ASSESSMENT OF ASSESSMENT OF PATIENTS WITH SPINAL PATIENTS WITH SPINAL CORD INJURYCORD INJURY

KRISTOFFERSON G. MENDOZA, PTRPKRISTOFFERSON G. MENDOZA, PTRPCOLLEGE OF ALLIED MEDICAL COLLEGE OF ALLIED MEDICAL PROFESSIONSPROFESSIONSUNIVERSITY OF THE PHILIPPINES MANILAUNIVERSITY OF THE PHILIPPINES MANILA

PT142: Assessment in Physical PT142: Assessment in Physical TherapyTherapy

Why evaluate?

Establish the functional level of the neurologic injury

Establish the likelihood of sensorimotor recovery

Establish short- and long-term goals Design an effective treatment program

Clinical Manifestation

Spinal Shock

Motor and sensory impairments

Spasticity

Clinical Manifestation

Bladder dysfunction Reflex bladder (spastic,

autonomic) Nonreflex blader (flacid,

autonomous)

Bowel dysfunction

Temperature control

Clinical Manifestation

Respiratory impairment Sexual impairment

Complications

Contractures

Pressure sores

Autonomic dysreflexia

Pain

Heterotropic ossification

Complications

Orthostatic hypotension (postural hypotension)

Deep vein thrombosis Osteoporosis

Component of the Evaluation Subjective assessment Respiratory function Motor control Range of motion Sensory Function Skin integrity Functional Status

Subjective Assessment

Demographics (name, age, etc.) Medical diagnosis HPI

Injury: Cause, circumstances, onset Complications that may limit therapy

Other injuries, co-morbidities (PMHx) Precautions

Stability of the spine, presence of fractures, other injuires

Subjective Assessment

Personal/Social History Previous employment Education Civil status Family status Important for planning for discharge

Goals and expectations

Respiratory Function

Determine Respiratory capacity Function of the pulmonary muscles Chest mobility

Respiratory Function

Above T12: may respiratory involvement Below C3: (+)

diaphragmatic function, (-) intercoastal and abdominal control

Above C3: (+) diaphragmatic paralysis, (-) intercoastal and abdominal control

Respiratory Function

Function of respiratory muscles Diaphragm, intercostals, abdominals, neck

Breathing pattern Chest expansion Cough

Functional: strong enough to clear secretions Weak functional: adequate force to clear

upper respiratory tract secretions in small quantities

Non-functional: unable to produce any cough force

Vital Capacity

Motor Control

To determine extent and level of injury To set appropriate goals To design an effective treatment

program

Motor Control

Manual muscle testing Upright motor control Testing for spasticity

Range of Joint Motion

To determine potential problems that might interfere with goals

Measured using standard procedures ROM Joint Mobility Assessment Muscle length test

Usual areas that has LOM /tightness

Skin Integrity

Maintain skin integrity: highest priority

Skin checked for redness Positioned to remove pressure from these

areas Self-skin inspection Palpate for changes in temp

Sensory Function

Superficial Skin Sensation Proprioception Tone and deep tendon

Sitting Balance

Timed unsupported sitting useful for patients with severely impaired

sitting balance ability to maintain unsupported sitting for at

least 30 seconds has acceptable reliability (ICC no lower than

0.7) Not good at discriminating between patient

sub-groups

Roswell-Ruys et al. (2007)

Sitting Balance

Seated arm reach test useful for patients who are able to maintain

unsupported sitting for at least a few minutes (backboard allowed, but slanted 10 degrees from the vertical) and who are with enough upper limb strength to hold one shoulder in 90 degrees flexion

able to discriminate chronicity of injury (p = 0.002)

Sitting Balance

Donning/Doffing of a T-shirt useful for patients who are able to maintain

unsupported sitting for at least a few minutes and who are with some upper limb strength to grasp a t-shirt

most repeatable (ICC = 0.912) able to discriminate between subject injury level

(p = 0.003)

Functional Status

Includes Body handling for self range of motion Dressing Bed mobility Feeding Hygiene Bowel and bladder care Ambulation

Classificationcomplete

no sensory or motor function below the level of the lesion complete transection, severe

compression, extensive vascular impairment

permanent motor, sensory and autonomic paralysis below lesion after spinal shock

Classificationincomplete

presence of some sensory or motor function below the level of the lesion partial transection, contusions caused

by displaced bone/soft tissue, swelling inside the spinal column

Motor Level

the most distal segment with a muscle grade of 3

the immediately proximal segment have at least a muscle grade of 4

determined using the key muscles

Muscle Grading

Grade 5 - able to hold position against maximum resistance

Grade 4 - able to hold position against moderate resistance

Grade 3 - able to hold position against gravity

Grade 2 able to move extremity only with gravity eliminated

Grade 1 - muscle twitchGrade 0 - no movement

Key Muscles

C5 Elbow flexors

C6 Wrist extensors

C7 Elbow extensors

C8 Flexor digitorum profundus to the middle finger

T1 Small finger abductors

L2 Hip flexors

L3 Knee extensors

L4 Ankle dorsiflexors

L5 Extensor hallucis longus

S1 Ankle plantar flexors

Sensory Level

the most distal segment with a normal sensory function

dermatomes  test both pain and light touch sensation is graded

0 - absent sensation 1 - impaired sensation 2 - normal sensation

Dermatomes

C2 occipital protuberance

C3 supraclavicular fossa

C4 top of the acromioclavicular joint

C5 lateral side of the antecubital fossa

C6 thumb

C7 middle finger

C8 little finger

Dermatomes

T1 medial side of the antecubital fossa

T2 apex of the axilla

T3 third intercostal space

T4 fourth intercostal space (nipple line)

T5 fifth intercostal space (midway between T4 and T6)

T6 sixth intercostal space (xiphisternum)

T7 continuation of the seventh intercostal space to the midline (midway between T6 and T8)

Dermatomes

T8 continuation of the eighth intercostal space to the midline (midway between T6 and T10)

T9 continuation of the ninth intercostal space to the midline (midway between T8 and T10)

T10 continuation of the tenth intercostal space to the midline (umbilicus)

T11 continuation of the eleventh intercostal space to t he midline (midway between T10 and T12)

T12 inguinal ligament

L1 one third distance between T12 and L2

L2 midanterior thigh

Dermatomes

L3 medial femoral condyle

L4 medial malleolus

L5 dorsum of the foot at the third MTP joint

S1 lateral heel

S2 midline of popliteal fossa

S3 ischial tuberosity

S4-S5 perianal area

ASIA A : Complete SCI. No sensory or motor preservation in S4 or S5 distribution.

ASIA B : Incomplete SCI. Sensory but no motor function is preserved below the neurologic level extending through S4 or S5 segments.

ASIA C : Incomplete SCI. Sensory & motor preservation below the neurological level and majority of key muscles below neurological level are graded less than 3.

ASIAASIA IMPAIRMENT SCALE IMPAIRMENT SCALE

ASIA D : Incomplete SCI. Sensory & motor preservation below the neurological level and majority of key muscles below neurological level are graded 3 or

greater in strength.

ASIA E : Normal or full recovery of motor and sensory function.

ASIAASIA IMPAIRMENT SCALE IMPAIRMENT SCALE