Flashcards in SCI Deck (25)
ASIA Impairment Scale (AIS)
AIS A = Complete SCI. May have preservation of strength/sensation below level of injury, called Zone of Partial Preservation (ZPP).
AIS B = Sensory Incomplete. Sensation, but no motor control below level of injury.
AIS C = Motor Incomplete. Motor function and more than half key muscles grade <3 (Fair) below level of injury.
AIS D = Motor Incomplete. Motor function and more than half key muscles grade 3 (Fair) or more below level of injury.
AIS E = Tests with normal sensation and motor control.
International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI)
Determines neurological level of injury. Exam performed at arrival and at 72 hours to 1 week post-onset by trained medical professional; tests key muscles and sensory points. Region given as part of spine (C, T, L, or S). Level given is most caudal segment where sensation is intact and muscle strength at least 3/5. ISNCSCI exam also determines if injury is complete/incomplete, and its AIS classification.
Ex.: “C6 AIS A with ZPP at C7” (classification given)
Prognosis for Recovery
If no sensation or return of motor function below level of injury after 1 week (ISNCSCI testing period), motor function less likely to return. Partial to full return of function one spinal nerve root level below vertebral fracture can be gained in first 6-9 months, though. Majority of improvements occur in first year, but up to 3-4 years.
With incomplete lesions, progression is possible but varies depending on lesion type. Brown-Séquard syndrome has best prognosis (75-90% ambulate indep after inpatient rehab). Anterior Cord syndrome has poorest prognosis (10-20% chance of motor recovery).
Purposes of SCI Rehabilitation
• Prevent further medical complications through education
• Maintain and improve strength and skills present
• Maximize function and facilitate mobility
• Optimize lifestyle options for individual and family
(These are good to emphasize to patient so they understand the process they are going through.)
Types of Pain
Musculoskeletal Pain = Result of muscular, joint or bone damage; usually worse with movement/better with rest.
Neuropathic/Neurogenic Pain = Result of damage to nerve fibers; abnormal communication betw spinal cord and brain, causing misinterpretation of signals. Usually felt as burning, stabbing, tingling pain.
Visceral Pain = Described as aching or cramping in abdomen; can be result of medical problem such as constipation, kidney stone, ulcer, appendicitis, etc.
Common body locations of pain in SCI patients
NECK/BACK: causes include recent surgery to fuse spine, soft tissue involvement (muscle strain, bruises), increased motion above/below spinal fusion, and overuse of mouth- or chin-operated joysticks.
SHOULDER: most common location after SCI, most severity increasing over time. In acute/post-acute, extremely common for C4-C7, causing decreased shoulder and scapular ROM and impacting activities. Can be caused by:
• scapular immobilization from bed rest
• nerve root compression
• subluxation of GH joint
During outpatient phase, shoulder pain common in C5-C8, due to:
• repetitive motions (manual w/c, pressure reliefs, transfers)
• chronic impingement syndrome
• rotator cuff tears
• arthritic changes.
OT Assessments for SCI
• OT Profile (client factors, context, goals)
• Sensation (light touch, pinprick)
• Pain (type, location, rating)
• ROM (active and passive)
• Grip/Pinch strength
• Modified Ashworth Scale (MAS)
• Self-care Function
Assessment of SCI Body Functions/Structures includes:
• Sensory functions
• Neuromusculoskeletal and movement-related functions (joint mobility/stability)
• Muscle functions (power, endurance, tone)
• Movement functions (voluntary motor skills, involuntary reactions, gait patterns)
• Mental Functions (cognition, affect)
• ALSO: How SCI affects cardiovascular, respiratory, voice/speech, digestive, genitourinary, reproductive, and skin functions
Sensation evaluations may include:
• Light touch
• Superficial pain
• Monofilament testing
General OT intervention objectives for SCI patients:
1) Maintain/increase joint ROM and prevent bodily problems via prep activities, splinting, positioning, education
2) Increase strength and address problems with other body functions through prep and purposeful activities
3) Increase endurance and other perf skills/patterns through purposeful activities
4) Maximize independence in all areas of occupation
5) Aid in psychosocial adjustment to disability
6) DME/AE evaluation/recommendation/education
7) Ensure safe home/environmental accessibility
8) Assist in developing communication skills
9) Educate client/family on habits to maintain function during aging process
Post-Acute Rehab Phase therapy time required:
3 hours of intense therapy a day, 5-6 days/week (Pt. needs to be able to do this before leaving acute phase)
Role of OT in Acute Phase
• Preserving joint integrity/mobility with positioning/splinting and early mobilization
• Restoring function through self-care training
• Initiating education and training of families/caregivers
• Coordinating care (incl prep for transition to next level)
• Assess for baseline neurological, clinical, and functional status to formulate early intervention program
• Follow medical precautions
Bed positioning for tetraplegic SCI
• Arms intermittently positioned at 75-80 degrees shoulder aBd, ext rotation, with scapular depression and full elbow extension, with other arm to side, hand back above head, arm in aBd/ext rotation, with elbow bent.
• Hand splint used when muscle strength cannot support wrist/hands properly
Hand splints used in acute phase positioning:
• If wrist extension strength < 3+/5, splint should support wrist at neutral, thumb in opposition, fingers flexed slightly at MP and PIP
• If wrist ext strength 3+/5 or more, short opponens splint to maintain web space and support thumb in opposition. Can also be used while training for tenodesis grasp.
Post-Acute Rehab/Inpatient Phase OT Goals
• Introduce importance of self-management
• Collaborate with Pt in setting realistic/attainable goals
• SCI Education integrated throughout
Self-Management Skills for SCI Pt include:
• Being proactive
• Problem solving
• Communicating effectively
• Staying organized
• Managing stress
*Can be taught individually by OT or in group sessions
Topics to cover in SCI Education
• Transportation/driving resources
• Emergency preparedness
• Community resources
• Finance management
• How to select/direct caregivers
• Bladder/bowel management
• Skin care/pressure relief
• Autonomic dysreflexia
• Pain management
C1-C3 Injury Characteristics
• Limited movement of head/neck
• Dependent on ventilator to breathe (may also have suction equip.)
• Difficult/impossible to speak
• Requires full assistance; may use AE
• Operates w/c with head control, mouth stick, sip/puff or chin control.
C3-C4 Injury Characteristics
• Head/neck control; may shrug at C4
• May initially require ventilator; may need cough-assist
• Full A for turning, tsfrs, self-care.
• May be able to I eat/other tasks with AE
• Power w/c using head control, mouth stick, sip/puff, chin.
C5 Injury Characteristics
• Head/neck control, can shrug/some shoulder control, can bend elbows and turn palms up
• Can be I with specialized equip to eat, groom, with s/u
• Requires total A for bed mobility/tsfrs/other self-care
• May assist with UB dressing/bathing using AE
• Needs caregiver assist for cough
• May be able to push manual w/c short distances; power w/c controlled with hand for daily use
• May be able to drive with specialized hand controls
• Total A for bowel/bladder mgmt. (catheterization)
C6 Injury Characteristics
• Movement in head, neck, shoulders, arms, wrists; can shrug, bend elbows, turn palms up/down, and extend wrists
• With special equip and s/u, can be I with most feeding, grooming, UB dressing. Some A for LB dressing.
• Can assist with UB during bathing
• Sliding board tsfr with some/total A from caregiver
• Some light meal prep tasks
• May need help with pressure relief/turning
• May use manual or power w/c independently
• Some or total A, AE, for bowel/bladder mgmt.
C7-T1 Injury Characteristics
• Movement of head, neck, shoulders, arms, wrists, elbows (bend and straighten). C8-T1, added strength and precision of hands/fingers
• I with feeding, grooming, UB dressing with AE.
• Some/no A with LB dressing/bathing & AE
• Some/no A with sliding board tsfrs
• w/c pushups/lateral leans for pressure relief
• I with manual w/c; I with driving if able to load/unload w/c
• Some/total A with bladder/bowel with AE/meds
T2-T12 Injury Characteristics
• Normal function of head, neck, shoulders, arms, hands, fingers. Increased use of rib/chest muscles/trunk control. T10-12, more increased trunk control/ab strength
• I with self-care, incl bowel/bladder, with some AE
• I with w/c pushups
• I with bed mobility, tsfrs, with or without AE. I with w/c; able to load/unload to I drive with hand controls
L1-L5 Injury Characteristics
• Additional return of motor movement in hips/knees
• I with bed mobility/tsfrs, with or without AE
• I with w/c; can use special leg braces and walking devices, depending on leg strength
• Drives I with hand controls