1. RCS 6080 Medical and Psychosocial Aspects of Rehabilitation Counseling Spinal Cord Injury

2. Anatomy of the Spine Vertebrae Body Front section, shaped like drum Supports weight Lamina Towards the back Boney arch surrounds spinal canal Spinous process Boney process from arch Points of attachment for muscles and ligaments Discs Cushions between vertebrae

4. Anatomy of the Spine Vertebrae: 7 Cervical Flexion, extension, bending and turning of head 12 Thoracic Chest region, allows mostly for rotation 5 Lumbar Larger boney structures to support added wgt 5 Sacral Fused together Coccyx

6. Anatomy of the Cord Cervical Cord C1-C2: C3-4: Phrenic nucleus C4: Deltoids C4-5: Biceps C6: Wrist extensors C7: Triceps C8: Wrist extensors C8-T1: Hand muscles

7. Anatomy of the Cord Thoracic Cord Intercostal muscles and associated dermatones Lumbarsacral Starts at T9 and continues to L2 Innervates hips, legs, buttocks and anal region Cauda Equina (horses tail) Spinal cord ends at L2 Tip called conus, below conus a spray of spinal roots

9. Dermatomes/Sensory Level Dermatome: patch of skin innervated by a given spinal cord level

10. C2 to C4. The C2 dermatome

11. Myotomes/Motor Level Myotome: Spinal nerve roots which innervates muscles groups Most muscles are innervated by more than one root

14. ASIA Impairment Scale ASIA A: Complete: no motor or sensory function is preserved in the sacral segments S4-S5 ASIA B: Incomplete: sensory but NOT motor function is preserved below the neurological level and includes the sacral segments ASIA C: Incomplete: motor function is preserved below the neurological level and more than half of key muscles below the neurological level have a muscle grade <3 ASIA D: Incomplete: motor function is preserved w/ muscle grade > 3 ASIA E: Normal

15. Definition of Disability Tetraplegia (preferred to quadriplegia) Refers to impairment or loss of motor/sensory function in cervical segments of the spinal cord Impairment of function in arms, trunk, legs and pelvic organs ASIA Scale vs quadriparesis

16. Definition of Disability Paraplegia Refers to impairment or loss of motor/sensory function in thoracic, lumbar or sacral segments of the spinal cord Arm function spared Possible impairment of function in trunk, legs and pelvic organs ASIA Scale vs paraparesis

17. Clinical Syndromes Central Cord Syndrome: lesion occurring almost exclusively in the cervical region Sacral sensory sparing Weakness > UE vs LE Brown-Sequard Syndrome: Lesion that produces ipsilateral, proprioceptive and motor loss and contralateral loss of sensitivity to pain and temp

18. Clinical Syndromes Anterior Cord Syndrome: Lesion that produces variable loss of motor function and of sensitivity while preserving proprioception Cauda Equina Syndrome: Injury to the lumbosacral nerve roots w/ in the neurocanal resulting in areflexive bladder, bowel and lower limbs

19. Achievement of Functional Goals Age Body type Comorbidities Prior athletic sense Fatigue level Type of stabilization HX HO/POA Spasticity Psychosocial factors Nutrition

20. Functional Outcomes Motor/sensory recovery Ability to perform or direct ADLs Social reintegration Quality of life

21. Functional Outcomes LEVEL C1-C3 Limited head/neck movement Rotate/flex neck (sternocleidomastoid) Extend neck (cervical paraspinals) Speech and swallowing (neck accessories) Total paralysis of trunk,UE and LE

22. LEVEL: C1-3 24 hr care needs Able to direct care needs ADLs Ventilator dependent Impaired communication Dependent for all care needs Mobility Power wheelchair Hoyer lift

23. LEVEL: C1-C3 Equipment Needs Adapted computer Bedside/portable ventilator Suction machine Specialty bed Hoyer Reclining shower chair

24. Functional Outcomes LEVEL: C4 Head and neck control (cerv paraspinals) Shoulder shrug (upper traps) Inspiration(diaphragm) Lack of shoulder control (deltoids) Paralysis of trunk, UE and LE Inability to cough, low respiratory reserve

25. LEVEL: C4 24 hr care needs Able to direct care needs ADLs May or may not be vent dependent Improved communication Assisted cough Dependent for all care needs Mobility Power wheelchair Hoyer lift

26. LEVEL: C4 Equipment Needs Adapted computer Bedside/portable ventilator as needed Suction machine Specialty bed Hoyer Reclining shower chair

27. Functional Outcomes LEVEL: C5 Shoulder control (deltoids) Elbow flexion (biceps/elbow flexors) Supinate hands (brachialis and brachioradialis) Lack elbow extension and hand pronation Paralysis of trunk and LE

28. LEVEL: C5 10hrs personal care need 6 hrs homemaking assistance ADLs Set-up/equipment: eating, drinking, face wash and teeth Assisted cough Dependent for bowel, bladder and lower body hygiene Dependent for bed mobility and transfers

29. LEVEL: C5 Mobility Hoyer or stand pivot Power wheelchair w/ hand controls Manual wheelchair Drive motor vehicle w/ hand controls Equipment Needs Power and manual wheelchairs Adaptive splints/braces Page turners/computer adaptations

30. Functional Outcomes LEVEL: C6 Wrist extension (extensor carpi ulnaris and extensor carpi radialis longus/brevis) Arm across chest (clavicular pectrocialis) Lack elbow extension (triceps) Lack wrist flexion Lack hand control Paralysis of trunk and LE

31. LEVEL: C6 6 hrs personal care needs 4hrs homemaking assistance ADLs Assisted cough Set-up for feeding, bathing and dressing Independent pressure relief, turns and skin assessment May be independent for bowel/bladder care

32. LEVEL: C6 Mobility Independent slide board transfer Manual wheelchair Drive with adaptive equipment

33. Functional Outcomes LEVEL: C7 Elbow flexion and extension (biceps/triceps) Arm toward body (sternal pectoralis) Lack finger function Lack trunk stability

34. LEVEL: C7 6hrs personal care needs 2hrs homemaking assistance ADLs More effective cough Fewer adaptive aids Independent w/ all ADLs May need adaptive aids for bowel care

35. LEVEL: C7 Mobility Manual wheelchair Transfers without adaptive equipment

36. Functional Outcomes LEVEL: C8-T1 Increased finger and hand strength Finger flexion (flexor digitorum) Finger extension (extensor communis) Thumb movement (policus longis brevis) Separate fingers (introssi separates)

37. LEVEL: C8-T1 4hrs personal care needs 2hrs homemaking assistance ADLs Independent w/ or w/o assistive devices Assist w/ complex meal prep and home management Mobility Manual wheelchair

38. Functional Outcomes LEVEL: T2-T6 Normal motor function of head, neck, shoulders, arms, hands and fingers Increased use of intercostals Increase trunk control (erector spinae)

39. LEVEL: T2-T6 3hrs personal care needs/homemaking ADLs Independent in personal care Mobility Manual wheelchair May have limited walking with extensive bracing Drive with hand controls

40. Functional Outcomes LEVEL: T7-T12 Added motor function Increased abdominal control Increased trunk stability

41. LEVEL: T7-T12 2 hrs personal care needs/homemaking ADLs Independent Improved cough Improved balance control Mobility Manual wheelchair May have limited walking with bracing Driving with hand controls

42. Functional Outcomes LEVEL: L2-L5 Added motor function in hips and knees L2 Hip flexors (iliopsas) L3 Knee extensors (quadriceps) L4 Ankle dorsiflexors (tibialis anterior) L 5 Long toe extensors (ext hallucis longus)

43. LEVEL: L2-L5 May need 1hr personal care/homemaking ADLs Independent Mobility Manual wheelchair May walk short distance with braces and assistive devices Driving with hand controls

44. Functional Outcomes LEVEL: S1-S5 Ankle plantar flexors (gastrocnemius) Various degrees of bowel, bladder and sexual function Lower level equals greater function

45. LEVEL: S1-S5 No personal or homemaker needs ADLs Independent Mobility Increased ability to walk with less adaptive/supportive devices Manual w/c for distance

46. Functional Outcomes Achieving maximum functional outcomes provides the opportunity to reach the highest level of independence and quality of life

47. Spinal Cord Injury Epidemiology 30-40 million per year 10,000 new cases per year Etiology Motor vehicle accident: 44.5% Falls: 18.1% Violence: 16.6% (and increasing)

48. Spinal Cord Injury Classification Paraplegia/Tetraplegia ASIA Impairment Scale ASIA Motor/Sensory FIM – functional limitations Acute Care Management Immediate spinal immobilization Methylprednisolone within 8 hours of injury

49. Spinal Cord Injury Economic Consequences Between $7.3 billion and $8.3 billion per year A person with a high cervical injury at age 25 incurs lifetime costs of more than $3 million Rehabilitation Treatment Systematic, intensive, coordinated team approach

50. Spinal Cord Injury Potential Complications Deep venous thrombosis (47-100%) Pulmonary embolism (3-15%) Pressure ulcers (25% annual incidence) Pneumonia Autonomic dysreflexia (usually above T6) Spasticity (78%) and Spasms (95%) Heterotopic ossification (16-53%) Gastrointestinal complications (e.g., impactions – 33%)

51. Spinal Cord Injury Potential Complications Urinary tract infections Chronic pain (69%, severe 33%) Overuse syndrome (35-68%) Post-traumatic syringomyelia (1-5%)

52. Additional Resources and Information from the Web American Spinal Cord Injury Association (www.asia-spinalinjury.org)www.asia-spinalinjury.org TIRR Spinal Cord Injury Research Program (www.tirr.org/research/?page=54)www.tirr.org/research/?page=54 Spinal Cord Injury Information Network (www.spinalcord.uab.edu/show.asp?durki=19 679)www.spinalcord.uab.edu/show.asp?durki=19 679 American Paraplegia Society (www.apssci.org)www.apssci.org

53. Additional Resources and Information from the Web National Spinal Cord Injury Association (www.spinalcord.org)www.spinalcord.org Christopher & Dana Reeve Paralysis Resource Center (www.paralysis.org)www.paralysis.org Paralyzed Veterans of America (www.pva.org)www.pva.org American Association of Spinal Cord Injury Psychologists and Social Workers (www.aascipsw.org)www.aascipsw.org