SCI: Rehab of C5-S1

Which muscles receive C5-6 motor innervation?

Levator scapulae, rhomboids, serratus anterior, supraspinatus, infraspinatus, subscapularis, teres major/minor, pectoralis major/minor, biceps brachii/brachialis/coracobrachialis, extensor carpi radialis

Nerve roots: levator scapulae

C4-5 (dorsal scapular n.)

Nerve roots: rhomboids

C4-5 (dorsal scapular n.)

Nerve roots: serratus anterior

C5, 6, 7 (long thoracic n.)

Nerve roots: supraspinatus

C5 (suprascapular n.)

Nerve roots: infraspinatus

C6 (suprascapular n.)

Nerve roots: subscapularis

C5-6 (upper & lower subscapular n.)

Nerve roots: teres major/minor

C5-6 (teres major = lower subscapular n., teres minor = axillary n.)

Nerve roots: pectoralis major/minor

C5, 6, 7 (upper and lower pectoral n.)

Nerve roots: biceps brachii/brachialis/coracobrachialis

C5, 6, 7 (musculocutaneous n.)

Nerve roots: ECR

C6-7 (radial n.)

Which muscles receive C7-8 motor innervation?

Latissimus dorsi, triceps brachii, wrist extensors/supinator, finger extensors, finger flexors

Nerve roots: latissimus dorsi

C6, 7, 8 (thoracodorsal n.)

Nerve roots: triceps brachii

C6, 7, 8 (radial n.)

Nerve roots: wrist extensors/supinator

C6, 7, (8) (radial n.)

Nerve roots: finger extensors

C7-8 (radial n.)

Nerve roots: finger flexors

C8-T1 (median & ulnar n.)

C5-6 Key Muscle Group: _________

Elbow flexors

W/ a C5-6 SCI, there is no ___________ (x3)

Triceps, wrist extension, or active hand movements

Which muscles need to be maximized w/ a C5-6 SCI?

Brachialis/coracobrachialis/partial biceps, deltoids, partial rotator cuff

How do you support your body weight w/o triceps?

Elbow "lockout" w/ shoulder ER, biceps, and delts

What are some functional goals for a C5-6 SCI? (x7)

- Prevent elbow flexion/supination contractures

- Prevent overstretching wrist extensors - PRESERVE TENODESIS

- Manual WC skills

- ADL's w/ adaptive tools and set-up assist

- Bed mobility

- Transfers

- Driving w/ adaptive controls

What level of assistance w/ bed mobility and transfers can be expected w/ a C5-6 SCI?

Mod to max assist for rolling and supine to/from sit, mod to max assist for slideboard transfers

What should you facilitate in terms of rolling in bed? (x4)

- Flexion of the head and neck for supine to prone vs. extension and rotation for prone to supine

- Symmetrical UE rocking (note: consider no triceps w/ arms overhead in supine...we want to use gravity to keep arms extended

- Setting LE's up for rolling success (i.e., ankles cross, one leg bent at knee so the hips fall w/ gravity)

- Use pillows to decrease range of rolling movement

To complete a supine to/from sit, a patient must be able to obtain _______

Prone

First time prone, need clearance from ________

MD (c-collar/cervical precautions)

How do you instruct a patient on the transition from prone on elbow to sitting? What are the next steps?

--> lateral weight shifts to "shimmy" elbows towards feet

--> hook arm around upper thigh to pull towards long sit

--> C walk to full long sit if enough hammie flexibility

--> use pecs/anterior shoulders to push-up to sitting

How do you instruct a patient on the transition from sidelying to sitting? What are the next steps?

Extend bottom shoulder to prop on elbow & use momentum to swing top arm up and roll into prone

How do you instruct a patient on the transition from supine to sitting? What are the next steps?

Lateral weight shift until posterior prop on elbows achieved, "tuck" hands in back pockets to utilize biceps

When addressing long sit, which muscle provides tension--and if there is no tension, the patient will tend to fold forward more easily?

Hamstrings

True or false: when anterior/posterior propping, you want to maintain tenodesis ALWAYS

TRUE!! DO NOT STRAIGHTEN FINGERS

_________: shoulder ER, bicep extension, and ant deltoid activation

Posterior prop

_________: shoulder IR, pecs, biceps and hammie tension

Anterior prop

When posterior/anterior propping, which body part can't you forget about?

Head!! (throw it forward for anterior prop, backward for posterior prop)

How should you initiate short sit?

PT in front of patient

How do you progress short sit?

Single arm, no UE balance using head/trunk to find center of stability -- add weights, balloon toss, lateral reaching, etc.

What is KEY w/ slideboard transfers in C5-6 SCI?

Lateral propping for placement, LE placement/management, head/hip relationship, hand placement, forward lean, shoulder depression to achieve "life and shift"

True or false: all patients w/ C5-6 will achieve independent popover

FALSE!!

What is KEY w/ popover transfers?

FULL FORWARD LEAN, shoulder depression and head/hips relationship

How should you initiate popover transfers? Progress?

Downward transfer --> upward transfers at increasing heights, varying surfaces

C6-7 Key Muscle Group: _________

Wrist Extensors

W/ a C6-7 SCI, no __________

Triceps, BUT can utilize tenodesis for hand grip

Which other muscles are intact in a C6-7 SCI?

Full innervation of SITS, lats, serratus anterior, pec major: clavicular head

What are some functional goals for a C6-7 SCI? (x6)

- Maintain tenodesis for hand grip

- Independent weight shifts

- Manual WC skills

- Independent w/ ADL's (may use tricep driven orthosis)

- Independent bed mobility

- Slideboard transfers w/ little assist for level transfers, increases assist for uneven surfaces

C7 Key Muscle Group: _________

Triceps (may have PARTIAL innervation of finger extensors)

W/ a C7 SCI, there is a significant increase in __________

Independence!! Go triceps!!

C8 Key Muscle Group: _________

Finger flexors (now have some grasp/release and MUCH more independence w/ ADL's/dressing)

Which muscles do patients still lack w/ a C8 SCI?

Abdominal/trunk musculature

What are some functional goals for a C7 SCI? (x4)

- Independent in all ADL's (set-up assist)

- Independent functional mobility INCLUDING transfers to uneven surfaces (may use slideboard or popover, independent floor transfers)

- Full-time manual WC user

- Adaptive control for driving

What are some functional goals for C8 SCI?

Independent w/ all aspects of ADL's and functional mobility: slideboard or popover transfers, floor and car transfers, manual WC skills, driving w/ adaptive controls

Which muscles receive T1-12 motor innervation?

Chest muscles: T2-5

Chest & ab muscles: T6-8

Abdominal muscles: T9-12

Which muscles receive L1-5 motor innervation?

Hip flexors: L1-2

Knee extension: L3

Dorsiflexion: L4

Toe extension: L5

There is FULL UE activation is injury below _______

T1

What is the key muscle group for thoracic SCI?

Abdominals (BUT there is absent trunk/core for "normal" balance)

What are some functional goals in thoracic SCI? (x5)

- Independent in all ADLs, transfers and increased ease for leg management

- Full-time manual WC user

- Adaptive controls for driving

- Therapeutic ambulation using braces @ upper thoracic injuries

- May be household ambulatory w/ T11-12 SCI using braces

To reiterate, a patient w/ a thoracic SCI will likely be able to ambulate in a therapeutic setting using braces with a ________ SCI, while a patient w/ a ________ SCI may be household ambulatory

Upper thoracic, T11-12

What are some functional goals in lumbar SCI? (x3)

- Independence w/ all aspects of functional mobility

- Level of injury determines bracing needs

- Mobility varies w/ levels -- any zones of preservation and health and strength profile

_________: long leg braces for short distances

L1-2

_________: forearm/Lofstrand crutches w/ AFO's

L3-4

_________: independent ambulation w/ AFO's

L5

What are the key muscles in sacral SCI?

Plantarflexors (L4-S2)

Individuals w/ a sacral SCI may require _______ for ambulation but otherwise ambulate independently

AFO's

While individuals w/ sacral SCI often have a good prognosis/recovery, what is a possible complication?

Bowel/bladder -- CES?