1. T10 – L1 LevelsExpected Functional OutcomesEquipment Respiratory BowelIndependent Elevated or standard padded toilet seat BladderIndependent Bed MobilityIndependent Full to king standard bed TransfersIndependent May need transfer board Pressure reliefIndependent  W/C pressure-relief cushion  Postural support devices as indicated  Pressure-relief mattress or overlay may be indicated EatingIndependent DressingIndependent GroomingIndependent

2. T10 – L1 LevelsExpected Functional OutcomesEquipment BathingIndependent Handheld shower Padded tub transfer bench W/C propulsionIndependent Manual lightweight rigid or folding W/C Standing/ Ambulation Standing: Independent Ambulation: some assist to independent Standard standing frame Forearm crutches or walker Knee, ankle, foot orthosis (KAFO) CommunicationIndependent TransportationIndependent in car, including W/C loading/unloading Hand controls HomemakingIndependent complex meal prep and light housecleaning; some assist for heavy housekeeping Assist Required Homecare: 2 hours/day

3. L2 – S5 LevelsExpected Functional OutcomesEquipment Respiratory BowelIndependent Standard padded toilet seat BladderIndependent Bed MobilityIndependent Full to king standard bed TransfersIndependent May need transfer board Pressure reliefIndependent W/C pressure-relief cushion Postural support devices as indicated EatingIndependent DressingIndependent GroomingIndependent Hip flexors (L2) Knee extensors (L3)

4. L2 – S5 LevelsExpected Functional OutcomesEquipment BathingIndependent Handheld shower Padded tub transfer bench W/C propulsionIndependent Manual lightweight rigid or folding W/C Standing/ Ambulation Standing: Independent Ambulation: some assist to independent Standard standing frame Forearm crutches or cane as indicated Knee, ankle, foot orthosis (KAFO) or ankle, foot orthosis (AFO) CommunicationIndependent TransportationIndependent in car, including W/C loading/unloading Hand controls HomemakingIndependent complex meal prep and light housecleaning; some assist for heavy housekeeping Assist Required Homecare: 0-1 hours/day Hip flexors (L2) Knee extensors (L3)

5. Medical Treatment after SCI Methylprednisolone “steroids” for traumatic SCI within 8 hours of injury  standard of care vs. experimental

6. Medical Treatment after SCI Respiratory/pulmonary Gastrointestinal Nutrition Neurogenic Bowel  Suppositories, mini-enemas, timed bowel program, digital stimulation, strain with increased intra-abdominal pressure Neurogenic Bladder  Intermittant catheterization, indwelling catheter, condom catheter, vasalva or crede Vascular/DVT Skin

7. FES bike Potential benefits:  Cardiovascular  Circulation  Bone density  Muscle mass  Sense of well-being  Neurological improvement FES = functional electrical stimulation

10. Surgical Management Spine stabilization  Instability: under normal physiologic loads there is potential for deformity, additional neurologic deficit, or incapacitating pain Spinal cord decompression

11. Surgical Management Tendon transfers  Gain function  Eliminate need for assistive devices

12. Surgical Management Experimental Neural Transplantation (regenerative & reconstructive cellular strategies)  Adult stem cells  Embryonic stem cells  Olfactory mucosal cells

15. Length of Stay Acute care unit (hospital)  25 days – 1974  18 days – 2004 Rehab unit  115 days – 1974  39 days – 2004

16. Lifetime Costs Severity of InjuryFirst YearEach Subsequent Year 25 years old50 years old High Tetraplegia (C1- C4) $741,425$132,807$2,924,513$1,721,677 Low Tetraplegia (C5-C8)$478,782$54,400$1,653,607$1,047,189 Paraplegia$270,913$27,568$977,142$666,473 Incomplete Motor Functional at Any Level $218,504$15,313$561,827$472,392 Average Yearly Expenses (in May 2006 dollars) Estimated Lifetime Costs By Age at Injury

17. Life Expectancy Age at Injury No SCIParaLow Tetra (C5-C8)High Tetra (C1-C4)Ventilator Dependent 2058.446.341.737.923.3 4039.528.624.721.611.1 6022.213.510.88.83.1 Life Expectancy (years) post-injury by severity and age (for persons surviving at least 1 year after injury)

18. Social Aspects of SCI Quality of social support has a positive relationship with adjustment & enhancing independent functioning

19. Psychological counseling for coping and adjustment Patients can have difficulty maintaining relationships with friends they had before their injury  Embarrassed  feel their friends’ discomfort  let friendships “drift away” Socially isolated

20. Psychological counseling for coping and adjustment Family effects:  loss of personal space & time  Financial concerns  Loss of spontaneity  Worry about the present & future  Family member role changes/role confusion  Patient’s anger - often directed at loved ones

21. Vocation 64% employed at time of injury (if between 16 – 59 years old) Post-injury employment increases with time % Patients Year Post-injury

22. Vocation Predictors of postinjury employment:  Younger age  Greater functional capability (paraplegia > tetraplegia)  Able to drive  Greater elapsed time since injury  Physical intensity of preinjury occupation/secondary gain considerations  Social support  Internal locus of control

23. Vocation Job assessment (VR counselor or OT)  Functional assessment  Work environment/physical factors  Job tasks  Production needs/expectations  Adaptive equipment  State/community agencies, support groups, state/county employment programs

24. Vocation Benefits  Economical  Quality of life Self esteem Self identity Life satisfaction/well being Psychological adjustment to disability

30. Assistive technology resources www.agrabilityproject.org/assistivetech/ www.abledata.com

31. Factors impeding expected functional outcome Pre-existing medical conditions Concomitant injuries Secondary complications Cognitive impairment (pre-existing or injury-related) Age Body type Psychological factors Social factors Availability of financial resources Cultural factors