Functional Expectations for Patients With Spinal Cord Injury
L1,L2,L3 Key muscles (5) Available movements (3) Functional Capabilities ambulation? assesitive device? Equipment and Assistance required
Key muscles -Gracilis Iliopsoas Quadratus lumborum Rectus femoris Sartorius Available movements -Hip flexion Hip adduction Knee extension Functional Capabilities Equipment and Assistance required Ambulation Independent short distances in home and possibly community Many choose to use wheelchair in the community due to high energy demands of community ambulation Assistive devices (e.g., forearm crutches) Orthoses: HKAFO, KAFO, AFO (depending on which muscles are innervated)
C5 Key muscles (7) Available movements (5) Functional Capabilities ADL? feeding? bathing? attendant? bowel and bladder? wheel chair? what type? requires what extra stuff? bed mobility? transfers Equipment and Assistance required ambulation? driving?
Key muscles Biceps Brachialis Brachioradialis Deltoid Infraspinatus Rhomboid (major and minor) Supinator Available movements Elbow flexion and supination Shoulder external rotation Shoulder abduction and flexion to ~90° Equipment and Assistance required · ADL : Some assistance and/or setup required depending on the activity · Feeding : Mobile arm supports, deltoid aid Adapted utensils and splinting · Grooming, washing face, and oral hygiene : Adapted equipment (wash mitt, adapted toothbrush, and so forth) · Bathing and dressing (dependent) · Activation of computer, light switches, page turners, call buttons, electrical appliances, and speaker phones: Adapted computer keyboard Hand splints Adapted typing sticks ECU Part-time attendant required, directs care provided by attendants · Bowel and bladder: o Dependent, directs care provided by attendants · Wheelchair mobility and pressure relief in wheelchair: o Independent to some assist with manual wheelchair on level surfaces Requires plastic-coated hand rims/extensions Benefit from power-assist wheelchair Independent with power wheelchair using handheld joystick An electronically controlled seating system (tilt and/or recline) Wheelchair cushion and trunk support, dependent with positioning in wheelchair · Bed mobility: o Assistance to dependent -Adjustable bed with pressure reducing mattress - Bed rails and loops Directs care provided by attendants · Transfers o Dependent, attendants use mechanical lift Directs care provided by attendants May be able to perform with assistance and transfer board · Ambulation : unable · Driving: Independent with van with adaptive controls
C6 Key muscles (7) Available movements (9) Functional Capabilities ADL? dressing? bathing? transfers? ambulation driving home management? full time attendant? bowel and bladder? wheelchair? pressure relief? bed ? Equipment and Assistance required
Key muscles Extensor carpi radialis Infraspinatus Latissimus dorsi Pectoralis major (clavicular portion) Pronator teres Serratus anterior Teres minor Available movements: Shoulder flexion, extension, internal rotation, and adduction Scapular abduction, protraction, and upward rotation Forearm pronation Wrist extension (tenodesis grasp) Functional Capabilities Equipment and Assistance required · ADL o Assistance to independent with setup and/or equipment · Feeding Grooming, washing face, and oral hygiene: Universal cuff, adaptive utensils · Dressing: Adaptive equipment, universal cuff · Bathing : o Upper body: independent with adaptive equipment Lower body: assistance with adaptive equipment · Home management: o Assistance with adaptive equipment -Assistance, may be independent with certain tasks with adaptive equipment (e.g., light meal prep) Part-time attendant required · Bowel and bladder care o May be able to be independent with adaptive equipment, likely to require assistance/dependent · Wheelchair mobility and pressure relief in wheelchair o Independent with manual wheelchair on level surfaces May require power wheelchair in community Requires plastic coated hand rims/ extensions Benefit from power-assist wheelchair -Independent with pressure relief in wheelchair · Bed mobility: o Independent to some assistance with adaptive equipment (e.g., bed rails, loops, and so forth) · Transfers o Independent to some assistance with transfer board o Assistance with uneven transfers · Ambulation o unable · Driving o Independent with car/van with adaptive controls
C7 Key muscles (5) Available movements (3) Functional Capabilities ADL? home management? bowel and bladder? wheelchair? pressure relief? bed? transfers? driving? Equipment and Assistance required
Key muscles Extensor pollicus longus and brevis Extrinsic finger extensors Flexor carpi radialis Triceps Available movements Elbow extension Wrist flexion Finger extension Functional Capabilities Equipment and Assistance required · ADL: Independent · Feeding Grooming, washing face, and oral hygiene Dressing Bathing o Independent with most ADL with adaptive equipment (e.g. shower chair, hand rails, button hook, adaptive utensils) and wheelchair accessible environment · Home management: o Likely to require assistance with heavy household tasks · Bowel and bladder care o Independent with adaptive equipment · Wheelchair mobility and pressure relief in wheelchair o Independent with manual wheelchair in home and community with plastic-coated hand rims o May need some assist with ramps, curbs, and uneven terrain May benefit from power assist Independent with pressure relief · Bed mobility o Independent, may require adaptive equipment (i.e., bed rails, leg loops) · Transfers o Independent, may require assistance between uneven surfaces · Ambulation o unable · Driving o Independent with car with adaptive controls
C8 Key muscles (5) Available movements Functional Capabilities ADLs? Equipment and Assistance required bowelcare? wheelchair? bed? transfers?
Key muscles Extrinsic finger flexors Flexor carpi ulnaris Flexor pollicis longus and brevis Intrinsic Available movements finger flexion Functional : Capabilities Equipment and Assistance required · ADL o Independent · Feeding Grooming, washing face, and oral hygiene Dressing Bathing Home management o Independent in all ADL, may require adaptive equipment (e.g., shower chair, hand rails, reacher, adaptive utensils) for some tasks and wheelchair-accessible environment Better able to perform with less need for adaptive equipment due to improved hand function compared to higher cervical level injuries · Bowel and bladder care o Independent with adaptive equipment · Wheelchair mobility and pressure relief in wheelchair o Independent with manual wheelchair in home and community Better able to propel on ramps, curbs, and uneven terrain due to improved hand function compared to higher cervical level injuries May benefit from power assist Independent with pressure relief · Bed mobility o Independent, may require adaptive equipment (i.e., bed rails, leg loops) · Transfers o Independent, may require assistance between uneven surfaces May be able to transfer from floor into wheelchair · Ambulation o Unable · Driving o Independent with car with adaptive controls
T1 to T12 Key muscles (4) Available movements (3) Functional Capabilities ADL? bowel care? wheelchair? bed mobility transfers? ambulation driving Equipment and Assistance required
Key muscles Intercostals Long muscles of back (sacrospinalis and semispinalis) Abdominal musculature (~T7 and below Available movements Improved trunk control with more caudal SCI Increased respiratory reserve Pectoral girdle stabilized for lifting objects Functional Capabilities Equipment and Assistance required · ADL o Independent o Independent in all areas Generally tasks become easier and require less adaptive equipment to perform with improved trunk control with more caudal SCI · Bowel and bladder care o Independent with adaptive equipment · Wheelchair mobility and pressure relief in wheelchair o Independent with manual wheelchair in home and community Independent on ramps, curbs, and uneven terrain Independent with pressure relief Wheelchair mobility becomes easier and more efficient with improved trunk control with more caudal SCI · Bed mobility o Bed mobility skills become easier and more efficient with improved trunk control with more caudal SCI · Transfers o Independent Able to transfer from floor into wheelchair Transfers become easier and more efficient with improved trunk control with more caudal SCI · Ambulation o standing and ambulation for exercise over short distance in the home Assistive devices (e.g., forearm crutches) Orthoses: hip-knee-ankle-foot-orthosis (HKAFO), knee-ankle-foot orthosis (KAFO) o Improved · Driving o Independent with car with adaptive controls
L4, L5, SI Key muscles (10) Available movements (7) Functional Capabilities Equipment and Assistance required
Key muscles Quadriceps (L4) Anterior tibialis (L5) Hamstrings (L5-S1) Gastrocnemius (S1) Gluteus medius and maximus (L5-S1) Extensor digitorum, posterior tibialis, peroneals, flexor digitorum (L5, S1) Available movements Strong hip flexion Strong knee extension Knee flexion Ankle dorsiflexion Ankle plantarflexion Ankle eversion Toe extension Functional Capabilities Equipment and Assistance required ambulation: Independent ambulation in home and community (L4-level injury may elect to use wheelchair for long distances) Assistive devices (e.g., forearm crutches, canes) Orthoses: AFO Less supportive assistive device and orthoses the more caudal the SCI
C1, C2, C3, C4 Key muscles Available movements (5) Functional Capabilities: ADL? attendant required? wheelchair? independent or dependent? what do they require? ventiltation? positioning in wheelchair? bed mobility? transfers? ambulation? driving? Equipment and Assistance required
Key muscles: Face and neck muscles, cranial nerve innervation, diaphragm (partial innervation at C3 and C4) Available movements: Talking Mastication Sipping Blowing Scapular elevation Functional Capabilities: · Activities of daily living (ADL) : dependent · Dependence in basic ADL (BADL) Activation of computer, light switches, page turners, call buttons, electrical appliances, and speaker phones Bowel and bladder o Environmental control units (ECU) Brain-computer interface (BCI) - Adaptive equipment such as head or mouth stick - Full-time attendant required, directs care provided by attendants Dependent, directs care provided by attendants · Wheelchair mobility and pressure relief in wheelchair o Independent with power wheelchair Typical components include adaptive controls such as head, chin, tongue, or sip-and-puff control -Electronically controlled seating system (tilt and/or recline) Wheelchair cushion and head/trunk support Portable ventilator (depending on innervation of diaphragm) Dependent with positioning in wheelchair · Bed mobility o Dependent Adjustable bed with pressure reducing mattress -Directs care provided by attendants · Transfers: o Dependent, attendants use mechanical lift Directs care provided by attendants · Ambulation: unable · Driving : unable
C4 key muscles intact (3) Function: breathing, self care, mobility
o C4 tetraplegia - don't really have any innervation to key muscles to assist with lifting yourself. ▪ Key muscles intact = upper traps, diaphragm and cervical muscles (head control and also act as accessory respiratory muscles.) Rhomboids partially innervated ▪ Function ● Breathing independently ● Dependent in self care ● Independent in mobility using a power wheelchair using chin control, sip and puff or head array ● Should be independent in directing care
L3
paraplegia ● Key muscles: quadriceps ● Potential for functional community ambulation ● Will need wheelchair for sports, distances, parenting, maybe work ● Independent in all self-care ● Requires bilateral AFOs and UE assistive devices for gait
C5 muscles (7) transfers mobility
○ tetraplegia (preservation of shoulders are very important) Key ms: ● Biceps partially innervated - also C6 (elbow flexion, forearm supination and weak flexor of shoulder) ○ Other ms partially innervated ○ Deltoids (ant, post, middle) ○ serratus anterior, ○ Pectoralis major (at clavicular head) ● Posterior ms. ○ Rhomboids fully innervated ○ Rotator cuff - ER of shoulder partially innervated ■ Only shoulder muscles working so unstable due to not fully innervated ■ Lack of shoulder IR and adductors = limits mobility ■ No innervation of major ms. to trunk except trapezius ■ Unlikely to be independent in transfers (with rare exceptions) ■ Pressure relief ability is also limited, although able to perform adequate pressure change. ■ Usually use power tilt and recline mode of power wheelchair. ■ Independent with community mobility from a power w/c and require attendant assistance for all ADLs
C8-L2
● - totally independent. Can even have a manual wheelchair. Power is just easier on shoulders. ● Complete C6 to L2 have potential for same level of independence, just difference in how they achieve it ● and how long it takes to learn the skill ● C8 Key muscle = digit flexors allowing for active grip and release of hand ● T1 Key muscle = adductor digiti minimi, ● T1 - T12 → will need higher back support on the wheelchair. ● T2-L1 postural muscles and trunk rotation→ ↑ balance and postural stability ● L2 = hip flexors and adductors ● Independence in all self-care from the manual wheelchair ● Independent transfers without a board, including off the floor and over height ● Independent stowing a wheelchair in car ● Independent driving with hand controls ● Wheelie skills, including curbs up and down
C6
● Will still want a high back chair bc you don't have a lot of trunk control ● Considerable ↑ in functional potential due to stability and power of shoulder ms. ● Key muscles for C6 is wrist extensor ● IR with strong subscapularis and teres major, weak latissimus dorsi for scapular depression ● Teres major and lats perform shoulder adduction ● Serratus Anterior for scapular protraction ● Posterior rotator cuff, deltoids and biceps fully innervated ● Can reach across midline and move trunk over a fixed arm for rolling, transfers assuming good ROM and normal body weight ● Potential to reach independent transfers without a board, but mastery requires individual to be highly ● motivated, good pre-morbid fitness, minimal secondary complications and right body proportions ● Will use adaptive equipment for self-care, able to dress with some difficulty and ↑ time ● Also wrist extension for Tenodesis grip for hygiene and eating ● Often may use an attendant care for efficiency ● Manual w/c independence is possible (may use power assist wheels to preserve shoulders) ● Can drive in lift or ramp equipped van with transfer to vehicle seat ● Depending on environment and lifestyle, power mobility may be selected.
C7
● become a lot more independent at this level and can have a more "normal" life. ● Key muscle for C7 is triceps (active elbow extension) ● C7 innervation strengthens ms. that attach to thoracic wall = latissimus dorsi, serratus ant., pec major which ● improves ability to move body over fixed hand with transfers ● Triceps = improves transfers especially low to high ● Seated push-ups for pressure relief, w/c positioning ● Easier to push up from supine to sitting, reaching overhead ● Wrist flexion and active pronation. ● C7 tetraplegia mobility: ○ Independence in all self-care (may require adaptive equipment) from a manual w/c ○ Independent transfers without a board, including off the floor and over height ○ Independent stowing wheelchair into car ○ Independent driving car with hand controls ○ Wheelie skills, including curbs up and down (may be limited to jumping up 4 inch curbs due to ○ lack of grip strength)
