ASSESSMENT OF PATIENTS WITH SPINAL CORD INJURY KRISTOFFERSON G. MENDOZA, PTRP COLLEGE OF ALLIED MEDICAL PROFESSIONS UNIVERSITY OF THE PHILIPPINES MANILA PT142: Assessment in Physical Therapy

Why evaluate?  Establish the functional level of the neurologic injury  Establish the likelihood of sensorimotor recovery  Establish short- and long-term goals  Design an effective treatment program

Clinical Manifestation  Spinal Shock  Motor and sensory impairments  Spasticity

Clinical Manifestation  Bladder dysfunction  Reflex bladder (spastic, autonomic)  Nonreflex blader (flacid, autonomous)  Bowel dysfunction  Temperature control

Clinical Manifestation  Respiratory impairment  Sexual impairment

Complications  Contractures  Pressure sores  Autonomic dysreflexia  Pain  Heterotropic ossification

Complications  Orthostatic hypotension (postural hypotension)  Deep vein thrombosis  Osteoporosis

Component of the Evaluation  Subjective assessment  Respiratory function  Motor control  Range of motion  Sensory Function  Skin integrity  Functional Status

Subjective Assessment  Demographics (name, age, etc.)  Medical diagnosis  HPI  Injury: Cause, circumstances, onset  Complications that may limit therapy  Other injuries, co-morbidities (PMHx)  Precautions  Stability of the spine, presence of fractures, other injuires

Subjective Assessment  Personal/Social History  Previous employment  Education  Civil status  Family status  Important for planning for discharge  Goals and expectations

Respiratory Function  Determine  Respiratory capacity  Function of the pulmonary muscles  Chest mobility

Respiratory Function  Above T12: may respiratory involvement  Below C3: (+) diaphragmatic function, (-) intercoastal and abdominal control  Above C3: (+) diaphragmatic paralysis, (-) intercoastal and abdominal control

Respiratory Function  Function of respiratory muscles  Diaphragm, intercostals, abdominals, neck  Breathing pattern  Chest expansion  Cough  Functional: strong enough to clear secretions  Weak functional: adequate force to clear upper respiratory tract secretions in small quantities  Non-functional: unable to produce any cough force  Vital Capacity

Motor Control  To determine extent and level of injury  To set appropriate goals  To design an effective treatment program

Motor Control  Manual muscle testing  Upright motor control  Testing for spasticity

Range of Joint Motion  To determine potential problems that might interfere with goals  Measured using standard procedures  ROM  Joint Mobility Assessment  Muscle length test  Usual areas that has LOM /tightness

Skin Integrity  Maintain skin integrity: highest priority  Skin checked for redness  Positioned to remove pressure from these areas  Self-skin inspection  Palpate for changes in temp

Sensory Function  Superficial Skin Sensation  Proprioception  Tone and deep tendon

Sitting Balance  Timed unsupported sitting  useful for patients with severely impaired sitting balance  ability to maintain unsupported sitting for at least 30 seconds  has acceptable reliability (ICC no lower than 0.7)  Not good at discriminating between patient sub-groups Roswell-Ruys et al. (2007)

Sitting Balance  Seated arm reach test  useful for patients who are able to maintain unsupported sitting for at least a few minutes (backboard allowed, but slanted 10 degrees from the vertical) and who are with enough upper limb strength to hold one shoulder in 90 degrees flexion  able to discriminate chronicity of injury (p = 0.002)

Sitting Balance  Donning/Doffing of a T-shirt  useful for patients who are able to maintain unsupported sitting for at least a few minutes and who are with some upper limb strength to grasp a t-shirt  most repeatable (ICC = 0.912)  able to discriminate between subject injury level (p = 0.003)

Functional Status  Includes  Body handling for self range of motion  Dressing  Bed mobility  Feeding  Hygiene  Bowel and bladder care  Ambulation

Classification complete  no sensory or motor function below the level of the lesion  complete transection, severe compression, extensive vascular impairment  permanent motor, sensory and autonomic paralysis below lesion after spinal shock

Classification incomplete  presence of some sensory or motor function below the level of the lesion  partial transection, contusions caused by displaced bone/soft tissue, swelling inside the spinal column

Motor Level  the most distal segment with a muscle grade of 3  the immediately proximal segment have at least a muscle grade of 4  determined using the key muscles

Muscle Grading Grade 5 - able to hold position against maximum resistance Grade 4 - able to hold position against moderate resistance Grade 3 - able to hold position against gravity Grade 2 able to move extremity only with gravity eliminated Grade 1 - muscle twitch Grade 0 - no movement

Key Muscles C5Elbow flexors C6Wrist extensors C7Elbow extensors C8Flexor digitorum profundus to the middle finger T1Small finger abductors L2Hip flexors L3Knee extensors L4Ankle dorsiflexors L5Extensor hallucis longus S1Ankle plantar flexors

Sensory Level  the most distal segment with a normal sensory function  dermatomes  test both pain and light touch  sensation is graded  0 - absent sensation  1 - impaired sensation  2 - normal sensation

Dermatomes C2occipital protuberance C3supraclavicular fossa C4top of the acromioclavicular joint C5lateral side of the antecubital fossa C6thumb C7middle finger C8little finger

Dermatomes T1medial side of the antecubital fossa T2apex of the axilla T3third intercostal space T4fourth intercostal space (nipple line) T5fifth intercostal space (midway between T4 and T6) T6sixth intercostal space (xiphisternum) T7continuation of the seventh intercostal space to the midline (midway between T6 and T8)

Dermatomes T8continuation of the eighth intercostal space to the midline (midway between T6 and T10) T9continuation of the ninth intercostal space to the midline (midway between T8 and T10) T10continuation of the tenth intercostal space to the midline (umbilicus) T11continuation of the eleventh intercostal space to t he midline (midway between T10 and T12) T12inguinal ligament L1one third distance between T12 and L2 L2midanterior thigh

Dermatomes L3medial femoral condyle L4medial malleolus L5dorsum of the foot at the third MTP joint S1lateral heel S2midline of popliteal fossa S3ischial tuberosity S4-S5perianal area

ASIA A : Complete SCI. No sensory or motor preservation in S4 or S5 distribution. ASIA B : Incomplete SCI. Sensory but no motor function is preserved below the neurologic level extending through S4 or S5 segments. ASIA C : Incomplete SCI. Sensory & motor preservation below the neurological level and majority of key muscles below neurological level are graded less than 3. ASIA IMPAIRMENT SCALE

ASIA D : Incomplete SCI. Sensory & motor preservation below the neurological level and majority of key muscles below neurological level are graded 3 or greater in strength. ASIA E : Normal or full recovery of motor and sensory function. ASIA IMPAIRMENT SCALE