Upper Motor Neuron Lesions

1. Spinal Cord Injury (SCI)

Spinal cord injury (SCI) refers to damage to the bundle of nerves and nerve fibers that sends and receives signals from the brain, resulting from trauma or non-traumatic causes.

The extent of SCI-related impairment depends on injury severity and location in the spinal cord.

2. Prevalence

In 2021, 15.4 million people were living with SCI.

Males are more commonly affected by SCI than females (78% vs 22%).

3. Etiology

• Motor vehicle accidents

• Falls

• Violence

• Sports injuries

• Cancer / Tumor

• Arthritis at the spine

• Osteoporosis

• Infectious disease

• Congenital problems (e.g., Spina Bifida)

4. ASIA Impairment Scale

• International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI)

• American Spinal Injury Association

• A standardized neurological examination used to assess the degree of motor and sensory impairment in individuals with SCI.

4.1 Purpose:

• Helps clinicians evaluate the neurological level of injury in SCI patients.

• Guides treatment decisions, aids in rehabilitation prognosis, and facilitates multidisciplinary communication.

4.2 Components of the ASIA Exam:

• Myotomal-based motor

• Dermatomal-based sensory

• Anorectal examination

4.3 Sensory Examination:

• Sensory testing includes light touch (LT) and pin-prick (PP) discrimination.

• Normal sensation is assigned a score of 2.

• The maximum sensory score is 112 (56 for each modality).

• The score helps document sensory changes but cannot be calculated if any key sensory point is “not testable.”

4.4 Motor Examination:

• The motor examination grades five specific muscle groups in both the upper and lower extremities.

• The muscles tested represent the major cervical and lumbar myotomes.

• The motor level is defined by the lowest key muscle function with a grade of at least 3, assuming all key muscle functions above that level are intact (graded as 5).

4.5 Muscle Function Grading

• 0 = total paralysis

• 1 = palpable or visible contraction

• 2 = active movement, full range of motion (ROM) with gravity eliminated

• 3 = active movement, full ROM against gravity

• 4 = active movement, full ROM against gravity and moderate resistance in a muscle-specific position

• 5 = (normal) active movement, full ROM against gravity and full resistance in a functional muscle position expected from an otherwise unimpaired person

• 5* = (normal) active movement, full ROM against gravity and sufficient resistance to be considered normal if identified inhibiting factors (i.e., pain, disuse) were not present

• NT = not testable (i.e., due to immobilization, severe pain such that the patient cannot be graded, amputation of limb, or contracture of >50% of the normal ROM)

4.6 Sensory Grading

• 0 = Absent

• 1 = Altered, either decreased/impaired sensation or hypersensitivity

• 2 = Normal

• NT = Not testable

4.7 When to Test Non-Key Muscles

• In a patient with an apparent AIS B classification, non-key muscle functions more than 3 levels below the motor level on each side should be tested to most accurately classify the injury (differentiate between AIS B and C).

4.8 ASIA Impairment Scale (AIS)

• A = Complete: No sensory or motor function is preserved in the sacral segments S4-5.

• B = Sensory Incomplete: Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-5 (light touch or pin prick at S4-5 or deep anal pressure) AND no motor function is preserved more than three levels below the motor level on either side of the body.

• C = Motor Incomplete: Motor function is preserved at the most caudal sacral segments for voluntary anal contraction (VAC) OR the patient meets the criteria for sensory incomplete status (sensory function preserved at the most caudal sacral segments (S4-S5) by LT, PP or DAP), and has some sparing of motor function more than three levels below the ipsilateral motor level on either side of the body. For AIS C-less than half of key muscle functions below the single NLI have a muscle grade > 3.

• D = Motor Incomplete: Motor incomplete status as defined above, with at least half (half or more) of key muscle functions below the single NLI having a muscle grade > 3.

• E = Normal: If sensation and motor function as tested with the ISNCSCI are graded as normal in all segments, and the patient had prior deficits, then the AIS grade is E. Someone without an initial SCI does not receive an AIS grade.

• Using ND: To document the sensory, motor and NLI levels, the ASIA Impairment Scale grade, and/or the zone of partial preservation (ZPP) when they are unable to be determined based on the examination results.

4.9 Steps for Determining Neurological Level

• Determine the sensory levels: For light touch (LTR) and pin prick (PPR).

• Determine the motor level: Defined by the lowest key muscle function with a grade of at least 3 (supine testing), assuming all key muscle functions above that level are intact (graded as 5).

• Determine the neurological level of injury (NLI): This refers to the most caudal segment with intact (normal) sensory and motor function. The NLI is the most cephalad of the sensory and motor levels determined in steps 1 and 2.

• Determine whether the injury is complete or incomplete: (i.e., absence or presence of sacral sparing). If voluntary anal contraction = No AND S4-5 deep anal pressure = No, then injury is Complete; Otherwise, injury is Incomplete.

• Determine ASIA Impairment Scale (AIS) grade:

  • Is injury Complete? If YES, AIS=A and ZPP (lowest dermatome and myotome on each side with some preservation).

  • Is injury Motor Complete? If YES, AIS=B (No voluntary anal contraction (VAC) and no motor function preserved more than three levels below the motor level on a given side, if the patient has sensory incomplete, the classification)

  • Are at least half of the key muscles below the neurological level of injury graded 3 or better? NO AIS=C, YES AIS=D

  • If sensation and motor function are normal in all segments, AIS = E

5. Assigning Injury Grade and Level

• After completing the three components, clinicians assign an injury grade (A, B, C, D, or E) and determine the neurological level of injury.

• This designation can then be used for rehabilitation prognosis, to guide treatment interventions, and aid in multidisciplinary communication.

6. Types of Spinal Cord Injuries

6.1 By location:

• Cervical (C1-C7): Neck region

• Thoracic (T1-T12): Upper back to just below the navel

• Lumbar (L1-L5): Lower back, extending to the top of the buttocks

• Sacral (S1-S5): Pelvis, below the buttocks to the tailbone

6.2 By severity:

• Complete SCI: Characterized by no preservation of motor and/or sensory function more than 3 segments below the neurological level of injury (NLI).

• Incomplete SCI: Any damage to the spinal cord that preserves some function below the neurological level of the injury.

7. Functional Implications

• Quadriplegia (Tetraplegia): Paralysis that affects both arms and both legs; lesion in the cervical spinal cord.

• Paraplegia: Loss of sensory and motor functions in legs and pelvis, but retains function in arms; lesion typically in the thoracic or lumbar spinal cord.

8. Incomplete SCI Classifications

8.1 Central Cord Syndrome (CSS):

• Most common (15-25%)

• Weakness or paralysis more pronounced in the upper limbs (arms) than in the lower limbs.

• Sensory loss, difficulty with tasks (e.g., buttoning, writing).

• Urinary issues (e.g., incontinence).

8.2 Anterior Cord Syndrome (ACS):

• Rare (approx. ≤ 2%)

• Motor deficits and loss of sensation

• Preserved proprioception and vibration sense

8.3 Brown-Sequard Syndrome (BSS):

• Rare (approx. 1-2%)

• Hemiparaplegia: Paralysis on the side of the lesion.

• Contralateral loss of pain and temperature sensation.

• Ipsilateral loss of tactile sensation.

• Ipsilateral spastic paralysis (paralysis on the side of the lesion).

8.4 Posterior Cord Syndrome (PCS):

• Rarest (approx. ≤ 1%)

• Contralateral partial loss of tactile sensation.

• Gait ataxia (uncoordinated walking).

• Paresthesias (abnormal sensations).

• Loss of position and vibration sense.

• Urinary incontinence.

9. Spinal Cord Injury Levels and General Effects

• C1-C4: Paralysis in arms, hands, trunk, and legs; may not be able to breathe on their own; requires complete assistance with activities of daily living.

• C5-C6: Paralysis in wrists, hands, trunk, and legs; can raise their arms and bend elbows; needs assistance with most activities of daily living.

• C7-C8: Paralysis in hands, trunk, and legs; has elbow extension and some hand movement; independent with most activities of daily living.

• T1-T5: Paralysis in trunk and legs; normal arm, hand, and upper-body movement; independent with most activities of daily living.

• T6-T12: Paralysis in trunk and legs; normal arm, hand, and upper-body movement; independent with most activities of daily living.

• L1-L5: Injuries generally result in some loss of function in the hips and legs; may need a wheelchair or walk with braces.

• S1-S5: Injuries generally result in some loss of function in the hips and legs; most likely will be able to walk.

10. Complications

10.1 Early Complications

• Spinal shock

• Pressure sores

• Deep vein thrombosis (DVT)

• Autonomic Dysfunction (AD)

  • Autonomic Dysreflexia

  • Orthostatic hypotension / postural hypotension

  • Impaired thermoregulation

  • Bladder and bowel disturbances → Urinary tract infections

• Pulmonary disturbances → Pneumonia

10.2 Late Complications

• Spasticity

• Pain

• Osteoporosis

• Contractures

• Heterotopic ossification

• Neuropathic joint arthropathy

• Atelectasis

• Bloated stomach

• Scoliosis + early complications

11. Physiotherapy Assessment

• Subjective Assessment

• Objective Assessment

  • Assess impairments (standard assessment), activity limitations, and participation restrictions.

  • Use assessment tools such as Functional Independence Measure (FIM), Barthel Index, and The Tetraplegic Hand Activity Questionnaire (THAQ).

• Analysis – Patient’s problems/impairments, goals (SMART)

• Plan of Treatment – identify treatments

12. ICF Framework

• Assessing impairments, activity limitations, and participation restrictions

• Setting goals with respect to activity limitations and participation restrictions

• Identifying key impairments

• Identifying and administering treatments

• Measuring outcomes

13. Physiotherapy Treatment

13.1 Principles of Management

• Acute Management: Focus on treating respiratory complications and preventing secondary musculoskeletal problems related to prolonged bed rest.

• Rehabilitation Following SCI: As soon as the patient is medically stable after injury → strengthening training and focuses on goals related to motor tasks such as walking, pushing a wheelchair, and transferring → to enable the person to return to a productive and satisfying life.

13.2 Specific Treatment Approaches

• To Prevent Pulmonary Complications:

  • Breathing exercises

  • Assisted cough

  • Incentive spirometry

  • Percussion, vibration, and shaking

  • Suctioning

  • Positioning

• To Reduce Spasticity:

  • Stretching

  • Standing

  • Hydrotherapy

  • Positioning

• To Prevent and Treat Contractures:

  • Passive movement

  • Stretching exercises

  • Positioning

• To Increase Strength:

  • Progressive strength training program

  • For upper limbs

  • For lower limbs for patients with partial paralysis of the lower limbs

• To Improve the Performance of Motor Tasks:

  • Bed mobility and transferring training

  • Sitting Unsupported training

  • Sitting unsupported with the knees extended

  • Balance training

14. Bed Mobility and Transferring Training:

• C6 Tetraplegia: Rolling onto the side

  • Pre-swing: The head and both arms are rotated away from the direction of the roll.

  • Practice of this sub-task can be made easier if:

    • a small weight is placed in the hands

    • elbow extension splints are used

  • Swing: The head and both arms are thrown across the body.

  • Practice of this sub-task can be made easier if:

    • a pillow is placed behind the trunk

    • the ankles are crossed

    • the leading hip is supported in 45°flexion

    • elbow extension splints are used

• Paraplegia: Lying to long sitting

  • Rolling onto the side

  • Lifting the upper trunk off the bed: The left arm is horizontally abd, and weight is borne through both hands.

  • Practice of this sub-task can be made easier if:

    • a pillow is placed under the chest

    • the sub-task is practiced in reverse

  • Moving into the upright position: The elbows are extended.

  • Practice of this sub-task can be made easier if:

    • a pillow is placed under the chest

    • the sub-task is practiced in reverse

• C6 Tetraplegia: Lying to long sitting

  • Rolling onto the side

  • Lifting the upper trunk off the bed: The left arm is horizontally abd., and weight is borne through the left elbow.

  • Practice of this sub-task can be made easier if:

    • a pillow is placed under the chest

    • the sub-task is practiced in reverse

  • Supporting the upper trunk: The right hand is placed on the bed to help prevent a forward collapse of the trunk. Alternatively, both elbows are placed on the bed.

  • Practice of this sub-task can be made easier if: a pillow is placed under the chest

  • Positioning the top hand under the leg: The right wrist is extended and hooked behind the right knee.

  • Practice of this sub-task can be made easier if: a pillow or block is placed under the left elbow

  • Shuffling the bottom elbow around the body: The right arm is adducted with the wrist anchored behind the knee.

  • Practice of this sub-task can be made easier if:

    • a pillow or block is placed under the left elbow

    • the sub-task is practiced in reverse

  • Moving into the upright position: The right arm is adducted with the wrist anchored behind the knee. The left arm is abducted.

  • Practice of this sub-task can be made easier if:

    • a pillow or block is placed under the left elbow

    • the sub-task is practiced in reverse

• Thoracic paraplegia: Moving directly into sitting from the supine position

  • Strategy for Sitting Up: Use the upper arms to push directly into a sitting position from lying down

  • Paraplegia Patients: Place the hands behind the body.

  • Lifting the Trunk: Push down through the hands and extend the elbows to lift the trunk.

• C6 tetraplegia : Lifting on a plinth (Vertical Lift)

  • Positioning the hands: The hands are placed next to and in front of the hips.

  • Practice of this sub-task can be made easier if:

    • elbow extension splints are used to help prevent elbow collapse

    • very high blocks are placed under the arms and the patient lifts through fully flexed elbows

    • small blocks are placed under the hands or under the buttocks

  • Lifting the body: The shoulders are depressed. The elbows are ‘passively’ extended

  • Practice of this sub-task can be made easier if: The feet are stabilized to prevent a forward slide

  • Rotating the trunk: The trunk is rotated forwards about the wrists and shoulders

• Paraplegia: Lifting in a wheelchair (Vertical Lift)

  • Positioning the hands: The hands are placed on the apex of the back wheels

  • Practice of this sub-task can be made easier if:

    • the vertical position of the back wheels is adjusted to optimize elbow position

    • the thickness of the cushion is adjusted to optimize elbow position

  • Lifting the body: The elbows are extended, and the shoulders adducted and depressed

• C6 tetraplegia : Lifting in a wheelchair (Vertical Lift)

  • Positioning the hands: One hand is placed on the apex of the wheel and the other on the seat.

  • Practice of this sub-task can be made easier if: the width of the seat is increased

  • Lifting the body: The shoulders are adducted and depressed. The elbows are ‘passively’ extended

• Paraplegia: from wheelchair to bed with the legs down and using the rotatory strategy Transfer

  • Moving to the front edge of the wheelchair: The elbows are extended, and the shoulders adducted and depressed to vertically lift the body.

  • Practice of this sub-task can be made easier if:

    • a firm cushion is used

    • the back of the wheelchair is raised

    • the cushion cover and the patient’s lower limb clothing

    • the feet are placed on the ground

    • The vertical position of the back wheels is adjusted to optimal elbow position

  • Positioning the feet on the floor: The left arm lifts the right leg onto the ground. The right arm is used to hold the trunk upright.

  • Positioning the hands: The right hand is placed on the bed, and the left hand on the front corner of the wheelchair.

  • Practice of this sub-task can be made easier if:

    • the wheelchair is positioned as close as possible to the bed

    • the bed is slightly lower than the wheelchair

    • additional beds are placed in front and to the side of the patient

  • Lifting and shifting the body onto the bed: The elbows are extended, and the shoulders adducted and depressed to vertically lift the body.

  • Lifting the legs onto the bed: Weight is borne through the right elbow while the left arm is used to lift each leg onto the bed

  • Practice of this sub-task can be made easier if:

    • the wheelchair is positioned as close as possible to the bed

    • A slide board is used

• C6 tetraplegia: from wheelchair to bed with the legs up and using the translatory strategy

  • Moving to the front edge of the wheelchair: The head and trunk are extended over the back of the wheelchair.

  • Practice of this sub-task can be made easier if:

    • a firm cushion is used

    • the back of the wheelchair is raised

    • the cushion cover and the patient’s lower limb clothing are slippery

    • the feet are placed on the ground

    • the backrest of the wheelchair is lowered

  • Lifting the first leg onto the bed: The left arm is hooked around the back of the wheelchair to prevent a forward fall.

  • Practice of this sub-task can be made easier if: the feet are placed on a raised stool

  • Lifting the second leg onto the bed: As above

  • Positioning the hands: The left hand is placed on the bed, and the right hand on the apex of the far wheel.

  • Practice of this sub-task can be made easier if:

    • the wheelchair is positioned as close as possible to the bed

    • A slide board is used

  • Lifting and shifting the body onto the bed

15. Training for Pushing a Wheelchair

• Mobilizing with manual wheelchair

  • Move forward

  • Move backward

  • Turning

  • The wheelstand

  • A.K.A. ‘wheelie’

• Mobilizing with power wheelchairs practice driving the wheelchairs on the types of terrains that the patient is likely to encounter.

16. Standing and walking with lower limb paralysis

• Standing in a standing frame.

• Standing with a tilt table

• Standing in parallel bars using knee extension splints.

• Thoracic paraplegia: walking with a hip– knee– ankle–foot orthosis.

• Treadmill training with body weight support

17. Multiple Sclerosis (MS)

• An inflammatory demyelinating condition that results from an autoimmune attack on myelin, the fatty insulation that surrounds the nerves in the brain and spinal cord.

• This disrupts the electrical impulses that are sent through the nerves to the rest of the body and results in scars (plaques or sclerosis).

18. Risk Factors

• Age: 16 - 55

• Gender: Women > men

• Family History: Having a parent or sibling with MS

• Infections: Certain viruses such as Epstein-Barr, human herpes virus type 6, and mycoplasma pneumonia

• Race: White people have the highest risk of developing MS. The risk is lowest among Asian, African, or Native Americans.

• Vitamin D: Low levels of vitamin D

• Autoimmune Diseases: People with certain autoimmune diseases, such as thyroid disease, type 1 diabetes, or inflammatory bowel disease

• Smoking

19. Etiology

• Complex and multifactorial, involving both genetic and environmental factors

• Genetic Predisposition: MS is thought to have a genetic component, particularly inherited immunoregulatory abnormalities.

  • Certain genetic factors, such as HLA DRB1*15:01, have been associated with an increased risk of MS.

• Infections: Certain infections, such as Epstein-Barr virus, human herpes virus type 6, and mycoplasma pneumonia, have been associated with an increased risk of MS.

• Environmental Factors : Environmental links in the causal chain of disease, such as antigenic exposures, trauma, or other insults, have been postulated to interact with genetic factors.

• Host Susceptibility Factors: Additional host susceptibility factors, such as acquired faulty immune system regulation, age, nutritional status, and endocrine status.

• Lifestyle Factors: Lifestyle factors, such as low vitamin D levels, cigarette smoking, and obesity.

20. Effects

20.1 Respiratory

• Diminished cough reflex

• Potential Complication: Respiratory infections

20.2 Urinary

• Hesitancy

• Frequency

• Retention

• Reflex bladder emptying

• Potential Complications:

  • Recurring UTIs

  • Incontinence

20.3 Gastrointestinal

• Oral/esophageal

  • Difficulty chewing

  • Dysphagia

• Upper/lower GI

  • Decreased or absent sphincter control

  • Bowel incontinence

  • Constipation

20.4 Musculoskeletal

• Fatigue

• Limb weakness

• Ataxic movements. (shaky, irregular, uncoordinated)

• Intention tremors

• Spasticity

• Muscular atrophy

• Dragging of foot and foot drop

• Dysarthria with slurred speech

20.5 Neurologic

• Emotional lability (euphoria or depression)

• Forgetfulness

• Apathy

• Scanning speech

• Impaired judgment

• Irritability

• Potential Complications:

  • Convulsive seizures

  • Dementia

20.6 Sensory

• Visual

  • Blurred vision

  • Diplopia

  • Nystagmus

  • Visual field defects (blind spots)

  • Eye pain

  • Potential Complication: Blindness

• Auditory

  • Vertigo

  • Nausea

• Tactile (especially hands or legs)

  • Numbness

  • Paresthesias (tingling, burning sensation)

  • Diminished sense of temperature

  • Pain with spasms

  • Loss of proprioception

20.7 Reproductive

• Impotence (male)

• Loss of genital sensation

21. Main Symptoms

• Central: Fatigue, Depression, Cognitive impairment, Unstable mood

• Throat: Dysphagia

• Muscular: Weakness, Cramping, Spasm, lack of coordination

• Senses: Increased sensitivity to pain, Tingling, Burning, Pins and needles feeling

• Visual: Nystagmus, Optic neuritis, Diplopia

• Mouth: Difficulty swallowing food, Sudden slurring or stuttering in speech

• Urinary: Frequent urination, Incontinence

• Digestive System: Sudden change, Constipation, Diarrhea

22. Types of MS

• Clinically Isolated Syndrome (CIS)

• Relapsing-Remitting MS (RR MS): Most common type, characterized by relapses and remissions.

• Secondary Progressive MS (SP MS): Steady progression of symptoms after years of RRMS.

• Primary Progressive MS (PP MS): Gradual worsening of disease from the start, with little to no remissions.

• Progressive Relapsing MS (PR MS): Progressive worsening with occasional relapses.

23. Rarer Forms

• RIS: Lesions on brain or spinal cord consistent with MS.

• Fulminate/Malignant/Marburg MS: Most aggressive type.

• Inactive/Benign MS: Mild and stable type.

• Burned-Out MS: Inactive late-stage type.

• Balo’s Disease: Rare and progressive type.

24. CIS vs MS

25. Aims of Physiotherapy

• Re-educate and maintain all available voluntary control.

• Re-educate & maintain postural mechanisms.

• Incorporate treatment techniques into ways of life by relating to ADLs (Activities of Daily Living).

• Inhibit abnormal tone.

• Prevent abnormal movement,

• Stimulate all sensory and perceptual experience.

26. PT Assessment

• focuses on movement, and function

• realize the patient's performance may be limited by fatigue, pain, or other factors.

• Evaluation Tools: Expanded disability, Multiple Sclerosis Functional Composite

• Gait, Balance, Posture

  • Reduced speed

  • Shorter strides

  • Prolonged double limb support phase

  • Altered muscle activity and kinematics

  • Skeletal changes

27. Recommendations for exercise testing in MS patients

28. Physiotherapy treatment

• Strength training for the upper limbs and lower limbs

• Positioning

• Weight is used to help reduce tremor and ataxia during functional exercise of the upper limb

  • Strengthening exercises

  • Weight-bearing exercise is recommended for lower limbs.

• Stretching exercises

• Functional exercises

• Balance and coordination exercises – improve stability and reduce the risk of falls

• Aerobic exercises - increase wellbeing and improve mental state: increase

• Aquatic therapy/exercises - improve flexibility and range of motion, cardiovascular endurance, fatigue level, muscle strength, mobility function (including gait and balance), quality of life, and psychological well-being

• Respiratory muscle training:

  • breathing exercises

  • incentive spirometry

29. Special considerations and precautions for exercise prescription in MS patients