Redefining Tetraplegia
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REDEFINING TETRAPLEGIA
Michael Keith MDAnn Bryden OTRL
Cleveland Ohio USA
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SCI Classification An important component in
determining potential interventions is the classification of the level of injury
Classification schemes provide a common platform for understanding the degree of function associated with the level of SCI
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SCI Classification International Standards for Neurological
Classification of Spinal Cord Injury (ISNCSCI)American Spinal Injury Association (ASIA)International Spinal Cord Society (ISCoS)Most commonly used
International Classification for Surgery of the Hand in Tetraplegia (ICSHT)For cervical level SCI only
Both classifications include a motor and sensory portion
The ICSHT is focused on the upper extremity
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Who are the Stakeholders, and Why? An increasing number of stakeholders
International Tetraplegia Group – Therapists and Surgeons International Campaign for Cures of Spinal Cord Injury
Paralysis (ICCP) American Spinal Injury Association (ASIA) / International
Spinal Cord Society (ISCoS) – UE Basic Data Set Why?
Detect changes from natural recovery Better define incomplete lesions Measure the impact of interventions
○ Aimed at cure○ Activity based therapy○ Surgical reconstruction
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NEW Version 2/2013
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ASIA Update – Non Key Muscles
Movement Root LevelShoulder: Flexion, extension, abduction, internal and external rotationElbow: Supination
C5
Elbow: PronationWrist: Flexion
C6
Finger: Flexion at proximal joint, extensionThumb: Flexion, extension and abduction in plane of thumb
C7
Finger: Flexion at MP jointThumb: Opposition, adduction and abduction perpendicular to palm
C8
Finger: Abduction of the index finger T1
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Congruence with ICSHT?Movement Root
LevelICSHT
Shoulder: Flexion, extension, abduction, internal and external rotationElbow: Supination
C5 No Shoulder
Elbow: PronationWrist: Flexion
C6 45
Finger: Flexion at proximal joint, extensionThumb: Flexion, extension and abduction in plane of thumb
C7 867
Finger: Flexion at MP jointThumb: Opposition, adduction and abduction perpendicular to palm
C8 8
Finger: Abduction of the index finger T1
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Current ClassificationsA classification should tell you what to do.
ASIA, ISCOS, AIS, ISNCSCIWork well with complete lesions, complicated -
perhaps without predictive use for surgical treatment. Does not classify results or permit patient reported outcomes.
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Current ClassificationsA classification should tell you what to do.
International Surgical ClassificationWork well with complete motor paralysis,
voluntary (C5,C6), Group 0,1,2,3, 1/3 of cases.
Many Patient choices, surgical variations in C7,C8
Does not report anatomic change or PRO. Can be used for equivalency of function.
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.Functional Enhancement for Cervical SCI - 1990Electrical Stimulation Tendon Transfers
Finger, thumb flexion
Finger, thumb extension
C4
C5
C6
C7
C8
O:0
O:1
OCu:2
OCu:3
OCu:4OCu:5OCu:6
OCu:7
OCu:8
PD
->Tr
icep
s
FES
EC
RL-
>FD
P
PT-
>FP
L
Br-
>EC
RB
Br-
>FP
L
Br-
>ED
C
Thumb abduction
Elbow extension
Elbow flexion
Wrist extension
Shoulder abduction
OCu:9
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Where do the Classifications Fail?
ASIA (arms) C4 – 2 C5 – 5 C6 – 6 C7 – 3 NC - 2
ICSHT (arms) Group 0 – 4 Group 1 – 3 Group 2 – 5 Group 5 – 3 NC - 3
Subject Characteristics (n=9, 18 Arms*)
Specific Examples
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Where do the Classifications Fail?
Incomplete Injuries Spasticity Characterizing Paralysis Examples
77VC R: C5, -C6, C7, C8 / 5, -6, -7, 899VC R: C6 / 0, -1, 2, -3, 4, 5, 6, -799 VC L: C6, -C7, C8 / 2, -3, -4, 5, 6, -7, 8
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“IC Exceptions”Partial TetraplegiaAsymmetrical lesionsRecovered- Regenerated, RepairedHyper-reflexiveContractedBi-manual activities
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Clinical Decision Support Evidence Based Clinical Practice
Guidelines Appropriate Use Criteria Cumulative experience without evidence Informed Opinion
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Clinical Practice Guidelines Evidence based if outcome based. Solve problems of clinical decision
making. Make Recommendations based on
strong evidence. Find directions for outcomes research. Form the basis for national Performance
Measures and Appropriate Use Criteria. Search: www.guidelines.gov
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Appropriate Use CriteriaRAND Methodology Writing Group
ClassificationRisk AdjustmentImportant Clinical CriteriaAlternative Treatments
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Appropriate Use Criteria Review Group
Refine credibility of application by experts
Voting GroupShareholders Rate for Appropriate,
Maybe Appropriate, Rarely Appropriate
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Examples of AUC- AAOS App. http://aaos.webauthor.com/go/auc
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AAOS AUC App, Distal Radius Fx
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Potential AUC writing table
Scenarios for AUC on Tetraplegia Management
Appropriate *, Maybe &, Not %
Muscle Scores- Voluntary
IC Key Muscle
ASIA/AIS/ISNCSCI/ISCOS Key Muscle Contracture release
Osteotomy, HO resection
Hyper-reflexia Botox, Chemo neuromodulation
Tendon, Nerve Transfer,
O:0 A-C4
O:1 Deltoid A-C5 Elbow Flexor Bi to Tri* Baclofen Pump&
Radial Osteotomy- pronation 40*
Ocu2 ECBL ECRB A-C6 Wrist Extensor
Ocu3 Biceps BR A-C7 Elbow Extensor
Ocu4 FDP FDS A-C8 Finger Flexor Fractional Lengthening*
APB ADQ A-T1 5th Abductor
etc
These combinations include both .AND. And .OR.
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Measuring Spasticity Challenges in measuring spasticity
AshworthTardieuOther
Distinguishing between measures of spasticity and spasmsPenn spasm scale, others>
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Lets write a AUC about Surgical Decision Making in Tetraplegia. Review the literature for outcomes
summary. CPG unlikely. Writing group Review Group Voting Group