Clinical Management of Individuals with Traumatic Spinal Cord Injury – Part 2

- Intact pinprick

- Age <50-65

- Knee extensor and/or hip flexor strength at least 2/5 within 2 months post-injury

What are the ANPT Guidelines for positive prognosticators for ambulation in SCI patients

- Complete at T12 and below

- Incomplete cervical

What are Less severe initial injury classification of SCI that are good prognostic indicators for the possibility to ambulate again

ALS

lateral corticospinal

Intact pinprick is an important prognostic indicator since it is sensed by the _____ which is close to the ________ tract which does movement, so if you have pinprick you are more likely to recover motor function.

NLI

the most caudal sensory or muscle innervation will sometimes, but not always, match ____

ASIA C SCI

Gait recovery in 80-90% (but only 30-40% in patients over 50)

ASIA D SCI

Gait recovery in almost 100% of younger patients, approx. 80% in patients over 50

- greater LE strength initially (especially hip flexion)

- better pinprick sensation

- more recovery within first 2 months after injury

What are signs that a patients may have a better prognosis for recovery with a traumatic ASIA C or D SCI

MRI

what is the best imaging technique for prognosis of SCI

ASIA prognosticating factors

In order to make an informed prognosis, what examination strategy should be used along MRI

Cord edema

MRI findings in SCI patients

• ________ (without hemorrhage) associated with more incomplete injuries; the fewer spinal levels showing this, the better the prognosis

Hemorrhage

MRI findings in SCI patients

• what often denotes complete SCI injury?

- Face

- Neck (especially where supplied by cranial nerves)

- Diaphragm (partial from C3/C4)

what are the key muscle groups to focus when making goals for SCI patients with a C1-C4 level injury

- Chewing

- Talking

- Sipping

- Maybe blowing (if able to breath without ventilator)

- Scapular elevation

what are the key movements/actions to focus when making goals for SCI patients with a C1-C4 level injury

- Bed Mobility: dependent

- Transfers: dependent with mechanical lift

- Power Wheelchair Mobility: independent

- Manual Wheelchair Mobility: unable

- Pressure Relief: independent with power tilt

- Standing: dependent with tilt table

- Ambulation: unable

what are mobility expectations to set for patients with a C1-C4 level SCI when making goals

- Head array

- Chin control

- Sip and puff (least desirable)

- Enables independent mobility and weight shifting

what tasks should a person with a C1-C4 level SCI who is independent with power wheelchair mobility be able to do

- Feeding: dependent

- Grooming: dependent

- Dressing: dependent

- Bathing: dependent

- B&B: dependent

- Home Management: dependent

- Driving: Unable

what are ADL expectations to set for patients with a C1-C4 level SCI when making goals

- Biceps brachii (with brachialis/brachioradialis)

- Deltoid

- Infraspinatus

- Rhomboids

- Supinator

what are the key muscle groups to focus when making goals for SCI patients with a C5 level injury

- Elbow flexion

- Forearm supination

- Shoulder flexion/ABD to 90 degrees

- Shoulder ER

what are the key movements/actions to focus when making goals for SCI patients with a C5 level injury

- Bed Mobility: assistance to dependent

- Transfers: assistance to dependent

- Power Wheelchair Mobility: independent

- Manual Wheelchair Mobility: independent to some assist on level surfaces

- Pressure Relief: independent with power tilt

- Standing: assist with tilt table or standing frame

- Ambulation: unable

what are mobility expectations to set for patients with a C5 level SCI when making goals

- Feeding: some assistance/setup

- Grooming: some assistance/setup

- Dressing: some assistance/setup

- Bathing: some assistance/setup

- B&B: dependent

- Home Management: some assistance/setup

- Driving: independence possible with adaptations

what are ADL expectations to set for patients with a C5 level SCI when making goals

- Latissimus dorsi

- Extensor carpi radialis

- Pec major

- Pronator teres

- Serratus anterior

- Teres minor

what are the key muscle groups to focus when making goals for SCI patients with a C6 level injury

- Shoulder flexion, extension, IR, ADD

- Scapular protraction and upward rotation

- Forearm pronation

- Wrist extension (Tino Desis grip)

what are the key movements/actions to focus when making goals for SCI patients with a C6 level injury

- Bed Mobility: independent to some assistance

- Transfers: independent to some assistance - often assistance needed for uneven transfers

- Power Wheelchair Mobility: independent

- Manual Wheelchair Mobility: independent to some assist on level surfaces (Consider power assist devices)

- Pressure Relief: independent

- Standing: assist with tilt table or standing frame

- Ambulation: unable

what are mobility expectations to set for patients with a C6 level SCI when making goals

- Feeding: assistance to independent

- Grooming: assistance to independent

- Dressing: assistance to independent (May need assistance with LBD)

- Bathing: assistance to independent

- B&B: often assistance but potentially independent with adaptive equipment

- Home Management: some assistance/setup (May be independent with light housework with adaptive equipment)

- Driving: independence possible with adaptations

what are ADL expectations to set for patients with a C6 level SCI when making goals

Tenodesis Grip

- Active wrist extension = passive finger flexion

- Allows for functional grasp in the absence of motor function of the finger flexors

Adaptive shortening of the finger flexors

what do we want to happen to the finger flexors to facilitate a tenodesis grip

- Triceps

- Long finger extensors

- EPL/EPB

- Flexor carpi radialis

what are the key muscle groups to focus when making goals for SCI patients with a C7 level injury

- Elbow extension

- Finger extension

- Some wrist flexion

what are the key movements/actions to focus when making goals for SCI patients with a C7 level injury

- Bed Mobility: independent

- Transfers: independent

- Manual Wheelchair Mobility: independent

- Pressure Relief: independent

- Standing: standing frame

- Ambulation: unable

what are mobility expectations to set for patients with a C7 level SCI when making goals

- independent

- With or without transfer board

- May need assist for uneven transfers

what are mobility expectations for transfers to set for patients with a C7 level SCI when making goals

- Feeding: independent

- Grooming: independent

- Dressing: independent

- Bathing: independent

- B&B: independent with adaptive equipment

- Home Management: assistance for heavy household tasks

- Driving: independent with adaptations

what are ADL expectations to set for patients with a C7 level SCI when making goals

- Intrinsic muscles of the hand

- Long finger flexors

- Flexor carpi ulnaris

- Finger flexion

- FPL/FPB

what are the key muscle groups to focus when making goals for SCI patients with a C8-T1 level injury

- Finger flexion

- Fine motor of the hand

what are the key movements/actions to focus when making goals for SCI patients with a C8-T1 level injury

- Bed Mobility: independent

- Transfers: independent

- Manual Wheelchair Mobility: independent

- Pressure Relief: independent

- Standing: standing frame

- Ambulation: unable

what are mobility expectations to set for patients with a C8-T1 level SCI when making goals

- independent

- With or without transfer board

- May need assist for uneven transfers

- Floor transfers possible

what are mobility expectations for transfers to set for patients with a C8-T1 level SCI when making goals

- Feeding: independent

- Grooming: independent

- Dressing: independent

- Bathing: independent

- B&B: independent with adaptive equipment

- Home Management: assistance for heavy household tasks

- Driving: independent with adaptations

what are ADL expectations to set for patients with a C8-T1 level SCI when making goals

Segmental innervation of intercostals and spine extensors

what are the key muscle groups to focus when making goals for SCI patients with a T2-T6 level injury

- Trunk extension

- Improved breathing with intercostals

- Improved trunk balance and stability

what are the key movements/actions to focus when making goals for SCI patients with a T2-T6 level injury

- More innervation of intercostals and spine extensors

- Abdominals (varies by level)

what are the key muscle groups to focus when making goals for SCI patients with a T7-T12 level injury

- Improvement in trunk control and respiratory function improved endurance

- Below T6: less risk for autonomic complications

what are the key movements/actions to focus when making goals for SCI patients with a T7-T12 level injury

- Bed Mobility: independent

- Transfers: independent from various surfaces and heights, including floor

- Manual Wheelchair Mobility: independent with Advanced skills possible

- Pressure Relief: independent

- Standing: independent with AD and orthotics

- Ambulation: independent to some assist for household distances with crutches/walker and bilateral HKAFOs/KAFOs/RGO

what are mobility expectations to set for patients with a T2-T12 level SCI when making goals

- Feeding: independent

- Grooming: independent

- Dressing: independent

- Bathing: independent

- B&B: independent

- Home Management: independent to assistance for heavy household tasks

- Driving: independent with adaptations

what are ADL expectations to set for patients with a T2-T12 level SCI when making goals

- Gracilis

- Iliopsoas

- Quadratus lumborum

- Rectus femoris

- Sartorius

what are the key muscle groups to focus when making goals for SCI patients with a L1-L3 level injury

- Hip flexion

- Hip ADD

- Some knee extension

what are the key movements/actions to focus when making goals for SCI patients with a L1-L3 level injury

- Quadriceps (L4)

- Tibialis anterior (L5)

- Hamstrings (L5-S1)

- Gastrocnemius (S1)

- Gluteus medius and maximus (L5-S1)

- Lower sacral: bowel/bladder/sexual function

what are the key muscle groups to focus when making goals for SCI patients with a L4-S1 level injury

- Strong knee extension

- Knee flexion

- Ankle dorsiflexion

- Hip extension and ABD

- Ankle plantarflexion

- Bowel/bladder/sexual function

what are the key movements/actions to focus when making goals for SCI patients with a L4-S1 level injury

- Bed Mobility: independent

- Transfers: independent

- Manual Wheelchair Mobility: may use for longer distances

- Pressure Relief: independent

- Standing: independent with AD and orthotics

- Ambulation: independent with canes/crutches/walker

what are mobility expectations to set for patients with a L1-S1 level SCI when making goals

- independent with canes/crutches/walker

- L1-L3: bilateral KAFOs/AFOs

- L4-S1: bilateral AFOs/orthotics or no bracing

- Variable distance

what are ambulation expectations to set for patients with a L1-S1 level SCI when making goals

- Feeding: independent

- Grooming: independent

- Dressing: independent

- Bathing: independent

- B&B: independent

- Home Management: independent

- Driving: independent with adaptations

what are ADL expectations to set for patients with a L1-S1 level SCI when making goals

- ASIA Impairment Scale (AIS)*

- Numeric pain rating scale

- MMT with handheld dynamometer

- Functional reach/modified functional reach

- 6 Minute Walk test

- 10-meter walk test

- Timed Up and Go

- Berg Balance Scale

- Walking Index for SCI (WISCI-II)

- SCI Functional Ambulation Inventory

- Spinal Cord Injury Independence Measure III

- Function in Sitting Test

- Wheelchair Skills Test

Common Standardized Outcome Measures for Clients with SCI

- ASIA Impairment Scale (AIS)*

- Walking Index for SCI (WISCI-II)

- SCI Functional Ambulation Inventory

- Spinal Cord Injury Independence Measure III

What are SCI specific outcome measures used to set goals and classify SCI patients

Strengthen all innervated muscles

what should strengthening interventions with SCI patients focus on

- Serratus anterior

- Lats

- Pec major

- Rotator cuff

- Triceps

what are key muscle utilized for transfers in SCI patients that should be strengthened

- Shoulder extension

- Elbow extension

- Wrist extension

what are Key targets for UE ROM/muscle length interventions for patients with tetraplegia

- Hip extension

- Hip flexion and knee extension/hamstring muscle length

- Ankle dorsiflexion

what are Key targets for LE ROM/muscle length interventions for patients with SCI

- Improve ventilation

- ↑ cough effectiveness

- Prevent chest tightness

What are goals that we should set for Respiratory Interventions in SCI patients

- Diaphragmatic breathing

- Respiratory muscle trainers

- Assisted coughing (Self-assisted or Caregiver-assisted)

- Abdominal binder

what are respiratory interventions used for SCI patients

100-120 bpm

Typical max HR for tetraplegia patients is ____-_____ bpm due to sympathetic impairment

30 minutes

For cardiovascular benefits, adults with SCI should perform _______ of moderate to vigorous intensity exercise 3x/week

- ↓cardiac output

- ↓BP response

- Impaired thermoregulation

How does SCI negatively affect exercise response

- Upright in wheelchair

- Upright at EOM

- Tilt table

- Standing frame

- Assisted standing in the parallel bars

What are options for progression with Upright Tolerance and Standing Training for patients with SCI

- Isometrics

- Mini squats

- Trunk control

what strengthening elements are achieved through Upright Tolerance and Standing Training for patients with SCI

- Orthostatic hypotension

- Ensure sufficient bone density

- Respiratory difficulties (position changes may cause coughing)

- Ensure proper support of all body segments, especially when sensation is impaired/absent

what are the challenges of standing for patients with SCI

- Short sitting

- Long sitting

- Quadruped

- Tall kneeling

- Standing

what are functional positions for sitting balance training in patients with SCI

- Goldilocks level of assistance

- Head-hips relationship is critical

- Form a tripod

- Trailing hand close to the body, lead hand away from the body

- Part to whole task training

- Lower extremity pivot point

- Lift and shift, not slide and shear

- Vary the surfaces

Key points and considerations for SCI Functional Mobility training: Squat-Pivot Transfers

- Strengthen available muscles

- Support denervated muscles with orthotics/AD

What are key points about the Compensatory Approach to gait training with SCI patients

- Donning/doffing orthoses

- Parallel bars → forearm crutches/walker

- Sit to/from stand

- Static balance and weight shifts

what are training activities that utilize a compensatory approach to gait training

- LE's maximally loaded for weight bearing

- Sensory cues consistent with task of walking

- Posture, trunk, pelvis, and limb kinematics are coordinated and specific to walking

- Compensatory movements minimized

what are key principles to consider when utilizing a Recovery-based Approach to gait training with SCI patients

- Technique will be compensatory

- Lack of innervation to LE musculature

- Poor prognosis for return

What does Gait Training for Upper to Mid Thoracic ASIA A entail

- Braced into knee extension and dorsiflexion

- Limbs move together in bilateral swing-through gait

What are orthosis needs for Gait Training for Upper to Mid Thoracic ASIA A

Bilateral assistive device (walker or crutches)

What are AD needs in order to engage in Gait Training for Upper to Mid Thoracic ASIA A

- Requires use of "para-stance"

- Hip extension beyond neutral

- Full knee extension

- Dorsiflexion beyond 10 degrees

What does the Swing-Through Technique for gait in SCI patients look like?

- Ambulate "reciprocally," with one leg advancing at a time using hip hiking and/or circumduction in a swing-through manner

- More work done by trunk and hips, less by UEs than B swing- through pattern

What does Gait Training for Lower Thoracic to Upper Lumbar ASIA A entail

Above the knee (likely KAFOs)

what type of orthosis is needed for Gait Training for Lower Thoracic to Upper Lumbar ASIA A

requires bilateral AD

what type of AD is needed for Gait Training for Lower Thoracic to Upper Lumbar ASIA A

- Patient possesses trunk, UE, and knee musculature, but hip stability may be seriously compromised

- Hip extensors and abductors innervated by sup/inf gluteal nerve L4, L5, S1

What does Gait Training for L3 ASIA A Injury or Lower entail

- May be able to utilize AFOs instead of KAFOs

- Selection will depend on quad strength

what type of orthosis is needed for Gait Training for L3 ASIA A Injury or Lower

either crutches or canes, bilateral or unilateral

what type of AD is needed for Gait Training for L3 ASIA A Injury or Lower

- often begin with techniques similar to with ASIA A, but prognosis for eventual motor return is much greater

- Monitor closely and use whatever they can!

What does Gait Training with Incomplete ASIA B SCI look like

- Detailed individualized assessment, both for MMT strength and to assess force production and balance in functional context

- UE function?

- Trunk function?

- Use of compensatory versus recovery movement patterns?

What are key points to consider for Gait Training with Incomplete ASIA C or D SCI

What are Advanced navigation Power Wheelchair Skills

- Reverse

- Tight spaces

- Inclines

- Obstacles

- Return to pre-injury pattern decreases risk of biomechanical/orthopedic secondary complications

- Often matches closely with patient's goals/vision for self

what are the advantages of using facilitation strategies for recovery

- Progress may take longer and be more frustrating

- May not be realistic or best practice depending on prognosis

what are the disadvantages of using facilitation strategies for recovery

- May be a quicker path (or only available path) to independence with a task

- May allow for less fatiguing and time-consuming mobility

what are the advantages of using compensation strategies for recovery

- Risk of overuse/malalignment injury (especially if overuse of one side of body)

- May not match with person's goals/vision

what are the disadvantages of using compensation strategies for recovery