RCS 6080Medical and Psychosocial Aspects of Rehabilitation Counseling

Spinal Cord Injury

Anatomy of the Spine

Vertebrae Body

Front section, shaped like drum Supports weight

Lamina Towards the back Boney arch surrounds spinal canal

Spinous process Boney process from arch Points of attachment for muscles and ligaments

Discs Cushions between vertebrae

                                                                

Anatomy of the Spine Vertebrae:

7 Cervical Flexion, extension, bending and turning of

head 12 Thoracic

Chest region, allows mostly for rotation 5 Lumbar

Larger boney structures to support added wgt 5 Sacral

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

Intercostal muscles and associated dermatones

Lumbarsacral 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 24 hr care needs Able to direct care

needs ADLs

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

24 hr care needs Able to direct care needs

ADLs 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 4hrs personal care needs 2hrs homemaking assistance

ADLs 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 3hrs personal care needs/homemaking

ADLs 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 2 hrs personal care needs/homemaking

ADLs 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 May need 1hr personal

care/homemaking ADLs

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 No personal or homemaker needs

ADLs 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)