Spinal Cord Injury Rehabilitation Functional

Spinal Cord Injury Rehabilitation
Functional Expectations and
Ambulation Potential
 Diane Johnston, MSPT
Objectives for the course
 Participants will have a general understanding of the
epidemiology of Spinal Cord Injury (SCI).
 Participants will better understand the levels of Spinal
Cord Injury and their functional implications
 Participants will have an awareness of the American
Spinal Injury Association (ASIA) Impairment Scale
 Participants will have a better understanding of incomplete
SCI clinical syndromes and their relationship to
ambulation potential.
Demographics - SCI
 Incidence: 12,000 cases
per year
 Prevalence: 231,000 to
311,000
 Mean age 40.2 since 2005
(28.7 years 1973-1979)
 Gender: 80.8% male,
19.2% female
 Race: 66.2% Caucasian,
27.0% African American ,
7.9% Hispanic, 2% Asian
Source: National Spinal Cord Injury Statistical Center, February 2010
Etiology
Source: National Spinal Cord Injury Statistical Center, February 2010
Neurological Level
 Tetraplegia 55.1%
 Complete 16.9%
 Incomplete 38.3%
 Paraplegia 44.4%
 Complete 22.9%
 Incomplete 21.5%
 Less than 1% experience full
recovery
Source: National Spinal Cord Injury Statistical Center, February 2010
Neurological Level By Age
PC
PI
TC
TI
16-30
46-60
61-75
76+
Average Yearly Expenses
2009 dollars
Severity
First Year
C1-4
$829,843
Each
Subsequent Yr
$148,645
C5-8
$535,877
$ 60,887
Para
$303,220
$ 30,855
Motor
Incomplete
$244,562
$ 17,139
Source: National Spinal Cord Injury Statistical Center, February 2010
Life Expectancy
Age at injury
Para
C5-C8
C1-4
Vent
Dependent
20 years
45.8
41.0
37.4
23.8
40 years
28.2
24.2
21.2
11.4
60 years
13.2
10.4
8.6
3.2
Source: National Spinal Cord Injury Statistical Center, February 2010
Estimated Lifetime Costs
Severity
C1-4
Assuming 25 years old
at time of injury
$3,273,270
C5-8
$1,850,805
Para
$1,093,669
Motor Incomplete
$729,560
Source: National Spinal Cord Injury Statistical Center, February 2010
Number of SCI Patients Served
 Overall 1,761 SCI persons
served per year
 Inpatient: 402 patients
 Outpatient:
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Day Program: 319
Single Service: 473
Beyond Therapy: 30
Promotion Wellness: 537
UE Clinic: 297
 Numbers lead to
expertise!
Shepherd Data: 04/01/2009-03/31/2010
Then and Now
 LOS
 Acute care
 1974: 25 days
 2010: 15 days
 Rehab
 1974: 115 days
 2010: 36 days
 Average age at injury
 1973-1989: 28.7 years
 2005-present: 40.2 years
 Injuries at 60 yo+
 1979: 4.7%
 2010: 26.8%
 Severity of injury
 ↓in complete injuries (41%)
 ↑in incomplete injuries (53%)
 Plasticity of the spinal cord!!!
Functional Expectations
Definition:
Complete vs/Incomplete Injury
 Complete Injury: An absence of sensory and motor function in
the lowest sacral segment.*
 Incomplete Injury: Partial preservation of sensory and/or motor
function is found below the neurological level and includes the
lowest sacral segment.
 Zone of Partial Preservation: Used only with complete injuries
and refers to those dermatomes and myotomes caudal to the
neurological level that remain partially innervated.
 *Water, R.L., Adkins, R.H., Yakura, J.S.: Definition of Complete spinal cord
injury. Paraplegia 1991; 9:573-581.
Neurological Categories
at Discharge
 Incomplete tetraplegia
 Complete paraplegia
 Complete tetraplegia
 Incomplete paraplegia
 No deficits
 Unknown
30.61%
25.3%
20.0%
18.6%
0.6%
3.4%
National Spinal Cord Injury Statistical Center 2009-2010
C1-3
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Respiratory: Vent
Bowel: 1
Bladder : 1
Bed Mobility : 1
Transfers: 1
Pressure Relief: 6
Eating: 1
Grooming: 1
Bathing: 1
Wheelchair Prop: 6
Communication: 5
Transportation: 1
Home making: 1
C1-3 Assistance Required
 24-hour attendant care
to include
homemaking
 Able to instruct all
aspects of care
C4
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Respiratory: No vent
Bowel: 1
Bladder : 1
Bed Mobility : 1
Transfers: 1
Pressure Relief: 6
Eating: 1
Grooming: 1
Bathing: 1
Wheelchair Prop: 6
Communication: 5
Transportation: 1
Home making: 1
C4 Assistance Required
 24-hour care to include
homemaking
 Able to instruct all
aspects of care
C5
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Bowel: 1
Bladder: 1
Bed Mobility: 2-3
Transfers 1-2
Pressure Relief: 6
Eating: 5
Dressing:
 Upper body: 4
 Lower body: 1-2
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Grooming: 1-3
Bathing: 1-3
Wheelchair prop: 6
Communication: 5
Transportation: 6
Home making 1
C5 Assist Required
 Person care: 10 hours
per day
 Home care: 6 hours per
day
C6
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Bowel: 3-5
Bladder: 3:6
Bed mobility: 3-6
Transfers: 3-6
Pressure Relief: 6
Eating: 6
Dressing
 UE 6
 LE 3-6
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Grooming: 5-6
Bathing: 4-6
Wheelchair: 6
Communication: 6-7
Transportation: 6
Home making:
 Light meals:5-6
C6
 Personal Care: 6 hours
per day
 Homecare: 4 hours per
day
C7-8
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Bowel: 6
Bladder: 6
Bed mobility: 6-7
Transfers: 6
Pressure relief: 6
Eating: 7
Dressing: 6-7
Grooming: 6-7
Bathing: 6-7
Wheelchair prop:
 Manual: 6
 Power: 6
 Communication: 6
 Transportation: 6
 Homemaking:
 Meal prep: 6
 Heavy housecleaning: 4-6
Assist Required C7-8
 Personal Care: 2-4
hours per day
 Homecare: 2 hours per
day
Para (T1-9)
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Bowel: 6
Bladder: 6
Bed Mobility: 6
Pressure Relief: 6
Transfers: 6-7
Eating:7
Dressing: 7
Grooming: 7
Wheelchair: 6
Communication: 7
Home making: 6-7
Para (T10 and ↓)
 All the same
 Add:
 Ambulation
 Bracing
 Assistive Devices
 Different levels of
community ambulation
 Below L2 generally
independent at community
level
Para Assist Required
 Personal care: 0 hours
per day
 Homemaking 0-2
hours per day
Statistically the percentage of
incomplete spinal cord injured (SCI)
persons has continued to increase as
emergency medical care has improved.
The variability seen
in neurological
recovery challenges
the clinician in
planning for these
clients functional
needs.
5 Most Common Levels of Injury
•
•
•
•
•
C5: 14.9%
C4: 13.6%
C6: 10.8%
T12: 6.7%
C7: 5.3%
Source: National Spinal Cord Injury Statistical Center
MRI
 Hemorrhage with median
length of 10.5 mm
associated with complete
spinal cord injury
 Hemorrhage of less than 4
mm associated with
incomplete spinal cord
injuries with good
prognosis
http://bjr.birjournals.org/cgi/content/full
/76/905/347
Source: Boldin C, et al. Spine. 2006;31(5):554-559.
ASIA Impairment Scale (AIS)
AIS Changes
Admission
No Change
Improved
Declined
A
48.0%
86.7%
11.3%
0%
B
13.1%
46.9%
45.6%
4.5%
C
14.7%
41.9%
52.7%
3.0%
D
18.0%
90.1%
4.8%
2.1%
A= Complete Injury
B= Incomplete, sensory only
C= Incomplete, motor (non functional)
D= Incomplete, motor (functional)
Source: National Spinal Cord Injury Statistical Center, January 2008
ASIA and Walking Outcomes
 Attained independent walking by inpatient DC
 AIS A: 6.4%
 AIS B: 23.5%
 AIS C: 51.4%
 AIS D: 88.6%
Morganti et al, 2005
Clinical Syndromes
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Central cord Syndrome
Anterior Spinal Artery Syndrome
Brown-Sequard Syndrome
Posterior Cord Syndrome
Cauda Equina Syndrome
Conus Medullaris Syndrome
 Other diagnoses: Multiple sclerosis,
transverse myelitis, spinal cord tumors,
Gillian Barre’ Syndrome, peripheral
neuropathies, and amyotrophic lateral
sclerosis
Central Cord Syndrome
 Hyperextension injury
 Impairment of function
greater in upper
extremities than lower
extremities
 Majority of incomplete
lesions result in this
syndrome.
 77% of these clients will
ambulate.
Bosch A et al, 1971
Anterior Spinal Artery Syndrome
 Flexion injury
 Loss of motor
functions, pain and
temperature sensation
 Prognosis poor for
ambulation.
Bosch A et al, 1971
Brown-Sequard Syndrome
 Caused by penetrating injures
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(gun shot or stabs wounds)
Hemi section of the spinal cord
Loss of movement and position
sense on the same side
Loss of pain and light touch on
opposite side
Nearly all regain some level of
ambulation
Prognosis for recovery is good
80% regain hand function
80 – 100% gain bowel and
bladder function
Bosch A et al, 1971
Posterior Cord Syndrome
 Very rare
 Caused by compression from a
tumor or infarction
 Motor function is preserved
 Sensory modalities are lost
below the level of injury
 Functional ambulation is
difficult despite having strong
muscles
Bosch A et al, 1971
Cauda Equina Syndrome
 Injury to the L1 vertebral
level and below
 Lower motor neuron
lesion
 In most cases it is a
complete lesion
 Ambulation is probable
due to the injury being
low (quadriceps muscles
are spared)
Conus Medullaris
 Injury to the sacral cord
and lumbar nerve root
within the neural canal
 Lower extremity motor
and sensory loss
 Areflexic bladder and
bowel
 Can usually ambulate
Motor Indicators
 Lower extremity motor scores (Waters et al, 1994):
 20 or less use a wheelchair as their primary mode
of locomotion
 30 or more can become community ambulators
 Walked at community level by 1 year if (Gittler et al,
2002):
 Tetra plegia with LEMS of 20+
 Paraplegia with LEMS of 10+
 Initial muscle grade of 1/5 (trace) recovered to
muscle grade of 3/5 (fair) within 3 months of the
initial injury (Ditunno et al, 1992)
Sensory Indicators
Baseline lower extremity pin prick
preservation and sacral pinprick
preservation at 4 weeks post injury are
associated with an improved prognosis
for ambulation (Oleson et al, 2005)
 Muscles that initially scored 0/5 (Poynton
et al, 1997)

 Dermatomes with spared pin prick, 85%
regained ≥3/5 strength
 Dermatomes without spared pin prick, 1.3%
regained ≥3/5 strength
Age
 Regaining walking function:
 If younger than 50 2x more likely
to walk at discharge (Burns et al,
1997)
 Younger subjects more likely to
regain walking (Scivoletto et al,
2003)
Active Weight Bearing
Tilt Table/Standing Frame
 Combine with E-stim/vibration
 Angle footplates for tight ankles.
Incorporate US/STM
 Adjustable knees, seat and chest
positions for therapeutic exercise
Pool
 Shallow (aerobic steps, sitting,
standing therapeutic exercise,
walking all directions with device or
buoy bars)
 Deep water (inner tubes, foam
noodles, etc)
 Lap swim (supine with inflatable
neck support, ski belt, ankle floats,
½ flippers to increase
proprioceptive awareness and
resistance)
Initiating Gait with Body-Weight
Support Treadmill Systems
 Robotic
 Lokomat® (Hocoma)
 Autoambulator (Health South)
 Manual
 TheraStride™, Biodex, etc
 Lite Gait® (with or without treadmill)
Video With Trainer AFO
Video Scott Craig Orthoses
Para Step Video
Fillauer Stance Control Knee Joint
www.fillauer.com
Patient Video: Stance Control Brace
Patient Video: Stance Control Brace
on Stairs
Video with Malleolocs
Treadmill with Beach Ball
Balance Board w/ Hoola Hoop
So Much Available to Us
Think Outside The Box
Questions?