RCS 6080 Medical and Psychosocial Aspects of Rehabilitation Counseling

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

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

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%)