RCS 6080 Medical and Psychosocial Aspects of Rehabilitation Counseling Spinal Cord Injury.
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Transcript of RCS 6080 Medical and Psychosocial Aspects of Rehabilitation Counseling Spinal Cord Injury.
RCS 6080Medical 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 Points of attachment for muscles and ligaments
Discs Cushions between vertebrae
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
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
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
Dermatomes/Sensory Level
Dermatome: patch of skin innervated by a given
spinal cord level
C2 to C4. The C2 dermatome
Myotomes/Motor Level
Myotome: Spinal nerve roots which innervates
muscles groups Most muscles are innervated by more
than one root
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
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
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
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
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
Achievement of Functional Goals Age Body type Comorbidities Prior athletic
sense Fatigue level
Type of stabilization
HX HO/POA Spasticity Psychosocial
factors Nutrition
Functional Outcomes
Motor/sensory recovery Ability to perform or direct ADLs Social reintegration Quality of life
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
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
LEVEL: C1-C3 Equipment Needs
Adapted computer Bedside/portable
ventilator Suction machine Specialty bed Hoyer Reclining shower
chair
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
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
LEVEL: C4 Equipment Needs
Adapted computer Bedside/portable
ventilator as needed
Suction machine Specialty bed Hoyer Reclining shower
chair
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
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
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
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
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
LEVEL: C6
Mobility Independent slide board transfer Manual wheelchair Drive with adaptive equipment
Functional Outcomes
LEVEL: C7 Elbow flexion and extension
(biceps/triceps) Arm toward body (sternal pectoralis) Lack finger function Lack trunk stability
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
LEVEL: C7
Mobility Manual wheelchair Transfers without adaptive equipment
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)
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
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)
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
Functional Outcomes
LEVEL: T7-T12 Added motor function Increased abdominal control Increased trunk stability
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
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)
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
Functional Outcomes
LEVEL: S1-S5 Ankle plantar flexors (gastrocnemius) Various degrees of bowel, bladder
and sexual function Lower level equals greater function
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
Functional Outcomes Achieving maximum functional
outcomes provides the opportunity to reach the highest level of independence and quality of life
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)
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
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
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%)
Spinal Cord Injury Potential Complications
Urinary tract infections Chronic pain (69%, severe 33%) Overuse syndrome (35-68%) Post-traumatic syringomyelia (1-5%)
Additional Resources and Information from the Web American Spinal Cord Injury Association
(www.asia-spinalinjury.org) TIRR Spinal Cord Injury Research
Program (www.tirr.org/research/?page=54)
Spinal Cord Injury Information Network (www.spinalcord.uab.edu/show.asp?durki=19679)
American Paraplegia Society (www.apssci.org)
Additional Resources and Information from the Web National Spinal Cord Injury Association (
www.spinalcord.org) Christopher & Dana Reeve Paralysis
Resource Center (www.paralysis.org)
Paralyzed Veterans of America (www.pva.org)
American Association of Spinal Cord Injury Psychologists and Social Workers (www.aascipsw.org)