Spinal Cord Injury: Functional and Expected Outcomes PDF

NEED TO KNOW  NEED TO Exceptional Functional Outcomes KNOW When age (young), advantageous body build, high de...

NEED TO KNOW  NEED TO Exceptional Functional Outcomes KNOW When age (young), advantageous body build, high degree of motivation, good funding, and access to good medical & rehab care, the person s/p SCI may acquire more advanced skills than are typical for their level of injury. Therapists that impose inflexible ceilings on individual’s goals CAN LIMIT functional gains. Problem Solving Exercise Patient A is a 52 y.o. male who has a C7 AIS A tetraplegia. The pt.’s innervated musculature is strong. Passive ROM is normal in all extremities and the pt. echibits 1+ spasticity in both LE’s. The patient has no medical problems other than the SCI. Before the accident, the patient had a sedentary lifestyle. The patient cooperates in therapy, but does not show much drive or initiative. What are the expected functional outcomes? Patient B is a 19 y.o. otherwise healthy male who has a C7 AIS A tetraplegia. The pt. has identical strength, ROM, and muscle tone as pt. A. This patient was a star athlete before the accident and shows high level of motivation in therapy. What are the expected functional outcomes? Expected Functional Outcomes per level of Injury with Treatment Interventions Use for Cases Complete SCI – AIS A AIS A: C1, C2, C3 No Functional Motor Preservation for mobility Limited Head Movements No trunk or UE Respiratory Dysfunction Ventilator Impacts communication Functional Outcomes Functional Abilities: Depends on funding available for adapted equipment Power lifts, power wheelchair Voice or mouth controls Functional Outcomes Sip & Puff Example: Independent pressure relief with power tilt/recline https://www.instagram.com /janeycarter_/p/CL2ga7zn5P Dependent for positioning/transfers E/ Independent with sip-n-puff power WC Pt should be independent with family/caregiver instruction Intervention How to educate others FOCUS OF TREATMENT Family body mechanics Power wheelchair Pressure relief Equipment Consider pressure relieving hospital bed Proper WC cushion (later) Lift for home use 24hr care AIS A: C4 Motor Function Full head/neck movements possible No trunk/UE Respiratory Dysfunction Impaired cough (may need assistance with secretions/cough assistance) Diaphragm innervated (no vent possible) AIS A: C4 (con't) Same outcomes as C1-C3 Educate caregivers, 24hr care, pressure relief with power wheelchair, equipment Power wheelchair maybe head array, chin control or sip and puff Head Array Chin Control Sip and Puff  AIS A: C5 Motor Function Partial innervation deltoids, RC cuff, serratus anterior, supinator Biceps Respiratory Dysfunction Cough Assistance Possibly Personal Care 10 hours a day Bowel/bladder, positioning, food prep AIS A: C5-Functional Outcomes Bed Mobility/supine to sit mod A to modified independent May progress to decreased assistance with use of ADs Loops, trapeze bar, bed rails, weighted gloves Transfers Dependent to max A with lift or transfer board Max Assistance for ADLs Independent with power mobility (tilt, recline) Independent Power Wheelchair Mobility Independent Indoor Manual WC mobility? AIS A: C5-EXCEPTIONAL Outcomes Long-term Outcomes: Independent lateral transfers/bed mobility with adapted equipment (transfer board, loops, bars) Independent Carpeted Manual WC indoors with AD (pegged handrims) Independent pressure relief without power AIS A: C5-Intervention EDUCATION Strengthening Especially RC/shoulders/biceps Task Specific Training Reduce likelihood of contractures (elbows) Teach positioning/PROM NEED FLEXIBLE HAMSTRINGS at least 90 degrees for long sit  AIS A: C6 Motor Function Improved Serratus Full innervation RC, deltoid, Partial Latissimus Dorsi, Pectoralis Minor, Clavicular portion of Pect Major Extensor Carpi radialis longus Respiratory May need cough assistance but less likely Personal care 6 hours a day (Bowel/bladder, ADLs) AIS A: C6-Functional Outcomes Min A-Modified Independent rolling/bed mobility Min A-Independent transfer board lateral transfers, supine to sit Independent indoor manual WC mobility Maybe ramps, carpet Independent with power mobility (tilt, recline) Pressure relief Independent in power WC Min A-independent manual chair AIS A: C6-Intervention EDUCATION Strengthening Especially RC/shoulders/biceps/pecs/deltoids Task Specific Training FULL ROM OF UE for optimal function especially shoulder ER and elbow extension NEED FLEXIBLE HAMSTRINGS at least 90 degrees for long sit AIS A: C6-EXCEPTIONAL Outcomes Independent bed mobility and lateral transfers without equipment lateral transfer (https://youtu.be/h9EfpZe6l8k) Community manual WC Ramps, curbs, grass (unlevel) Independent pressure relief manual WC  AIS A: C7, C8 C7 Motor Function TRICEPS, TRICEPS, TRICEPS!, Full shoulder strength (RC/Lats/Pects) Full innervation shoulders, extensor carpi radialis longus C8 Similar added finger/wrist flexors Full innervation triceps Respiratory Functioning Personal Care Assistance based on independence with bowel/bladder C7- use of tenodesis may be independent or min Assist C8- should be independent AIS A: C7, C8-Functional Outcomes Independent bed mobility even lateral transfers with or without transfer board Supine to sit Manual WC indoor and outdoor (min A curbs and steep ramps) Pressure relief Manual WC and/or power WC may need assistance for ramps, curbs, uneven terrain AIS A: C7, C8-Intervention Same as previous but increased emphasis on independence with all mobility if possible Advanced WC skills possible C7- need tenodesis C8- do not need tenodesis AIS A: C7, C8-Exceptional Outcomes Community manual WC use only with all advanced skills Floor to chair, falls safely out of chair, 4” curbs, steep ramps AIS A: T1-T9 Motor Function Full UE use Varying degree of trunk control improves caudally Respiratory No assistance necessary Personal Care Maybe short term Longer if additional co-morbidities Dependent on postural control for bowel/bladder managment  AIS A: T1-T9: Functional Outcome Independent with all bed mobility and level transfers without AD (even and a few inches below or above) Independent pressure relief Independent manual wheelchair indoors and outdoors Independent pressure reliefs and positioning Mod A to independent for WC to and from floor Assistance with stairs AIS A: T1-T9-Intervention Same as above Increased emphasis on advanced WC skills Maybe Standing in bracing or gait training AIS A: T1-T9-Exceptional Outcomes Independent floor to w/c transfer Independent >6 inch curbs Wheelies on up and down May walk/stand for exercise with AD and bracing (later lecture)  AIS A: T10 and below Motor Function Adding LE function improves Leg management Full trunk control No Respiratory Dysfunction Personal Care Not necessary AIS A: T10 and below-Functional Outcomes Independent with all bed mobility, transfers, pressure relief and ADLs. Independent all manual WC skills Ambulation based on NLI and bracing HKAFOs-KAFOs for T1-L1 KAFOs-AFOs for L2-L3 AFO-no bracing for L4 and lower Functional Community Ambulation expected for L5-S2 L5-S1:May use straight cane and/or AFO  Energy Cost of Ambulation Considerations Although ambulation is possible, many chose WC for community/longer distances due to energy cost of ambulation https://www.instagram.com/reel/C4EjK0pJeH5/?utm_source=ig _web_copy_link&igsh=MzRlODBiNWFlZA== Zac’s Story → incomplete SCI – watch him walk AIS A: T10 and below-Exceptional Outcomes WC skills Stairs, >6 inch curb Ambulation T10-L1: Home/Limited Community with HKAFO or KAFO walker or forearm crutches L2-L3: Home/Limited Community with KAFO MAYBE ground reaction AFOs L4: Limited community or full community AFOs and forearm crutches