RCS 6080 Medical and Psychosocial Aspects of Rehabilitation

RCS 6080 Medical and Psychosocial Aspects of Rehabilitation Counseling Spinal Cord Injury

Anatomy of the Spine n Vertebrae n Body n n n Lamina n n n Towards the back Boney arch surrounds spinal canal Spinous process n n n Front section, shaped like drum Supports weight Boney process from arch Points of attachment for muscles and ligaments Discs n Cushions between vertebrae

Anatomy of the Spine n Vertebrae: n 7 Cervical n n 12 Thoracic n n Larger boney structures to support added wgt 5 Sacral n n Chest region, allows mostly for rotation 5 Lumbar n n Flexion, extension, bending and turning of head Fused together Coccyx

Anatomy of the Cord n Cervical Cord n n n n C 1 -C 2: C 3 -4: Phrenic nucleus C 4: Deltoids C 4 -5: Biceps C 6: Wrist extensors C 7: Triceps C 8: Wrist extensors C 8 -T 1: Hand muscles

Anatomy of the Cord n Thoracic Cord n n Lumbarsacral n n n Intercostal muscles and associated dermatones Starts at T 9 and continues to L 2 Innervates hips, legs, buttocks and anal region Cauda Equina (horses tail) n n Spinal cord ends at L 2 Tip called conus, below conus a spray of spinal roots

Dermatomes/Sensory Level n Dermatome: n patch of skin innervated by a given spinal cord level

C 2 to C 4. The C 2 dermatome

Myotomes/Motor Level n Myotome: n n Spinal nerve roots which innervates muscles groups Most muscles are innervated by more than one root

ASIA Impairment Scale n n n ASIA A: Complete: no motor or sensory function is preserved in the sacral segments S 4 -S 5 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 n Tetraplegia (preferred to quadriplegia) n n n 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 n Paraplegia n n 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 n Central Cord Syndrome: n n lesion occurring almost exclusively in the cervical region Sacral sensory sparing Weakness > UE vs LE Brown-Sequard Syndrome: n Lesion that produces ipsilateral, proprioceptive and motor loss and contralateral loss of sensitivity to pain and temp

Clinical Syndromes n Anterior Cord Syndrome: n n Lesion that produces variable loss of motor function and of sensitivity while preserving proprioception Cauda Equina Syndrome: n Injury to the lumbosacral nerve roots w/ in the neurocanal resulting in areflexive bladder, bowel and lower limbs

Achievement of Functional Goals n n n Age Body type Comorbidities Prior athletic sense Fatigue level n n n Type of stabilization HX HO/POA Spasticity Psychosocial factors Nutrition

Functional Outcomes n n Motor/sensory recovery Ability to perform or direct ADLs Social reintegration Quality of life

Functional Outcomes n LEVEL C 1 -C 3 n n n 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: C 1 -3 n n n ADLs n n 24 hr care needs Able to direct care needs Ventilator dependent Impaired communication Dependent for all care needs Mobility n n Power wheelchair Hoyer lift

LEVEL: C 1 -C 3 n Equipment Needs n n n Adapted computer Bedside/portable ventilator Suction machine Specialty bed Hoyer Reclining shower chair

Functional Outcomes n LEVEL: C 4 n n n 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: C 4 n n n ADLs n n n 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 n n Power wheelchair Hoyer lift

LEVEL: C 4 n Equipment Needs n n n Adapted computer Bedside/portable ventilator as needed Suction machine Specialty bed Hoyer Reclining shower chair

Functional Outcomes n LEVEL: C 5 n n n 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: C 5 n n n 10 hrs personal care need 6 hrs homemaking assistance ADLs n n 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: C 5 n Mobility n n n Hoyer or stand pivot Power wheelchair w/ hand controls Manual wheelchair Drive motor vehicle w/ hand controls Equipment Needs n n n Power and manual wheelchairs Adaptive splints/braces Page turners/computer adaptations

Functional Outcomes n LEVEL: C 6 n n n 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: C 6 n n n 6 hrs personal care needs 4 hrs homemaking assistance ADLs n n Assisted cough Set-up for feeding, bathing and dressing Independent pressure relief, turns and skin assessment May be independent for bowel/bladder care

LEVEL: C 6 Mobility n n n Independent slide board transfer Manual wheelchair Drive with adaptive equipment

Functional Outcomes n LEVEL: C 7 n n Elbow flexion and extension (biceps/triceps) Arm toward body (sternal pectoralis) Lack finger function Lack trunk stability

LEVEL: C 7 n n n 6 hrs personal care needs 2 hrs homemaking assistance ADLs n n More effective cough Fewer adaptive aids Independent w/ all ADLs May need adaptive aids for bowel care

LEVEL: C 7 n Mobility n n Manual wheelchair Transfers without adaptive equipment

Functional Outcomes n LEVEL: C 8 -T 1 n Increased finger and hand strength n n Finger flexion (flexor digitorum) Finger extension (extensor communis) Thumb movement (policus longis brevis) Separate fingers (introssi separates)

LEVEL: C 8 -T 1 n n n ADLs n n n 4 hrs personal care needs 2 hrs homemaking assistance Independent w/ or w/o assistive devices Assist w/ complex meal prep and home management Mobility n Manual wheelchair

Functional Outcomes n LEVEL: T 2 -T 6 n n n Normal motor function of head, neck, shoulders, arms, hands and fingers Increased use of intercostals Increase trunk control (erector spinae)

LEVEL: T 2 -T 6 n n ADLs n n 3 hrs personal care needs/homemaking Independent in personal care Mobility n n n Manual wheelchair May have limited walking with extensive bracing Drive with hand controls

Functional Outcomes n LEVEL: T 7 -T 12 n n n Added motor function Increased abdominal control Increased trunk stability

LEVEL: T 7 -T 12 n n ADLs n n 2 hrs personal care needs/homemaking Independent Improved cough Improved balance control Mobility n n n Manual wheelchair May have limited walking with bracing Driving with hand controls

Functional Outcomes n LEVEL: L 2 -L 5 n Added motor function in hips and knees n n L 2 Hip flexors (iliopsas) L 3 Knee extensors (quadriceps) L 4 Ankle dorsiflexors (tibialis anterior) L 5 Long toe extensors (ext hallucis longus)

LEVEL: L 2 -L 5 n n ADLs n n May need 1 hr personal care/homemaking Independent Mobility n n n Manual wheelchair May walk short distance with braces and assistive devices Driving with hand controls

Functional Outcomes n LEVEL: S 1 -S 5 n n n Ankle plantar flexors (gastrocnemius) Various degrees of bowel, bladder and sexual function Lower level equals greater function

LEVEL: S 1 -S 5 n n ADLs n n No personal or homemaker needs Independent Mobility n n Increased ability to walk with less adaptive/supportive devices Manual w/c for distance

Functional Outcomes n Achieving maximum functional outcomes provides the opportunity to reach the highest level of independence and quality of life

Spinal Cord Injury n Epidemiology n n n 30 -40 million per year 10, 000 new cases per year Etiology n n n Motor vehicle accident: 44. 5% Falls: 18. 1% Violence: 16. 6% (and increasing)

Spinal Cord Injury n Classification n n Paraplegia/Tetraplegia ASIA Impairment Scale ASIA Motor/Sensory FIM – functional limitations Acute Care Management n n Immediate spinal immobilization Methylprednisolone within 8 hours of injury

Spinal Cord Injury n Economic Consequences n n n 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 n Systematic, intensive, coordinated team approach

Spinal Cord Injury n Potential Complications n n n n Deep venous thrombosis (47 -100%) Pulmonary embolism (3 -15%) Pressure ulcers (25% annual incidence) Pneumonia Autonomic dysreflexia (usually above T 6) Spasticity (78%) and Spasms (95%) Heterotopic ossification (16 -53%) Gastrointestinal complications (e. g. , impactions – 33%)

Spinal Cord Injury n Potential Complications n n Urinary tract infections Chronic pain (69%, severe 33%) Overuse syndrome (35 -68%) Post-traumatic syringomyelia (1 -5%)

Additional Resources and Information from the Web n n 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=19 679) American Paraplegia Society (www. apssci. org)

Additional Resources and Information from the Web n n 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)