Functional Level

Question 1

Impairments

Answer 1

Cognition (Dual Diagnosis)
Respiratory
GIT incl Swallowing
Bladder
Bowel
Nutrition
DVT
HO
Spasticity
Contractures
Skin
Orthostatic Hypotension
Hypercalcaemia
AD
Spine

Question 2

High Tetraplegia

Answer 2

Persons with motor levels at or above C3 will usually require long-term ventilator assistance, whereas most individuals with lesions at C4 will be able to wean off the ventilator.
Respiratory equipment including a ventilator, a method for secretion management (i.e., suction machine, mechanical insufflator/exsufflator), backup ventilator batteries, and a generator in case of power failure, should be obtained.
One should be in touch with the local power company and emergency services to alert them of the patient’s status and condition prior to discharge.

Question 3

C4

Answer 3

weight shifts, ROM, positioning in bed, donning orthoses, transfers, and in setting up their ECU.

• hese individuals should be independent in power wheelchair mobility, using breath control, mouth stick, head array, and tongue or chin control mechanisms.
• the patient can control a power chair, then both a power chair (power recline or tilt wheelchair) and a manual positional wheelchair should be prescribed . The manual wheelchair is used when accessibility for a power wheelchair is not available, or in case the power wheelchair fails. Once properly set up, persons at these levels of injury should be independent in their ECU control.

Question 4

C4

Answer 4

Persons with an NLI at C4 who have some elbow flexion and deltoid strength may be able to use a mobile arm support (MAS) or balanced forearm orthosis (BFO) to assist with feeding, grooming, and hygiene. Once the elbow flexors have antigravity strength with adequate endurance, the MAS is no longer needed. A long straw or a bottle that the person can easily access to drink fluids should be obtained as early as possible.

Question 5

C5

Answer 5

The C5 motor level adds the key muscle group of the elbow flexors (biceps), as well as the deltoids, rhomboids and partial innervation of the brachialis, brachioradialis, supraspinatus, infraspinatus, and serratus anterior. It is important during the acute period after SCI to prevent elbow flexion and forearm supination contractures caused by unopposed biceps activity. Continued stretching should be performed acutely and in the
P.1734
chronic phase after rehabilitation.

Question 6

C5

Answer 6

The addition of the elbow flexors should allow for use of a joystick for a power wheelchair and can allow manual wheelchair propulsion on level surfaces with either rim projections (lugs) or plastic coated hand rims with a protective glove. A power wheelchair, with a power recline or tilt mechanism, is usually still required in addition to the manual wheelchair. A power or manual-assist wheelchair may also be advantageous to improve the distance one can propel the wheelchair.

Question 7

C5

Answer 7

A long opponens splint, with a pocket for inserting different utensils, is important to assist with many tasks including feeding, hygiene, grooming, and writing. Most functional activities will require the use of assistive devices, and therefore tendon transfers may be considered after neurological recovery is complete. Implanted electrical stimulation units may also be beneficial.

Question 8

C6

Answer 8

The C6 level adds the key muscle group that performs wrist extension (extensor carpi radialis), as well as partially innervating the supinator, pronator teres, and latissimus dorsi.
Active wrist extension can allow for tenodesis, the opposition of the thumb and index finger with flexion as the tendons are stretched with wrist extension.
One should avoid overly stretching the finger flexors initially after injury in C5 and C6 motor level patients to avoid potentially losing the tenodesis action.

Question 9

C6

Answer 9

Feeding, grooming, and UE hygiene are usually independent after assistance with setting up the appropriate utensils, however, clothing modifications such as Velcro closures on shoes, loops on zippers, and pullover garments are recommended.
Assistance for meal preparation is still required as well as for other homemaking tasks.
Transfers may be possible using a transfer board and with loops for LE management, but most often requires assistance. Although persons with a C6 motor level can propel a manual wheelchair with plastic-coated rims, a power wheelchair is often required for long distances, especially if the individual will be returning to the workplace. A power-assist wheelchair may be of benefit as well.

Question 10

C7, C8

Answer 10

The C7 motor level adds the elbow extensors (triceps) as the key muscle group; C8 the long finger flexors. The C7 level is considered the key level for becoming independent in most activities at the wheelchair level, including weight shifts, transfers between level surfaces, feeding, grooming, upper body dressing, and light meal preparation.
Uneven surface transfers, lower body dressing, and house cleaning may require some assistance.
The independent use of a car is possible if the individual can transfer and load /unload the wheelchair.
IC in males can be performed although it is more difficult for females, especially if LE spasticity is present.
Bowel care on a padded commode seat, especially suppository insertion, may still require assistance or the use of adaptive devices (i.e., suppository inserter).

Question 11

Respiratory

Answer 11

Ventilator dependent (some C3, many C4 may be able to be weaned off ventilator)
C5-7-8 Low endurance and vital capacity; may require assistance to clear secretions

Question 12

Pressure relief

Answer 12

Total assist; may be independent with equipment

Question 13

Wheelchair propulsion

Answer 13

C5: Power: independent
Manual: independent to some assist indoors on non-carpet surface; some to total assist outdoors
C6: Power: independent with standard arm drive on all surfaces
Manual: independent indoors; some assist outdoors
C7: Manual: independent on all indoor surfaces and level outdoor terrain; may need some assist or power for uneven terrain or long distances

Question 14

Bed

Answer 14

Electric hospital bed or full to king size standard bed, pressure relief mattress or overlay

Question 15

Transfers

Answer 15

Power or mechanical lift, transfer board

Question 16

Wheelchair

Answer 16

Power wheelchair with tilt or recline with arm drive control, manual lightweight chair with hand rim modifications, pressure relief cushion

Question 17

Bathing & Toileting

Answer 17

Padded shower-commode chair or padded transfer tub bench with commode cutout, hand-held shower

Question 18

Eating, Dressing & Grooming

Answer 18

C 3-4;: Total assist; specialized equipment, such as a balanced forearm orthosis, may allow limited feeding ability in those with C4 SCI and minimal (< 3/5) strength in deltoid and biceps
C5: Long opponens splint (with pocket for inserting utensils), long-handled mirror, adaptive devices as needed
C6: Short opponens splint, universal cuff, long-handled mirror, adaptive devices as needed

Question 19

Communication

Answer 19

C3-4: Mouthstick, high-tech computer access, environmental control unit
C5: Adaptive devices as needed (e.g., for page turning, writing, button pushing, computer access)
C6: Adaptive devices as needed (e.g., tenodesis splint, writing splint)

Question 20

Driving

Answer 20

C3-4 Attendant-operated van (with lift, tie-downs)
C5: Highly specialized modified van with lift
C6: Modified van with lift, tie-downs, hand controls

Question 21

Domains

Answer 21

1. Respiratory, bowel, and bladder function. For respiratory function, this category includes the ability to breathe with or without mechanical assistance and the ability to clear secretions. For bowel and bladder function, the ability to adjust clothing, manage elimination, and maintain hygiene are necessary components for successful performance.
2. Bed mobility, bed and wheelchair transfers, wheelchair propulsion and positioning, and pressure relief. Neurologic deficits resulting from SCI can severely affect the ability to perform these activities safely. Modifications or specialized equipment may be needed to attain expected outcomes.
3. Standing and ambulation.Standing and ambulation activities may be for psychologic or physiologic benefit as well as for functional mobility.
4. Eating, grooming, dressing, and bathing.
5. Communication (keyboard use, handwriting, and telephone use).
6. Transportation(driving, attendant-operated vehicle, and public transportation). The ability to utilize one or more transportation options is essential for independence within the community.
7. Homemaking (meal planning and preparation, and home management). Equipment and modifications, as well as hours of weekly assistance for homemaking activities, are presented.

Question 22

Prognosis

Answer 22

Marino and colleagues have determined that the 1-week Frankel and AIS scales have prognostic value for functional motor recovery.
Individuals with AIS grade D have the best outcome and those with AIS grade A have the poorest outcome.

Question 23

Prognosis

Answer 23

64 percent of muscles with either 1/5 or 2/5 strength at one month will have grade 3/5 strength at 1 year.
Only 5 percent of individuals with complete paraplegia will become community ambulators 1 year after injury. By definition, community ambulators are able to walk for more than 250 meters (the distance needed to perform routine community activities).

Question 24

Prognosis

Answer 24

Paraplegics lacking sufficient hip flexion to achieve a reciprocal gait pattern must utilize an energy intensive swing-through, crutch-assisted gait pattern to walk. Among patients with incomplete paraplegia, 76 percent will attain community ambulation status at 1 year.

Question 25

Incomplete Paraplegia

Answer 25

For muscles with 0/5 strength at 1 month, 26 percent will recover functional strength at 1 year. Eighty-five percent of muscles with an initial strength of 1/5 or 2/5 will recover to 3/5 strength at 1 year

Question 26

Complete Tetraplegia

Answer 26

Only 10 percent of those with complete tetraplegia at 1 month following injury will convert to incomplete status.

Question 27

Wrist Extensors

Answer 27

97 percent of wrist extensors with an initial strength of 1/5 will recover to at least 3/5 at 1 year following injury

Question 28

Incomplete Tetraplegia

Answer 28

Forty-six percent of those with incomplete tetraplegia become community ambulators at 1 year.

Question 29

Recovery

Answer 29

The majority of recovery occurs in the first 6 months following injury. The rate-of-change plateaus at approximately 9 months but it does not equal zero. Although some motor recovery may continue 2 or more years after injury, the amount is generally small and not likely to significantly improve function.

Question 30

C5

Answer 30

At the C5 NLI, individuals need less assistance for activities of daily living. For some activities, such as eating and upper-extremity dressing, they may require assistance with setup but then are able to complete tasks. At this level, the use of specialized adaptive devices becomes critical in determining the level of assistance required to perform various dressing, eating, and grooming activities. The use of a manual chair with handrim projections is a possibility at this level, although some assistance will likely be required for propulsion outdoors, up inclines, or on a rough surface.

Question 31

C6-8

Answer 31

At the lower cervical levels, C6 and C7–8, individuals will still likely need assistance with bowel and bladder management, but they have the capability to be independent with nearly all other functional activities (with appropriate adaptive equipment). Although patients with a C6 level may still need a power wheelchair for community mobility, at the C7–8 levels, a manual chair is typically used.

Question 32

Paraplegia

Answer 32

Individuals with paraplegia have the potential to be independent in all self-care activities, as well as with bowel and bladder management. The amount of assistance required for housekeeping declines with a more caudal NLI. Finally, ambulation is dependent on the level of NLI. Patients with NLI above T10 typically do not ambulate in a functional manner. At the T10–L2 levels, functional ambulation is possible but will probably entail a high energy cost if a swing-through gait pattern is required. Thus, at these levels, even an individual capable of walking may still elect to use a wheelchair as a more efficient means of mobility.

Question 33

Walkers

Answer 33

Of those with cervical lesions, 24 percent were functional walkers compared to 38 percent in the individuals with paraplegia.

Question 34

Reciprocal Gait Pattern

Answer 34

A reciprocal gait pattern can be utilized when there is pelvic control with at least 3/5 strength in the hip flexors and in one quadriceps (16). This gait allows for knee stability without the use of a knee-ankle-foot orthosis (KAFO). Although a reciprocal gait pattern requires less energy than a swing-through pattern, the rate of energy expenditure is still higher than that demonstrated by ablebodied subjects.

Question 35

Prognosis

Answer 35

Initial neurologic examinations 72 hours following injury and found that among individuals with motor complete injuries, those who had preserved pinprick as well as light touch sensation had an “excellent” prognosis for ambulation compared to those with preservation of only light touch.