Week 9-SCI Assessment/Balance and Transfers

C6 SCI Transfers

If people use tenodesis, have them ball their hands into a fist when possible with transfers to prevent from stretching their fingers out

Conus Medullaris Sydrome:

injury of the sacral cord and lumbar nerve roots, usually results in areflexic bladder, bowel and LEs.

Neurological Classification: Motor

key muscles (segmental myotomes)

AIS E:

motor and sensory functions normal

AIS C

motor incomplete- motor function preserved below with half of key muscles below have grade of less than 3

Facilitating Tenodesis Grasp

●Circumduction of wrists to prevent stiffness (keep fingers curled to prevent stretching) ●PROM to the fingers following the tenodesis pattern °Extension of the fingers when wrist is flexed °Flexion of the fingers when wrist is extended ●ROM will prevent the hands from getting stiff ●NMES for wrist extensors ●Do not range the thumb during tenodesis hand ranging

The Graded Redefined Assessment of Strength, Sensation and Prehension (GRASSP)

●Clinical impairment measure specific to the upper limb for use after tetraplegia ●The GRASSP measures sensorimotor and prehension function through three domains °Strength °Prehension °Sensation ●Not designed for the non-traumatic SCI populations ●Performance-based

Specific Assessments:UE Function

●Jebsen Hand Test ●The Graded Redefined Assessment of Strength, Sensation and Prehension (GRASSP) -specifically for clients with tetraplegic spinal cord injuries ●Dynamometer ●Pinchometer

Specific Assessments

●MMT ●ROM ●Numeric Pain Rating Scale

Braces

●May help promote proper posture and prevent further injury ●Wear for approximately 10 to 12 weeks, sometimes up to 6 months ●Read the chart or ask the physician if there are any restrictions

Lateral reach

●Measures lateral postural stability ●Maximum distance an individual can reach laterally in a standing position ●Start position: 90 degrees abduction with elbow extended ●Feet in contact with floor, no knee flexion, no trunk flexion or rotation ●Good test-retest reliability: .94

Functional impact of balance deficits

●Need to determine amount of assistance needed by client to maintain balance during occupations ●Also consider client's context and environment including physical and social environments ●Also need to consider client's risk for falls ●If you identify a problem through your balance screening efforts then follow up with a standardized assessment to determine severity of impairment

What are some other factors that might impact balance?

●Person ●Environment ●Occupation

General transfer set up

●Position wheelchair on stronger side (unless a "Pusher") ●Wheelchair at 45o angle ●Lock brakes ●Remove or swing away both leg rests ●Easiest to transfer downhill ●Sit at edge of bed or chair ●Rock them forward and use legs to lift

Things you must know prior to transfer

●Precautions ●Weight bearing status ●Equipment needed ●Type of transfer ●Level of assistance

Sliding board transfer

●Remove armrest between patient and transfer surface ●Angle bottom closer to the transfer surface and knees facing in the opposite direction ●Have the patient lean to the side and place sliding board approximately halfway under the upper thigh ●Squeeze patient's knees with your knees OR block both knees with your knees ●Make sure the patient leans forward and uses head/hip relationship ●Have the patient reach for the opposite armrest or end of the sliding board ●Slightly lift patient while you slide them along the board ●Break up into as many steps as needed

Sit or squat pivot transfers

●Remove armrest between patient and transfer surface ●Block patient's knee(s) with your knee(s) to prevent buckling ●Have the patient reach for the transfer surface ●Have them help you in lifting their bottom and pivot patient ●Seat patient on the transfer surface

Compensatory techniques

●Safe weight shifting techniques ●Bracing with the contralateral UE ●Getting dressed lying in bed ●Learning to complete all pieces of lower body dressing in sitting and standing only one time to pull pants up around hips ●Using alternate methods of lower body dressing to decrease the need to bend toward the floor ●Performing toileting hygiene in sitting when possible ●Pulling pants up over the knees before standing from toilet to prevent pants from falling to the floor while standing ●Performing standing activities in front of a chair in case of loss of balance or the need to take a seated rest break ●Learning to position self directly in front of a workspace to avoid reaching outside the BoS during housekeeping tasks, such as cooking, unloading the dishwasher, transferring laundry, and cleaning ●Making the bed while still lying in it ●Wearing a terry cloth bathrobe to dry off after the shower instead of towel drying

Types of transfers

●Sit to stand ●Stand pivot ●Sit pivot/squat pivot ●Sliding board ●Hoyer lift ●2-person lift

Cervical Brace

●Those with severe higher level cervical spinal cord injuries (C4 and up) may need to wear a halo brace to help stabilize their head and neck. ●Less severe cervical spinal cord injuries may wear a cervical collar ●Soft collars are more for treating whiplash ●Hard collars are usually worn 24 hours a day and to treat vertebral fractures

Back safety

●Use the hospital bed to make transfer easier when needed °Raise head of bed °Higher to lower ●Wide base of support with feet ●Pivot on feet - DON'T twist ●Keep core tight for stability and "neutral" back ●Knees bent ●Don't "lift" the patient, but rather rock them forward enough to move them

Stand pivot

●Usually done by patients that can walk ●Place assistive device in front of patient if appropriate ●Instruct patient to push up from the surface they are sitting on with at least one hand °DO NOT let them pull on the walker ●Pivot or walk to chair/bed ●Back up to chair/bed so that they are squared up ●Instruct them to reach back for the chair/bed to help them sit slowly

Sit to stand transfer

●Usually done by patients that can walk ●Place assistive device in front of patient if appropriate ●Instruct patient to push up from the surface they are sitting on with at least one hand °DO NOT let them pull on the walker ●Pivot to chair/bed ●Back up to chair/bed so that they are squared up ●Instruct them to reach back for the chair/bed to help them sit slowly

SCI Bed Mobility

●Why is it important? ·Relieves pressure sores ·Helps people move when they become uncomfortable ·Necessary for dressing ·Forms component for transfers ●Usually easier to practice in high low bed with rails at first

Tenodesis Splint

●Worn over the hand and forearm ●Usually custom made ●Facilitate tenodesis grasp

To maintain standing balance

●maintain center of mass over base of support during weight shifting in a variety of directions from one leg to the other °Flat foot on floor (90 deg ankle dorsiflexion) °Active knee extension °Active hip extension °Neutral pelvis

Specific Assessments: Spasticity

●more common in later phases ●Modified Ashworth Scale

Braces:Functions of spinal cord orthoses

●restrict spinal column movements to prevent further damage and promote healing ●correct misalignments and stabilize the spinal column ●combat spasticity and gently stretch tight muscles ●promote proper posture ●reduce weight-bearing and pain at the joints

ASIA & ISNCSCI

(American Spinal Injury Association) impairment scale classification (AIS) or International Standards for Neurological Classification of SCI (ISNCSCI)

Specific Assessments: Self-Efficacy

Moorong Self Efficacy Scale (MSES)

Neurogenic Pain

Painful sensations experienced at or below the level of injury Phantom sensations, burning, tingling, numbness, extreme hypersensitivity

Neurological Classification: Partial preservation

Partial preservation: complete injuries who have partial innervation below the neurological level

Sliding Board Transfers

Remember to watch out for skin! Limit the amount of sliding as much as possible.

Establishing Intervention: Goals and Objectives

The phase of recovery, of which the evaluation is being completed, will drive the goals. Ask these questions when thinking of goals. Objectives will typically be stepping stones for obtaining the over-all goal. ●What must be done to prevent further deformities and complications? ●What activity is important for the patient to engage in right now (BADLs, IADLs)? ●What needs to be done to increase activity tolerance, muscle endurance and muscle strength to complete activities/occupations? ●Are there psychosocial issues that need addressing? ●What equipment might be needed to complete tasks? ●What education might be needed for patient and family? ●What skills are needed to return to home/work/leisure? ●Are there environmental changes that need to happen? ●Consider age when creating goals.

AIS A:

complete with no sensory or motor preserved S4-S5

Anterior Spinal Cord Syndrome:

damage to anterior spinal artery or anterior aspect of cord, only proprioception is preserved below level of lesion

Neurological Classification: Sensory

dermatomes

Neurological Classification: Neurological level

diagnosed by MD, lowest segment of spinal cord at which key muscles grade 3 or above and sensation intact for that level of dermatome

Balance interventions: Compensatory approach

educate clients to use UE or weight shifting techniques to offset deficits for which they cannot remediate ●Adapt environment by adding adaptive equipment or devices to increase home safety

AIS D

incomplete with motor preserved below with at least half muscles of grade 3 or more

Balance interventions:Remedial/rehabilitative approach

increasing ROM, strength, and endurance ●Targeting motor deficits will improve balance ●Exercise and occupation based activities to improve UE, LE, core, and activity tolerance °Yoga, Tai Chi, and repetitive task training

Neurological Classification: Functional level

lowest segment at which strength of important muscles grade 3+ or above and sensation for that dermatome intact

Central Cord Syndrome:

more cellular destruction in the center of the cord than in the periphery. Losses are greater in UEs because these nerve tracts are more centrally located; older people-spinal stenosis, cervical hyperextension without fx

Nociceptive Pain

occurs in body parts innervated above the SCI

Brown-Sequard Syndrome:

only one side of the spinal cord is damaged, usually gunshot wound or stabbing, below level of injury there is motor and proprioception loss on the ipsilateral side, loss of pain, temperature and touch on contralateral side

Cauda Equina:

peripheral nerves, usually below the L2 level and results in flaccid type paralysis, better prognosis

AIS B:

sensory incomplete- sensory preserved below neurological level, no motor function preserved more than three levels below the motor level

Nociceptive Pain:treatment

°Decrease pain °Address secondary conditions °Prevent recurrence

Neurogenic Pain:Causes

°Nerve root irritation °Hypersensitive Nerve Tissue °Imbalanced and confused message circuitry between the brain and body

Neurogenic Pain:Treatment

°Relaxation/coping strategies °Medications °TENS °Biofeedback

Nociceptive Pain:causes

°Shoulder impingement °Overuse injuries °Degenerative Joint Disease °Bursitis °Cervical radiculopathy

Spinal Cord Independence Measure III (SCIM)

●A disability scale developed specifically for the SCI population to assess various activities of daily living (ADLs) ●There are a total of 19 items on the SCIM III, which are divided into 3 subscales (self-care, respiration and sphincter management, and mobility). ●Ideally is administered by clinical observation, however chart abstraction or clinical consultation can also be used to score the items when necessary ●There is a self-report version of the form too!

Evaluation of Performance Areas/Functional Status

●ADLs ●Leisure/sports ●School/vocation ●Home/community Level of injury and stage of recovery determine what kind of assessment (standardized, non-standardized, observation) should be completed.

Neurological and physiological basis for balance

●Achieving and maintaining balance requires coordination musculoskeletal and sensorimotor systems ●Reduced sensation and motor weakness impairs balance ●Balance processing system includes: vision, vestibular, tactile, proprioception components ●Postural control skills allows us to stay in balance by maintaining our center of mass within our base of support ●Postural control is required during postural adjustments for reaching from a sitting or standing position

Timed up & go test (TUG)

●Adaptation of Get Up & Go Test ●Designed for elderly population ●Scoring based on time it takes to go from sit to stand to walk 9.8 ft & back to sit °Score of 20 or less = independent with transfers & gait °Score of 20-30 = "a gray zone" °Score of 30 or more = assistance with balance & functional activities needed (Podsiadlo & Richardson, 1991) ●Norms: °60-69 years old = 8.1 °70-79 years old = 9.2 °80-99 years old = 11.3

Static sitting balance screening

●Can client sit unsupported without loss of balance and without UE support? ●If yes: apply pressure to trunk in anterior, posterior, lateral positions °Can client maintain balance against minimal, moderate, or maximal resistance? ●If no: can client maintain balance with UE support or is support needed from another individual or chair

Balance

●Critical skill for many daily occupations ●Required for activities done in sitting and standing ●Needed to transition between sitting and standing ●Needed for functional mobility and ambulation ●Correlation between sitting balance scores and occupational independence, length of stay in hospital, and occupational performance after stroke ●Impaired balance leading cause of falls °Can also lead to decrease QOL, high medical costs, and death

Functional reach test

●Designed for elderly population ●Consists of patient reaching as far forward as possible while maintaining a fixed BoS in standing ●Score is based on extent of forward reach along a yardstick ●Score of 6-7 inches indicates a frail person with limited ability to perform ADLs & increased risk of falls (Duncan et al., 1990) °< 7 inches = fall risk

Berg balance scale(Berg et al, 1992)

●Designed to test sitting & standing balance of elderly patients ●Consists of 14 items including sitting balance, sit to stand transfers ●Scoring: five point ordinal scale (0=unable, 4=independent) ●Score of < 45 = risk for multiple falls ●Score of < 36 = 100% risk of falling (Shumway-Cook et al., 1997) ●Norms for fall risk: 41-56 = low 21-40 = medium 0-20 = high

Static standing balance screening

●Determine whether the client can stand supported without UE support and without balance loss for 1 to 2 minutes °If so, apply pressure with your hands to the client's trunk in the anterior, posterior, and lateral directions °Determine whether the client is able to maintain balance against minimal, moderate, or maximal resistance; gradually increasing the amount of resistance to the extent the client is able to tolerate safely and comfortably °If not, determine whether the client can maintain standing without loss of balance with UE support and minimum, or moderate, or maximum support from another individual or assistive device

Tenodesis Grasp

●Does not require active finger movement ●By extending the wrist, the fingers naturally flex ●By flexing the wrist, the fingers naturally extend ●Usually people with C6 and C7 spinal cord injuries benefit the most from using it.

Thoracic Lumbar Sacral Orthosis (TLSO)

●Extends from just below the collar bones down to the pelvis ●Used to stabilize the spine after surgery or in the event of a spinal fracture to promote healing and decrease pain. ●Most of the time the TLSO is worn only when out of bed while sitting or standing. ●There are times when the doctor requires the TLSO to be worn at all times.

Weight bearing

●Full weight bearing (FWB): no weight bearing restriction ●Weight bearing as tolerated (WBAT): as much weight as patient can tolerate through affected limb ●Non-weight bearing (NWB): no weight through affected limb ●Toe touch weight bearing (TTWB): toe on floor for balance but no weight should be placed through the affected limb ●Partial weight bearing (PWB): specific pounds or percentage of body weight through affected limb

Occupational Profile

●Gather deep understanding of roles, activities and the meaning behind activities ●Open-ended questions ●Discover habits and routines ●Learn client factors related to values, beliefs and spirituality ●Occupational history ●Motivation and determination ●Socio-economic background and financial resources ●Education ●Family support ●Personal attitudes toward disability ●Problem solving skills ●Canadian Occupational Performance Measure (COPM) ●AOTA Occupational Profile

Adaptive equipment for balance impairment

●Grab bars ●Stair railings ●Electronic lift chairs ●Stair lifts ●Toilet safety frames/handles ●Shower chair/bench ●Nonslip adhesive surfaces for the bathtub/shower or stairs ●Use of adaptive devices such as canes, walkers, and wheelchairs ●Use of a reacher and other long-handled items (unless client has UE weakness) ●A pant clip for toileting clothing management ●Positioning equipment that can be added to wheelchair seating systems for postural support/alignment ●Bed rails for transfers or sitting balance ●Sliding boards for lateral (seated) transfers

Set yourself up for success

●Have a plan ●ALWAYS use a gait belt ●Explain to the patient what you are doing before starting ●Have all the equipment ready before beginning transfer ●If you are unsure at all, CALL FOR HELP

Dynamic sitting balance screening

●If client can sit unsupported against resistance, determine if and how far client can weight shift and cross midline by asking client to reach for items in multiple planes °Cross midline, contralateral side of body °Cannot use support of other arm °Classify as weight shifting and crossing midline minimally, moderately, and maximally °If unable to cross midline, see if can reach ipsilaterally and weight shift a little °If client cannot maintain seated position without maximal assist, then do not assess dynamic sitting balance

Dynamic standing balance screening

●If the client is able to stand independently unsupported, determine whether he or she is able to weight shift and reach across midline to the contralateral side minimally, moderately, or maximally °This can be accomplished by again asking the client to reach for an item and gradually increasing the distance as tolerated °If the client is able to stand independently unsupported, but cannot reach to the contralateral side, screen his or her ability to weight shift and reach to the ipsilateral side as well as cross midline °If the client is able to stand with supervision and reach to the ipsilateral side, determine whether he or she is able to weight shift °If the client is able to stand with minimal or moderate assistance, determine whether he or she is able to weight shift, reach to the ipsilateral side, or cross midline °If a client requires maximum assistance to maintain standing, you do not need to screen for dynamic balance because this indicates an absence of, or Poor, dynamic standing balance

Prognosis

●Incomplete injuries better prognosis ●The longer it takes for recovery to begin, the less likely it will occur ●70% to 85% of clients with complete tetraplegia will gain at least one level by 1 year post injury ●Most improvements are completed by 1 year post injury, but can continue to progress for 3 to 4 years ●Long-term survival only slightly less than general population ●Deaths typically from respiratory complications and infections ●No amount of hard work will cause nerve function to return ●Main purpose of rehab is to prevent further complications and maintain/improve strength/skills present for maximizing function

Levels of assistance

●Independent (I) - no help ●Modified Independent (Mod I) - use device, no help ●Supervision (SPV) or Stand By Assist (SBA) - no physical help; just stay close for safety ●Minimal Assist (Min A) - 25% or less physical help ●Moderate Assist (Mod A) - 26 to 50% physical help ●Maximum Assist (Max A) - 51 to 75% physical help ●Total Assist (Total A) or Dependent - 76 to 100% physical help OR requires 2 person assist

Abdominal Binder

●Restores abdominal pressure and consequently improves breathing capacity ●Reduces postural hypotension in patients who do not have functioning abdominal muscles ●Should fit snugly around the torso and be tight enough to provide support, but should not be uncomfortable. ●Typically worn under the shirt and are mainly used to improve circulation and breathing when in an upright position.

Beginning the Evaluation

●Review Chart -Other trauma (TBI) -Level of arousal -Talk with nurse or other team members to avoid redundancy in asking questions -Medical and psychological history -Evaluation begins the day of admission and continues long after discharge -Discharge planning begins during the initial evaluation -Want to gather enough information quickly to begin high-priority treatments such as splinting, positioning, and family training

Balance skills screening cont

●Review client's history and create occupational profile ●Note diagnoses, medications with side effects, history of falls, prior level of function, blood pressure ●Ensure safety and start assessing balance while seated ●Screen static seated balance before dynamic seated balance ●Use grading system to measure balance: normal, good, fair, poor

Results of Spinal Cord Injury

●SCI causes disruption in the motor and sensory pathways at the site of the lesion ●Complete and incomplete lesions ●Tetraplegia (once quadriplegia) ●Paraplegia ●Spinal shock (may last hours, days or even 4-8 weeks) ●Areflexia may remain at the level of injury

Moorong Self-Efficacy Scale (MSES)

●Self-report questionnaire ●Developed to measure self-efficacy in performing functional activities of daily living in individuals with SCI ●Consists of two factors: °daily activities (e.g. I can maintain my personal hygiene with or without help), and °social functioning (e.g. I can enjoy spending time with my friends)

Environmental adaptations for balance impairments

●Setting up the environment to decrease reaching distance required to complete a task ●Setting up the environment to allow for tasks to be completed in sitting, such as a table in the kitchen for food prep ●Placing hygiene/grooming tools on the bathroom counter within reach from a chair

Evaluation of Performance Skills

●Specific areas of deficit -Begin with PROM -Shoulder pain -Muscle strength -Sensation -Gross grasp and pinch -Muscle endurance ●Oral motor control ●Head and trunk control ●LE function ●Psychosocial ●UE function ●Activity tolerance ●Cognition (15 to 60% have TBI too) ●Perception ●Vision

Specific Assessments: ADL/IADL

●Spinal Cord Independence Measure (SCIM) ●Continuity Assessment Record and Evaluation (CARE) Item Set: replacing the Functional Independence Measure (FIM) ●Barthel ●Lawton IADL Scale

Balance skills screening

●Start with posture assessment and observation in unsupported seated position: °Are shoulders even? °Is client leaning more to one side? °Can the client maintain balance while seated without support? °Core strength: can client flex/extend trunk while seated? °Postural adjustment: can client maintain control while reaching across midline? °Self-report: dizzy or lightheaded

Specific Assessments: Sensory

●Stereognosis ●Light touch