive, access is limited)
long term problems
Pressure sores Kyphosis Scoliosis Restricted neck flexion Hip flexion contractures Shoulder pain Osteoporosis Co-morbidities e.g. cardiovascular disease
