Various aspects of assessment of Spinal cord injury have been explained

1. PHYSIOTHERAPY ASSESSMENT
OF
SPINAL CORD INJURY
Prof. (Dr.) Nidhi Sharma
Professor
MMIPR, Mullana-Ambala, Haryana

2. OBJECTIVES
At the end of lecture student should be able to assess a spinal cord injury patient under
following headings
Incidence
Patient Assessment
Relevant History
Physical examination
Neurological examination
Muscle Performance
Pain
Range of motion
Reflexes
Aerobic capacity / Endurance
Arousal, Attention and cognition
Gait, Locomotion and balance
Motor Function
Self care and Home Management
Ventilation and Integument

3. INCIDENCE:
• Approximately 55% of spinal injuries occur in
the cervical region
• 15% in the thoracic region
• 15% at the thoracolumbar junction
• and 15% in the lumbosacral area.
Approximately 10% of patients with a cervical
spine fracture have a second, noncontiguous
vertebral column fracture

4. INCIDENCE Contd:
•Approximately one-third of patients with upper
cervical spine injuries die at the injury scene
from apnea caused by loss of central innervation
of the phrenic nerves caused by spinal cord
injury at C1.
•When a fracture-dislocation in the thoracic spine
does occur, it almost always results in a complete
spinal cord injury because of the relatively
narrow thoracic canal.

5. Patient Assessment
•The spine should initially be immobilized on
the assumption that every trauma patient
has a spinal injury until proven otherwise.
•In unconcious patient, definitive clearance
of the spine may not be possible in the
initial stages and spinal immobliziation
should be maintained, until MRI or
equivalent can be used to rule out unstable
spinal injury.

6. Patient Assessment
•Patients who have no findings on
examination, demonstrate no decreased
level of consciousness, and have no
distracting injuries can undergo clearance of
the spine by clinical means alone.
•Although plain radiographs of the spine are
acceptable, the high-quality images and rapid
availability associated with CT have made this
the modality of choice in most emergency
departments.

7. Relevant history
•The mechanism and velocity of injury
•Presence of spinal pain
•Onset of neurological symptoms
•Duration of neurological symptoms

8. PHYSICAL EXAMINATION
• Initial Assessment
The primary survey followed by carefull systems examination.
• Identification of shock
Three categories of shock may occur in spinal trauma:
1.Hypovolaemic shock
2.Neurogenic shock
3.Spinal shock
• Spinal Examination:
The entire spine must be palpated and the overlying skin is inspected
and formal log roll should be performed to achievethis.

9. PHYSICAL EXAMINATION Contd.
 Neurogenic shock results from impairment of the descending sympathetic
pathways in the cervical or upper thoracic spinal cord. This condition
results in the loss of vasomotor tone and in sympathetic innervation to
the heart.
Neurogenic shock loss of symapathetic
innervation
of heart
Loss of vasomotor tone
Vasodilatation of blood vessels
Hypotension Bradycardia or
Normal heart rate
Beacause of cervical cord injury above the level of sympathetic outflow
(C7/T1)
Warm Peripheries

10. PHYSICAL EXAMINATION contd.
The classic presentation of neurogenic
shock is hypotension in the
setting of warm well perfused extremities in
the paralyzed patient
Spinal shock. There is initial loss of all neurological
function below the level of the injury
Paralysis
Hypotonia Areflexia
Usually lasts 24 hours following spinal cord injury.
Once it has resolved the bulbocavernosus reflex
returns.

11. NEUROLOGICALEXAMINATION
• The American Spinal Injury Association (ASIA) neurological
evaluation system is an internationally accepted method of
neurological evaluation.
• This is a system of tests used to define and describe:
• Extent
• Severity
• Future Rehabilitation
• Recovery needs

12. Primary Survey and Resuscitation—
Assessing Spine Injuries

13. Secondary Survey--Neurologic
Assessment

14. Muscle Performance
• ASIA ISNSCI
• Manual Muscle
Test
• Hand Held
Dynamometer

15. THE ASIA/ISCoS EXAM
Steps in Classification
1.Determine sensory levels of injury for right and left side
2.Determine motor levels of injury for right and left side.
3.Determine neurological level of injury.
4.Determine whether the injury is Complete or Incomplete.
5.Determine Asia Impairment Scale (AIS) Grade:

16. THE ASIA/ISCoS EXAM
Level of Neurological Impairment
The ASIA neurological impairment scale is based on the Frankel
classification of Spinal Cord Injury
• A- Complete
• B- Sensation present, Motor absent
• C- Sensation present, Motor present but not useful
(MRC grade <3/5)
• D- Sensation present, Motor useful (MRC grade <3/5)
• E- Normal Function

17. Motor: how do you test each
segment ?

18. Sensory: how do you determine the level?
•

19. • The sensory levels are scored on a 0 to 2 scale for
each dermatome.
• If body is divided into two identical halves there are
28 key sensory points to be tested.
• Each dermatome is tested for light touch and pinprick
sensations and labeled as NT (not testable) if cannot
be tested.

21. PAIN ASSESSMENT
• Visual Analogue Scale
How severe is your pain
No pain Worst pain
Imaginable

22. PAIN ASSESSMENT
Wheelchair users Shoulder Pain
index

24. RANGE OF MOTION
• Goniometer

25. Reflexes
• Deep Tendon Reflexes
• Arm
• Bicipital: C5
• Styloradial: C6
• Tricipital: C7
• Leg
• Patellar: L3, some L4
• Achilles: S1

26. Pathological reflexes
• Babinski (UMN lesion)
• Hoffman (UMN lesion at or above cervical spinal
cord)
• Clonus (plantar or patellar) (long standing UMN
lesion)

27. BABINSKI’S SIGN

28. HOFFMAN’S SIGN

29. AROUSAL, ATTENTION AND
COGNITION
Mini Mental Scale Examination (MMSE)
General Practitioner Assessment of Cognition
(GPCOG)
Memory Impairment Screen (MIS)

30. MINI MENTAL STATUS
EXAMINATION

32. Unless specified, each question should only be asked once
Name and Address for subsequent recall test
1. “I am going to give you a name and address. After I have said it, I want you to repeat it.
Remember this name and address because I am going to ask you to tell it to me again in a
few minutes: John Brown, 42 West Street, Kensington.” (Allow a maximum of 4 attempts).
Time Orientation Correct
Incorrect
2. What is the date? (exact only)

33. GPCOG SCREENING TEST contd.
Clock Drawing – use blank page Correct
Incorrect
3. Please mark in all the numbers to indicate
the hours of a clock (correct spacing required)
4. Please mark in hands to show 10 minutes past
eleven o’clock (11.10)
Information
5. Can you tell me something that happened
in the news recently?
(Recently = in the last week. If a general answer is given,
eg “war”, “lot of rain”, ask for details. Only specific answer scores).

34. GPCOG SCREENING TEST contd.
Recall
6. What was the name and address I asked you to remember
John
Brown
42
West (St)
Kensington
(To get a total score, add the number of items answered correctly)
Total correct (score out of 9)
If patient scores 9, no significant cognitive impairment
and further testing not necessary.
If patient scores 5-8, more information required. Proceed
with Step 2, informant section.
If patient scores 0-4, cognitive impairment is indicated.
Conduct standard investigations.

35. MEMORY IMPAIRMENT SCREEN
Instructions for Administration
1. Show patient a sheet of paper with the 4 items to be recalled in 24-point
or greater uppercase letters (on other side), and ask patient to read the
items aloud.
2. Tell patient that each item belongs to a different category. Give a
category cue and ask patient to indicate which of the words belongs in the
stated category (eg, “Which one is the game?”). Allow up to 5 attempts.
Failure to complete this task indicates possible cognitive impairment.
3. When patient identifies all 4 words, remove the sheet of paper. Tell
patient that he or she will be asked to remember the words in a few
minutes.
4. Engage patient in distractor activity for 2 to 3 minutes, such as counting
to 20 and back, counting back from 100 by 7, spelling WORLD backwards.
5. FREE RECALL — 2 points per word: Ask patient to state as many of the 4
words he or she can recall. Allow at least 5 seconds per item for free recall.
Continue to step 6 if no more words have been recalled for 10 seconds.
6. CUED RECALL — 1 point per word: Read the appropriate category cue for
each word not recalled during free recall (eg, “What was the game?”).

36. MEMORY IMPAIRMENT SCREEN contd.
Word Cue Free Recall (2
points)
Cued Recall (1
point)
Checkers Game
Saucer Dish
Telegram Message
Red Cross Organization
SCORING
The maximum score for the MIS is 8.
• 5-8 No cognitive impairment
• ≤ 4 Possible cognitive impairment

37. ENVIROMNETAL OR WORK BARRIERS
GAIT, LOCOMOTION AND BALANCE
• Wheelchair Skill test
• Modified functional Reach test
• Berg Balance scale
• Walking index for spinal cord injury
• Spinal Cord injury Functional ambulation Inventory
• 6 min walk test
• Neuromuscular Recovery scale

38. WHEELCHAIR SKILL TEST
The wheelchair is among the most important therapeutic
devices used in rehabilitation.
 WST is practical, safe, well tolerated by wheelchair users, has
good reliability and validity, and is useful to clinicians.
This scale includes 32 items, adminster time is 30 minutes.
Score Score What this means
Pass 2 Task independently and safely accomplished without
any difficulty.
Pass with difficulty 1 The evaluation criteria are met, but the subject
experienced some difficulty worthy of note.
Fail 0 Task incomplete or unsafe
Not possible NP My wheelchair does not allow this skill. (Only for skills
where a NP score is noted as a possibility in the script.)
Testing error TE Testing of the skill was not sufficiently well observed to
provide a score

40. BERG BALANCE SCALE
• The Berg balance scale is used to objectively determine a patient's ability (or
inability) to safely balance during a series of predetermined tasks.
• It is a 14 item list with each item consisting of a five-point ordinal scale ranging
from 0 to 4, with 0 indicating the lowest level of function and 4 the highest level
of function and takes approximately 20 minutes to complete.
• It does not include the assessment of gait.
• Scoring: A five-point ordinal scale, ranging from 0-4. “0” indicates the lowest
level of function and “4” the
• highest level of function. Score the LOWEST performance. Total Score = 56
• Interpretation: 41-56 = independent
• 21-40 = walking with assistance
• 0 –20 = wheelchair bound

42. WALKING INDEX FOR SPINAL CORD INJURY
The WISCI/WISCI II scale was developed as a research tool in clinical trials
to measure improvements in walking in persons with acute and chronic
spinal cord injury. It is not intended to be used in a clinical setting.
The development of this assessment index required a rank ordering along
a dimension of impairment, from the level of most severe impairment (0)
to least severe impairment (20) based on the use of devices, braces and
physical assistance of one or more persons. The order of the levels
suggests each successive level is a less impaired level than the former.
Physical assistance:
 ‘Physical assistance of two persons’ is moderate to maximum
assistance.
‘Physical assistance of one person’ is minimal to moderate assistance.
‘Contact guarding’ is minimal assistance
Braces: ‘Braces’ means one or two braces, either short or long leg.
(Splinting of lower extremities for standing is considered long leg
bracing).
 ‘No braces’ means no braces on either leg.
Walker: ‘Walker’ is a conventional rigid walker without wheels.
Crutches: ‘Crutches’ can be Lofstrand (Canadian) or axillary.
Cane: ‘Cane’ is a conventional straight cane.

43. Level Description
• 0 Unable to stand and/or participate in assisted walking.
• 1 Ambulates in parallel bars, with braces and physical assistance of two persons, but less than 10 meters.
• 2 Ambulates in parallel bars, with braces and physical assistance of two persons, 10 meters.
• 3 Ambulates in parallel bars, with braces and physical assistance of one person, 10 meters.
• 4 Ambulates in parallel bars, no braces and physical assistance of one person, 10 meters.
• 5 Ambulates in parallel bars, with no braces and no physical assistance, 10 meters.
• 6 Ambulates with walker, with braces and physical assistance of one person, 10 meters.
• 7 Ambulates with two crutches, with braces and physical assistance of one person, 10 meters.
• 8 Ambulates with walker, no braces and physical assistance of one person, 10 meters.
• 9 Ambulates with walker, with braces and no physical assistance, 10 meters.
• 10 Ambulates with one cane/crutch, with braces and physical assistance of one person, 10 meters.
• 11 Ambulates with two crutches, no braces and physical assistance of one person, 10 meters.
• 12 Ambulates with two crutches, with braces and no physical assistance, 10 meters.
• 13 Ambulates with walker, no braces and no physical assistance, 10 meters.
• 14 Ambulates with one cane/crutch, no braces and physical assistance of one person, 10 meters.
• 15 Ambulates with one cane/crutch, with braces and no physical assistance, 10 meters.
• 16 Ambulates with two crutches, no braces and no physical assistance, 10 meters.
• 17 Ambulates with no devices, no braces and physical assistance of one person, 10 meters.
• 18 Ambulates with no devices, with braces and no physical assistance, 10 meters.
• 19 Ambulates with one cane/crutch, no braces and no physical assistance, 10 meters.
• 20 Ambulates with no devices, no braces and no physical assistance, 10 meters.

44. SIX MINUTE WALK TEST
Clinician-administered may be performed either indoors or
outdoors, along a long, flat, straight, and hard surface.
6 minutes is required for the actual test 5-10 minutes is
required to set up and explain the test to the patient
the American Thoracic Society (ATS) recommends that the
walking course should be:
 30 meters in length
marked at every 3 meters
marked with a cone at turn-around points
Scoring:
Total distance walked (rounding to the nearest meter) and the
number and duration of rests during the test is reported.
Physiological measures such as dyspnea and fatigue level can be
measured using the Borg Scale and pulse oximetry (baseline
heart rate and oxygen saturation) can also be recorded at the
beginning and end of the test

45. Motor Function
• Modified Ashworth scale
• Spinal Cord injury spasticity Evaluation tool

46. Modified Ashworth Scale

47. The Spinal Cord Injury Spasticity
Evaluation Tool:
The Spinal Cord Injury Spasticity Evaluation Tool (SCI-SET) is a self-report
questionnaire that assesses the impact of spasticity on daily life in people
with SCI. It requires participants to recall their past 7 days when rating
spasticity on a scale ranging from -3 (extremely problematic) to +3 (extremely
helpful).
Scoring: • Total score (-3 to +3) is generated by summing all the responses
from the applicable items then dividing the sum by the number of applicable
items

48. SELF CARE AND HOME MANAGEMENT
• Functional Independence Measure
• Spinal cord injury independence measure
• Quadriplegia Index of function
• Capabilities of upper extremity instrument

49. Functional Independence Measure

50. VENTILATION
• Chest circumference
with measure tape
• Vital capacity
• Respiratory Rate

51. INTEGUMENT
• Braden Scale
• Spinal Cord injury
pressure Ulcer scale
• Spinal Cord injury
pressure ulcer scale -
Acute

52. BRADEN SCALE FOR PREDICTING PRESSURE ULCER

53. BRADEN SCALE SCORING:
Scoring: The Braden Scale is a summated rating
scale made up of six subscales scored from 1-3 or
4, for total scores that range from 6-23.
A lower Braden Scale Score indicates a lower level
of functioning and, therefore, a higher level of risk
for pressure ulcer development.
A score of 19 or higher, for instance, would indicate
that the patient is at low risk, with no need for
treatment at this time.
The assessment can also be used to evaluate the
course of a particular treatment.

54. WORK COMMUNITY AND LEISURE
INTEGRATION OR REINTEGRATION
• Craig Handicap Assessment and Reporting technique
• Assessment of life habits
• Reintegration to Normal living index

55. Reintegration to Normal living index

56. CASES

57. CASE 1
The presence of paraplegia or quadriplegia is
is presumptive evidence of spinal instability.

58. CASE 2
Patients who are awake, alert, sober, and neurologically normal, and
have no neck pain or midline tenderness, or a distracting injury.
Remove the c-collar and palpate the spine. If there is no significant
tenderness, ask the patient to voluntarily move his or her neck from
side to side then flex and extend
If no pain, c-spine films are not necessary.

59. CASE 3
Patients who are awake and alert, neurologically normal, cooperative, and do not
have a distracting injury and are able to concentrate on their spine, but do have
neck pain or midline tenderness
Where available, all such patients should undergo multi-detector axial CT from the
occiput to T1 with sagittal and coronal reconstructions.
Lateral, AP,and openmouth odontoid x-ray examinations of the c-spine
• If these films are normal, remove the c-collar.
• if any of these films are suspicious, obtain consultation from a spine specialist.

60. CASE 4
Patients who have an altered level of consciousness or are too young to
describe their symptoms
Where available, all such patients should undergo multi-detector axial CT
from the occiput to T1 with sagittal and coronal reconstructions.
Where not available, all such patients should undergo lateral, AP, and
open-mouth odontoid films with CT supplementation through suspicious
areas.
If the entire c-spine can be visualized and is found to be normal, the
collar can be removed after appropriate evaluation

61. CASE 5
When in doubt
leave the collar on.
•Backboards: Patients who have neurologic deficits (e.g.,
quadriplegia or paraplegia) should be evaluated quickly and
removed from the backboard as soon as possible. A paralyzed
patient who is allowed to lie on a hard board for more than 2
hours is at high risk for pressure ulcers.

62. THANK YOU