Spinal Cord Injury Rehabilitation Functional Expectations and Ambulation Potential. Diane Johnston, MSPT

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1 Spinal Cord Injury Rehabilitation Functional Expectations and Ambulation Potential Diane Johnston, MSPT

2 Objectives for the course Participants will have a general understanding of the epidemiology of Spinal Cord Injury (SCI). Participants will better understand the levels of Spinal Cord Injury and their functional implications Participants will have an awareness of the American Spinal Injury Association (ASIA) Impairment Scale Participants will have a better understanding of incomplete SCI clinical syndromes and their relationship to ambulation potential.

3 Demographics - SCI Incidence: 12,000 cases per year Prevalence: 231,000 to 311,000 Mean age 40.2 since 2005 (28.7 years ) Gender: 80.8% male, 19.2% female Race: 66.2% Caucasian, 27.0% African American, 7.9% Hispanic, 2% Asian Source: National Spinal Cord Injury Statistical Center, February 2010

4 Etiology Source: National Spinal Cord Injury Statistical Center, February 2010

5 Neurological Level Tetraplegia 55.1% Complete 16.9% Incomplete 38.3% Paraplegia 44.4% Complete 22.9% Incomplete 21.5% Less than 1% experience full recovery Source: National Spinal Cord Injury Statistical Center, February 2010

6 Neurological Level By Age PC PI TC TI

7 Average Yearly Expenses 2009 dollars Severity First Year Each Subsequent Yr C1-4 $829,843 $148,645 C5-8 $535,877 $ 60,887 Para $303,220 $ 30,855 Motor Incomplete $244,562 $ 17,139 Source: National Spinal Cord Injury Statistical Center, February 2010

8 Life Expectancy Age at injury Para C5-C8 C1-4 Vent Dependent 20 years years years Source: National Spinal Cord Injury Statistical Center, February 2010

9 Estimated Lifetime Costs Severity C1-4 $3,273,270 Assuming 25 years old at time of injury C5-8 $1,850,805 Para $1,093,669 Motor Incomplete $729,560 Source: National Spinal Cord Injury Statistical Center, February 2010

10 Number of SCI Patients Served Overall 1,761 SCI persons served per year Inpatient: 402 patients Outpatient: Day Program: 319 Single Service: 473 Beyond Therapy: 30 Promotion Wellness: 537 UE Clinic: 297 Numbers lead to expertise! Shepherd Data: 04/01/ /31/2010

11 Then and Now LOS Acute care 1974: 25 days 2010: 15 days Rehab 1974: 115 days 2010: 36 days Average age at injury : 28.7 years 2005-present: 40.2 years Injuries at 60 yo+ 1979: 4.7% 2010: 26.8% Severity of injury in complete injuries (41%) in incomplete injuries (53%) Plasticity of the spinal cord!!!

12 Functional Expectations

13 Definition: Complete vs/incomplete Injury Complete Injury: An absence of sensory and motor function in the lowest sacral segment.* Incomplete Injury: Partial preservation of sensory and/or motor function is found below the neurological level and includes the lowest sacral segment. Zone of Partial Preservation: Used only with complete injuries and refers to those dermatomes and myotomes caudal to the neurological level that remain partially innervated. *Water, R.L., Adkins, R.H., Yakura, J.S.: Definition of Complete spinal cord injury. Paraplegia 1991; 9:

14 Neurological Categories at Discharge Incomplete tetraplegia 30.61% Complete paraplegia 25.3% Complete tetraplegia 20.0% Incomplete paraplegia 18.6% No deficits 0.6% Unknown 3.4% National Spinal Cord Injury Statistical Center

15 C1-3 Respiratory: Vent Bowel: 1 Bladder : 1 Bed Mobility : 1 Transfers: 1 Pressure Relief: 6 Eating: 1 Grooming: 1 Bathing: 1 Wheelchair Prop: 6 Communication: 5 Transportation: 1 Home making: 1

16 C1-3 Assistance Required 24-hour attendant care to include homemaking Able to instruct all aspects of care

17 C4 Respiratory: No vent Bowel: 1 Bladder : 1 Bed Mobility : 1 Transfers: 1 Pressure Relief: 6 Eating: 1 Grooming: 1 Bathing: 1 Wheelchair Prop: 6 Communication: 5 Transportation: 1 Home making: 1

18 C4 Assistance Required 24-hour care to include homemaking Able to instruct all aspects of care

19 C5 Bowel: 1 Bladder: 1 Bed Mobility: 2-3 Transfers 1-2 Pressure Relief: 6 Eating: 5 Dressing: Upper body: 4 Lower body: 1-2 Grooming: 1-3 Bathing: 1-3 Wheelchair prop: 6 Communication: 5 Transportation: 6 Home making 1

20 C5 Assist Required Person care: 10 hours per day Home care: 6 hours per day

21 C6 Bowel: 3-5 Bladder: 3:6 Bed mobility: 3-6 Transfers: 3-6 Pressure Relief: 6 Eating: 6 Dressing UE 6 LE 3-6 Grooming: 5-6 Bathing: 4-6 Wheelchair: 6 Communication: 6-7 Transportation: 6 Home making: Light meals:5-6

22 C6 Personal Care: 6 hours per day Homecare: 4 hours per day

23 C7-8 Bowel: 6 Bladder: 6 Bed mobility: 6-7 Transfers: 6 Pressure relief: 6 Eating: 7 Dressing: 6-7 Grooming: 6-7 Bathing: 6-7 Wheelchair prop: Manual: 6 Power: 6 Communication: 6 Transportation: 6 Homemaking: Meal prep: 6 Heavy housecleaning: 4-6

24 Assist Required C7-8 Personal Care: 2-4 hours per day Homecare: 2 hours per day

25 Para (T1-9) Para (T10 and ) Bowel: 6 Bladder: 6 Bed Mobility: 6 Pressure Relief: 6 Transfers: 6-7 Eating:7 Dressing: 7 Grooming: 7 Wheelchair: 6 Communication: 7 Home making: 6-7 All the same Add: Ambulation Bracing Assistive Devices Different levels of community ambulation Below L2 generally independent at community level

26 Para Assist Required Personal care: 0 hours per day Homemaking 0-2 hours per day

27 Statistically the percentage of incomplete spinal cord injured (SCI) persons has continued to increase as emergency medical care has improved.

28 The variability seen in neurological recovery challenges the clinician in planning for these clients functional needs.

29 5 Most Common Levels of Injury C5: 14.9% C4: 13.6% C6: 10.8% T12: 6.7% C7: 5.3% Source: National Spinal Cord Injury Statistical Center

30 MRI Hemorrhage with median length of 10.5 mm associated with complete spinal cord injury Hemorrhage of less than 4 mm associated with incomplete spinal cord injuries with good prognosis /76/905/347 Source: Boldin C, et al. Spine. 2006;31(5):

31 ASIA Impairment Scale (AIS) AIS Changes Admission No Change Improved Declined A 48.0% 86.7% 11.3% 0% B 13.1% 46.9% 45.6% 4.5% C 14.7% 41.9% 52.7% 3.0% D 18.0% 90.1% 4.8% 2.1% A= Complete Injury B= Incomplete, sensory only C= Incomplete, motor (non functional) D= Incomplete, motor (functional) Source: National Spinal Cord Injury Statistical Center, January 2008

32 ASIA and Walking Outcomes Attained independent walking by inpatient DC AIS A: 6.4% AIS B: 23.5% AIS C: 51.4% AIS D: 88.6% Morganti et al, 2005

33 Clinical Syndromes Central cord Syndrome Anterior Spinal Artery Syndrome Brown-Sequard Syndrome Posterior Cord Syndrome Cauda Equina Syndrome Conus Medullaris Syndrome Other diagnoses: Multiple sclerosis, transverse myelitis, spinal cord tumors, Gillian Barre Syndrome, peripheral neuropathies, and amyotrophic lateral sclerosis

34 Central Cord Syndrome Hyperextension injury Impairment of function greater in upper extremities than lower extremities Majority of incomplete lesions result in this syndrome. 77% of these clients will ambulate. Bosch A et al, 1971

35 Anterior Spinal Artery Syndrome Flexion injury Loss of motor functions, pain and temperature sensation Prognosis poor for ambulation. Bosch A et al, 1971

36 Brown-Sequard Syndrome Caused by penetrating injures (gun shot or stabs wounds) Hemi section of the spinal cord Loss of movement and position sense on the same side Loss of pain and light touch on opposite side Nearly all regain some level of ambulation Prognosis for recovery is good 80% regain hand function % gain bowel and bladder function Bosch A et al, 1971

37 Posterior Cord Syndrome Very rare Caused by compression from a tumor or infarction Motor function is preserved Sensory modalities are lost below the level of injury Functional ambulation is difficult despite having strong muscles Bosch A et al, 1971

38 Cauda Equina Syndrome Injury to the L1 vertebral level and below Lower motor neuron lesion In most cases it is a complete lesion Ambulation is probable due to the injury being low (quadriceps muscles are spared)

39 Conus Medullaris Injury to the sacral cord and lumbar nerve root within the neural canal Lower extremity motor and sensory loss Areflexic bladder and bowel Can usually ambulate

40 Motor Indicators Lower extremity motor scores (Waters et al, 1994): 20 or less use a wheelchair as their primary mode of locomotion 30 or more can become community ambulators Walked at community level by 1 year if (Gittler et al, 2002): Tetra plegia with LEMS of 20+ Paraplegia with LEMS of 10+ Initial muscle grade of 1/5 (trace) recovered to muscle grade of 3/5 (fair) within 3 months of the initial injury (Ditunno et al, 1992)

41 Sensory Indicators Baseline lower extremity pin prick preservation and sacral pinprick preservation at 4 weeks post injury are associated with an improved prognosis for ambulation (Oleson et al, 2005) Muscles that initially scored 0/5 (Poynton et al, 1997) Dermatomes with spared pin prick, 85% regained 3/5 strength Dermatomes without spared pin prick, 1.3% regained 3/5 strength

42 Age Regaining walking function: If younger than 50 2x more likely to walk at discharge (Burns et al, 1997) Younger subjects more likely to regain walking (Scivoletto et al, 2003)

43 Active Weight Bearing Tilt Table/Standing Frame Combine with E-stim/vibration Angle footplates for tight ankles. Incorporate US/STM Adjustable knees, seat and chest positions for therapeutic exercise

44 Pool Shallow (aerobic steps, sitting, standing therapeutic exercise, walking all directions with device or buoy bars) Deep water (inner tubes, foam noodles, etc) Lap swim (supine with inflatable neck support, ski belt, ankle floats, ½ flippers to increase proprioceptive awareness and resistance)

45 Initiating Gait with Body-Weight Support Treadmill Systems Robotic Lokomat (Hocoma) Autoambulator (Health South) Manual TheraStride, Biodex, etc Lite Gait (with or without treadmill)

46 Video With Trainer AFO

47 Video Scott Craig Orthoses

48 Para Step Video

49

50 Fillauer Stance Control Knee Joint

51 Patient Video: Stance Control Brace

52 Patient Video: Stance Control Brace on Stairs

53 Video with Malleolocs Treadmill with Beach Ball Balance Board w/ Hoola Hoop

54 So Much Available to Us Think Outside The Box

55 Questions?

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