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
 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  Type of stabilization
 Body type  HX HO/POA
 Comorbidities  Spasticity
 Prior athletic sense  Psychosocial factors
 Fatigue level  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=196
79
)
 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)