rcs 6080 medical and psychosocial aspects of rehabilitation counseling
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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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anatomy of the spine
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 spine4
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
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 cord7
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
Dermatomes/Sensory Level
  • Dermatome:
    • patch of skin innervated by a given spinal cord level
myotomes motor level
Myotomes/Motor Level
  • Myotome:
    • Spinal nerve roots which innervates muscles groups
    • Most muscles are innervated by more than one root
asia impairment scale
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
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 disability16
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
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 syndromes18
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

Achievement of Functional Goals
functional outcomes
Functional Outcomes
  • Motor/sensory recovery
  • Ability to perform or direct ADLs
  • Social reintegration
  • Quality of life
functional outcomes21
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
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
LEVEL: C1-C3
  • Equipment Needs
    • Adapted computer
    • Bedside/portable ventilator
    • Suction machine
    • Specialty bed
    • Hoyer
    • Reclining shower chair
functional outcomes24
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
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 c426
LEVEL: C4
  • Equipment Needs
    • Adapted computer
    • Bedside/portable ventilator as needed
    • Suction machine
    • Specialty bed
    • Hoyer
    • Reclining shower chair
functional outcomes27
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
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 c529
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 outcomes30
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
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 c632
LEVEL: C6

Mobility

  • Independent slide board transfer
  • Manual wheelchair
  • Drive with adaptive equipment
functional outcomes33
Functional Outcomes
  • LEVEL: C7
    • Elbow flexion and extension (biceps/triceps)
    • Arm toward body (sternal pectoralis)
    • Lack finger function
    • Lack trunk stability
level c7
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 c735
LEVEL: C7
  • Mobility
    • Manual wheelchair
    • Transfers without adaptive equipment
functional outcomes36
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
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 outcomes38
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
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 outcomes40
Functional Outcomes
  • LEVEL: T7-T12
    • Added motor function
    • Increased abdominal control
    • Increased trunk stability
level t7 t12
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 outcomes42
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
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 outcomes44
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
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 outcomes46
Functional Outcomes
  • Achieving maximum functional outcomes provides the opportunity to reach the highest level of independence and quality of life
spinal cord injury
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 injury48
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 injury49
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 injury50
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 injury51
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
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 web53
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)
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