Functional Expectations following Spinal Cord Injury

5/2/2011
Common Questions After SCI
 Will I walk again?
Shawn Smith, M.D.
 Will I be able to use my hands?
 What will I be able to do?
Neurological and Functional
Classification of SCI
Why have
Functional Goals?
Functional goals
provide realistic
expectations of
activities that a person
with spinal cord injury
eventually should be
able to do with a
particular level of
injury
ASIA Classification
Neurological Classification
 Does not guarantee outcome
 Uses standardized international classification system
 Allows for faster but accurate assessment
 Allows for communication between healthcare
professionals
Grade the
amount of “key
muscle” strength
of the body
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Key Motor Scores
0 = total paralysis
1 = palpable or visible contraction
2 = active movement, gravity eliminated
3 =active movement, against gravity
4 = active movement, against some resistance
5 = active movement, against full resistance
NT = not testable
Determining the Level of Injury
 The lowest point on the spinal cord
below which there is a decrease or
absence of feeling (sensory level) and
movement(motor level)
Neurological
Classification
Determine the key points
of “light touch”
and “pin prick sensation”
of the body
Types of Injury

Complete Injury* - no motor or sensory function
is preserved in the sacral segments (anal area)

Incomplete Injury* - all other injuries are
classified as one of 3 types of incomplete injuries
Cervical Region
Types of Injuries
*
Cervical nerve roots exit above vertebrae
 A higher level of injury
results in more loss of
feeling and movement
than a lower level of
injury
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Thoracic Region
Lumbar Region
Thoracic nerves exit below vertebrae
Lumbar nerves exit below vertebrae
Spinal cord ends around L1
*
*
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Sacral Region
ASIA Impairment Scale
Injuries at these levels usually occur
higher as cauda equina injuries
 A- Complete-no sacral motor or sensory sensation and
no change below lesion
 B-Sensory Incomplete; preservation of sensation
below injury extending through sacral segments
 C-Motor incomplete; voluntary anal sphincter or
*
sensory sparing +motor function 3 levels below injury
with majority of muscles <grade 3
 D-Motor incomplete; same a C but majority of key
muscles >grade 3
 E- normal motor and sensory recovery
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Factors to consider before
establishing functional goals
 Age
 Cognitive ability
 Medical complications
 Contractures
 Body size/proportion
 Psychosocial issues and support
 Motivation
Tolerate sitting 10 -12 hours a day
Maintain skin integrity
Able to verbalize any skill that person is not
independent ly able to perform
Caregiver will be independent in all aspects of
care for individual
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Functional Outcome Scales
 Functional Independence Measure
Functional
Expectations by
Spinal Cord
Levels
 Quadraplegic Index of Function
 Modified Barthel Index
 Walking Index for SCI
 Capabilities of Upper Extremity Instrument
 Spinal Cord Independence Measure
Functional Expectations C1-3
Functional Goals and Needs C1-3
 Wheelchair selection
 Typically ventilator





 Ramps/Access
dependent
Limited head & neck
movement, limited speech
Important for effective
communication with
caregivers
Assistive technologies
Wheelchair access
Transportation
Functional Goals for C4
 Transportation
 Pain/Spasticity
 Skin/contractures
 Pulmonary issues
 24 hr Care
C4 Functional Level
 Some Respiratory issues (unable to cough) but not
usually on ventilator
 Have diaphragm, scalenes, SCM, Trapezius, Levator
scapulae
 Communication (Mouthstick, Environmental Control
Unit, Page turner, Computer)
 Transportation and access
 Still need 24 hr care
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Classification of C5


Functional Goals for C5
 Independence with
To establish functional
goals at this level of
injury, motor function of
the elbow flexors, or
biceps brachii, must score
3 or better on the
classification form.
Have head, neck,
shoulder control
eating, drinking, face
washing, tooth brushing,
shaving, hair care, with
setup and equipment
 Personal care at least 10
hr/day
 Home care 6 hr/day
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Functional Goals for
C5
Classification of C6

Classification of C6

To establish functional goals at
this level of injury, motor
function of the wrist extensors,
which are the extensor carpi
ulnaris, extensor carpi radialis
longus and radialis brevis must
score 3 or better on the
classification form.

Has latissimus dorsi, serratus
anterior
To establish functional
goals at this level of
injury, motor function of
the wrist extensors, which
are the extensor carpi
ulnaris, extensor carpi
radialis longus and
radialis brevis must score
3 or better on the
classification form.
Functional Goals for C6
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C6 Great Expectations
Classification of C7
 Can self assist cough
 May be able to assist with bladder management
 Bed mobility, transfers, and functional ADL transfers

To establish functional
goals at this level of injury,
motor function of the
elbow extensors, or triceps
brachii, must score 3 or
better on the classification
form.

Has wrist flexors,triceps,
extensor digitorum
moderate to minimum assistance
 Pressure relief management
 Feeding, Dressing, Grooming uppers modified




Independent
Wheelchair propulsion
Driving with hand controls
Homemaking
Requires personal care 6 hr/day, home care 2-4 hr/day
Functional Goals for
C7
C7 Great Expectations
 Same as C6 but now has elbows
 Manual wheelchair more realistic
 More ease with household transfers, wheelchair
pushups and pressure reliefs
 Less adaptive equipment needed
 Still fatigue easily
 Still may require 6 hr/day personal care and 2hr/day
home care
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Classification of C8


To establish functional
goals at this level of injury,
motor function of the
flexor digitorum
profundus, specifically the
distal phalanx of the
middle finger, must score 3
or better on the
classification form.
Add strength and precision
of fingers
Classification of T1


To establish
functional goals at
this level of injury,
motor function of the
finger abductors,
specifically the
abductor digiti
minimi, must score 3
or better on the
classification form.
More normal hands
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Functional Goals for
C8-T1
Expectations with C8-T1
 Living independently
 Feeding, grooming, oral and facial hygiene, dressing,
transferring, bowel & bladder management with little
to no hand devices
 Still needs in home and personal care up to 6-8 hr/day
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Functional Goals for
T2-T6
Expectations T2-6
 Upper extremity control for T2 and above
 Better rib, chest, and trunk control as higher thoracic
levels innervated
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Functional Goals for
T7-T12
Added function with increased abdominal muscle control
Improved pulmonary and cough control
Increased ability to perform unsupported seating activities
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Walking with SCI
T2-12 Paraplegic Ambulation
 T2-12 levels have capability of
some walking but energy
demands and stress on upper
extremities provide no
functional advantages
 Some hope for future
technology
Classification of L2-L5
Classification of L2-L5
L2 - motor function in
the Iliopsoas

L3 - motor function in
the Quadriceps
femoris
 To be classified at any of
these levels, the person
must score 3 or better on
the classification form at
that level.
To be classified at any of
these levels, the person
must score 3 or better on
the classification form at
that level.
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Classification of L2-L5
L4 - motor function in
the Tibialis anterior

To be classified at any of
these levels, the person
must score 3 or better on
the classification form at
that level.
Graphic from Muscle Function Testing © 1983, by Michie,a
division of Matthew Bender and Company, Inc. All rights
reserved.
Classification of L2-L5
L5 - motor function in
the Extensor
hallucis longus
 To be classified at any of
these levels, the person
must score 3 or better on
the classification form at
that level.
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Functional Goals for
L1-L5
Expectations for L1-5
 More functional benefit to walking
 May have cauda equina syndrome with lower motor
neuron findings with legs and bowel and bladder
 More likely to employ braces and assistive devices for
gait
 Most able to live and work independently with
appropriate training and equipment if desired
 May require 1-2 hr/day homemaking/personal care
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Classification of S1

Functional Goals for
S1-S5
To establish functional
goals at this level of
injury, motor function of
the ankle plantar flexors,
specifically the
Gastrocnemius, must
score 3 or better on the
classification form.
Other SCI syndromes to know
 Central Cord syndrome
Credits
www.spinalcord.uab.edu/
Developed by
Phil Klebine, MA
Linda L Lindsey, MEd
 Anterior Cord Syndrome
Consultants
Amie B Jackson, MD
Mary Jane Wells, PT
 Brown Sequard
Graphics from Muscle Function Testing © 1983, by Michie, a division of
Matthew Bender and Company, Inc. All rights reserved.
Syndrome
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Recommended Reading
Neurological Rehabilitation, 4th Edition, Darcy, Mosby, 2001
Outcomes Following Traumatic Spinal Cord Injury: Clinical Practice
Guidelines for health-care Professionals,(PVA.org)
Somers M: Spinal Cord Injury: Functional Rehabiliation. Norwalk,CT,
Appleton and Lange, 1992
Finkbeiner K, Russo,S: Physical therapy Management of the Spinal Cord
Injured: Accent on Independence. Fisherville, VA, Woodrow Wilson
Rehabiliation Center.
McKinley W, Santos K, et al: Incidence and Outcomes of Spinal Cord Injury
Clinical Syndromes. Journal of Spinal Cord Medicine, Vol 30,No 3,2007.
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