Transcript Grade 3
ASSESSMENT OF PATIENTS WITH SPINAL CORD INJURY KRISTOFFERSON G. MENDOZA, PTRP COLLEGE OF ALLIED MEDICAL PROFESSIONS UNIVERSITY OF THE PHILIPPINES MANILA PT142: Assessment in Physical Therapy 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: Complications that may limit therapy Other Cause, circumstances, onset injuries, co-morbidities (PMHx) Precautions Stability injuires of the spine, presence of fractures, other 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 Classification complete 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 Classification incomplete 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 twitch Grade 0 - no movement Key Muscles C5 C6 C7 Elbow flexors Wrist extensors Elbow extensors C8 T1 L2 Flexor digitorum profundus to the middle finger Small finger abductors Hip flexors L3 L4 Knee extensors Ankle dorsiflexors L5 S1 Extensor hallucis longus 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 IMPAIRMENT SCALE ASIA A : Complete SCI. No sensory or motor preservation in S4 or S5 distribution. ASIA B : ASIA C : Incomplete SCI. Sensory but no motor function is preserved below the neurologic level extending through S4 or S5 segments. Incomplete SCI. Sensory & motor preservation below the neurological level and majority of key muscles below neurological level are graded less than 3. ASIA 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.