The term Spinal Cord Injury is used to refer to neurological damage of the spinal cord Any lesion involving the spinal cord result a syndrome called a “myelopathy” Spinal cord injuries are defined as complete or incomplete according to the International Standards for the Neurological Classifification of SCI and the American Spinal Injuries Association Impairment Scale (AIS) Complete lesions are defifined as AIS A, and incomplete lesions are defifined as AIS B, AIS C, AIS D or AIS E (Harvey, 2016)

1. ASSESSMENT & INTERVENTION
FOLLOWING
SPINAL CORD INJURY
Aditya Johan Romadhon., SST.FT, M.Fis

2. Incidence of SCI• Approximately 54 cases per one million people in the United
States, about 17,700 new SCI cases each year (SCI Data sheet,
2018)
• Indonesia in 2014, 104 SCI cases were registered at the
Fatmawati General Hospital whereat 37 had traumatic and 67
had non-traumatic SCI (Tulaar et al, 2017)
• The most common etiologies of traumatic SCI were car
accidents and falls from heights, whereas the major causes for
nontraumatic SCI were infection and neoplasm (Tulaar et al,
2017)

3. SCI DATA SHEET 2018.
https://www.nscisc.uab.edu/Public/Facts%20and%20Figures%202019%20-
%20Final.pdf

4. PREVALENCE

5. Spinal Cord Injury Term & Type
• The term Spinal Cord Injury is used to refer to neurological damage of the
spinal cord
• Any lesion involving the spinal cord result a syndrome called a “myelopathy”
• Spinal cord injuries are defined as complete or incomplete according to the
International Standards for the Neurological Classifification of SCI and the
American Spinal Injuries Association Impairment Scale (AIS)
• Complete lesions are defifined as AIS A, and incomplete lesions are defifined
as AIS B, AIS C, AIS D or AIS E (Harvey, 2016)

7. Neurological Outcomes of Spinal Cord Injury
• In clinical management of SCI, neurological outcomes are generally
determined at 72 h after injury using ASIA impairement scale
• Most of the functional recovery occurs during the first 3 months and
in most cases reaches a plateau by 9 months after injury
• However, additional recovery may occur up to 12–18 months post-
injury
• Hypovolemia and hemodynamic shock in SCI patients due to
excessive bleeding and neurogenic shock result in compromised
spinal cord perfusion and ischemia
• Increased tissue pressure in edematous injured spinal cord and
hemorrhage-induced vasospasm in intact vessels further disrupts
blood flow to the spinal cord

8. • Vascular insult, hemorrhage and ischemia ultimately lead to cell death
and tissue destruction through multiple mechanisms, including oxygen
deprivation, loss of adenosine triphosphate (ATP), excitotoxicity, ionic
imbalance, free radical formation, and necrotic cell death
• Cellular necrosis and release of cytoplasmic content increase the
extracellular level of glutamate causing glutamate excitotoxicity (the main
excitatory neurotransmitter in the CNS)

9. Severe acute spinal cord lesion there are
two clinical stages:
• Spinal shock : loss of all reflex activity below the level of lesion,
flaccid limbs, atonic bladder with incontinence, atonic bowel, loss of
genital reflexes and vasomotor control
• Heightened reflex activity : after 1-2 weeks associated with spasticity
of the limbs, brisk reflexes and extensor plantar response, spastic
bladder and hyperactive autonomic function (sweating)

10. The clinical feature
• Lesion affecting the cord below T1 will not involve the arms
• Lesion between C5 and T1 cause LMN and sometime UMN
signs in the arm and UMN signs in the legs
• Lesion above C5 cause UMN signs in the arms and legs
• when it occurs above the level L1 causes spastic paraparesis or
tetraparesis at high cervical level
• Below L1 level, the cauda equina will be affected and the
patient will have LMN syndrome affecting the leg and bladder

11. The spinal cord extends from the top of the C1
vertebra to the bottom of the body of the L1

12. Medulla Spinal Collumn

13. Projectory/ Tracts

14. Somatotopic

15. Sensory Pathways

16. Anterior & Posterior Spinocerebellar

17. Sensory Input

18. Dermatome
A dermatome is an area of
skin that is mainly
supplied by a single spinal
nerve

19. Motor Pathways

20. Myotome
The anatomical
term myotome refers to the
muscles served by a spinal nerve
root (a set of muscles innervated
by a specific, single spinal nerve)

21. Autonomic Pathways

23. The Clinical Syndrome of Spinal
Cord Disease
• There are tree main motor syndromes associated with spinal cord disease
Paraparesis (UMN involvement of legs only)
Tetraparesis (UMN involvement of all four limbs)
Brown-Sequard syndrome (Unilateral lesion causing UMN involvement of one side)
Paralysis is the complete loss of voluntary movement
The words “plegia” “palsy” and “paresis” are sometimes used interchangeably to
describe weakness
Paresis is the correct term to describe incomplete paralysis, Plegia means complete
paralysis and Palsy used when the paralysis affects cranial motor nerve (bell’s palsy,
pseudobulbar palsy) or a static weakness (cerebral palsy)

24. PARAPARESIS (SPASTIC PARAPARESIS OR PARAPLEGIA)
• Paraparesis indicates bilateral UMN damage involving
the axons that innervate the legs from both corticospinal
tracts
• The clinical signs include :
Increased tone with spasticity
Increased reflexes with clonus
Extensor plantar response (Babinski sign)
Sphincter dysfunction

25. • Spastic tetraparesis produces the same clinical
picture as paraparesis but involves both arms
and legs
• It is usually caused by lesion in the high
cervical cord, occasionally due to brainstem
TETRAPARESIS (SPASTIC TETRAPARESIS,
TETRAPLEGIA, QUADRIPARESIS, QUADRIPLEGIA)

27. BROWN SEQUARD SYNDROME (UNILATERAL CORD LESION)
• Brown Sequard syndrome is rare in its pure form but partial forms are more
common
• The pure brown Sequard syndrome clinical picture consist of :
• Ipsilateral spastic leg and sometimes arm if the lesion above C5, with brisk
reflexes and an extensor plantar response
• Ipsilateral loss of joint position sense and vibration or touch (dorsal column),
contralateral loss of pain and temperature
o Pain fibers ascend a few spinal segments before entering the dorsal horn
to synapse
o If the lesion damages the anterior horn cell as well as the white matter
tracts then the patient will have UMN signs below the level of the lesion
and LMN signs at and about the level of the lesion

29. A framework of Physiotherapy
Management
• The overall purpose of Physiotherapy for patients with spinal
cord injury is to improve health related quality of life
• By improving patient’s ability to participate in activities of daily
life
• The International Classification of Functioning Disability and
Helath (ICF) can be used to describe the process involved in
formulating a physiotherapy programs

30. • Step one : Assessing impairments, activity limitation and
participation retrictions
• Step two : Setting goal with respect to activity limitation
and participation retrictions
• Step three : Identifying key impairments
• Step four : Indentifying and administering treatments
• Step five : Measuring outcomes

31. Assessing impairements, functional
limitations and participation restrictions
• Various sources need to be used
• Age, cause of injury, time since injury, neurological status, orthopaedic status,
other injuries and complications, medical and surgical management etc
• Well accepted assessment tool used to measure functional limitation and
parcitipation restriction including :
• Functional Independence Measure (FIM)
• Spinal Cord Independence Measure
• Quadriplegic Index of Function
• Specific assessment i.e ability to walk 6 minutes walk test, TUG, 10m walk
test
• Ability to use hand i.e grab and release test, Sollerman test, Carrol test etc

32. Setting goals
• These goals should be expressed in term of participation
restrictions (i.e return to work or school)
• Sub domains of mobility, self care and domestic life
• Goals should be SMART (Specific, Measurable, Attainable,
Realistic and Timebound)

33. Setting goals for patients with complete lesions

34. Indentifying Key Impairements
• Once goals of treatment are defined in term of activity
limitation and participation restriction, it is necessary to
determine which impairements prevent the attainment of
each goal
• Key impairement need to be linked to specific activity
limitation and participation restriction
• Anatomical and functional limitation are different

35. C6 - tetraplegia sitting
Passive tension in
the paralysed
hamstring muscle
helps maintain the
trunk in upright
position
Hamstring cannot
prevent a forward
fall if they are highly
extensible

36. Indentifying and administering treatment
• Six key impairements are responsive to physiotherapy
intervention and commonly impose activity limitation and
participation restriction
• Poor skill
• Poor strength
• Poor joint mobility
• Pain
• Poor respiratory function
• Poor cardiovascular fitness

37. Measuring outcomes
• Outcomes are best expressed in term of initial goal with respect to
activity limitation and participation restriction
• i.e if an inability to transfer was deemed to be the consequence of
poor strength in the shoulder adductor muscle, then improvement of
adductor strength should be accompanied by improvement in the
ability to transfer

43. Flexor hinge splint
The splint is open the hand when
the wirst is flexed and closed the
hand when the wirst is extended

44. Sekian
&
Terimakasih