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RCS 6080 Medical and Psychosocial Aspects of Rehabilitation Counseling

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

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RCS 6080 Medical and Psychosocial Aspects of Rehabilitation Counseling

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  1. RCS 6080Medical 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

  3. 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

  4. 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

  5. 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

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

  7. C2 to C4. The C2 dermatome

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

  9. 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

  10. 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

  11. 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

  12. 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

  13. 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

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

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

  16. 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

  17. 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

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

  19. 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

  20. 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

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

  22. 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

  23. 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

  24. 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

  25. 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

  26. 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

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

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

  29. 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

  30. LEVEL: C7 • Mobility • Manual wheelchair • Transfers without adaptive equipment

  31. 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)

  32. 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

  33. 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)

  34. 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

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

  36. 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

  37. 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)

  38. 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

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

  40. 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

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

  42. 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)

  43. 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

  44. 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

  45. 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%)

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