C1-C3

Totally dependent in self-care but can instruct others

in preferences for care. Can chew and swallow.

C4
Totally dependent in self-care but can instruct others
in preferences for care. Can drink from a glass with a
long straw.

C5
*Feeding requires assistance with setup. Equipment
used may include: 
-suspension sling or mobile arm suppot. 
-dorsal wrist splint with universal cuff
-dycem to prevent slippage of plate 
-Scoop dish or plate guard
-Angled utensils
Dressing required minimal to moderate
assistance with upper body dressing. Dependent
with lower body dressing. 
*Bathing requires moderate to minimal assistance. 
*Grooming requires assistance with setup; however,
with splint and universal cuff can be independent with
brushing teeth and combing hair. Independent using
electric shaver that fits around the hand.

C6
*Feeding: Independent using adaptive equipment.
-universal cuff or tenodesis splint
-rocker knife 
-cup with large handles
*Dressing: Independent in lower body dressing
performed while in bed. Requires maximal assistance
with socks and shoes. Independent with upper body
dressing using button hook and zipper pull. 
*Bathing: requires moderate to minimal assistance. 
*Grooming: Independent using tenodesis grasp or
splint.

C7
Feeding: independent
Dressing: Independent, but may need button hook. 
Bathing: Same as C6 but performs depression
transfers. 
grooming: Same as C6.

C8-TI
Self Care: Independent 
Performs depressions transfers. Can transfer form
wheelchair to floor and back to chair with standby
assist.

T6 to L4
Independent in all self-care.

TRUE / FALSE According to the American Spinal

Injury Association (ASIA), the terms paraparesis and
quadriparesis should no longer be used
True: Paraplegia is the term to now use. Also, quadri-
is no longer preferred, rather tetraplegia.

Bob has 5/5 strength in elbow flexors (C5), wrist
extensors (C6), and elbow extensors (C7) bilaterally.
He has 1/5 strength in his right finger flexors and
2+/5 in his left finger flexors (C8). Sensation is intact
on the entire dorsal sides of Bob's hands
(dermatomes C6, C7 & C8). Bob has a complete
absence of sensory and motor function in the lower
sacral segment (S4-5) as determined by absence of
anal sensation and sphincter contraction. Determine
Bob's neurological level
(defined as the lowest level at which key muscles grade
3 or above and sensation is intact for dermatome; also,
level above must have a 5/5 grade and intact
sensation): C7

b. Determine Bob's ASIA Impairment Scale grade
A

c. Does Bob have a zone of partial preservation [only
used in complete (A)] for sensation?
Yes, C8

Autonomic dysreflexia
is a sudden major increase in blood pressure. It is a
very serious condition and needs to be acted upon
immediately (call the nurse or doctor right away!), as it
can be life threatening. Autonomic dysreflexia occurs
when your body is trying to tell you something is
wrong. It is caused by something that is painful or
annoying like a full bladder or bowel, a UTI, an
ingrown toenail, or a pressure sore. The problem is
this: someone with a spinal cord injury cannot
necessarily feel that pain and therefore doesn't know to
relieve it, so the body reacts by raising the blood
pressure."

the signs and symptoms of autonomic dysreflexia
Hypertension, pounding headache, flushed skin above
the level of injury (red face), profuse sweating, goose
bumps, blurry vision, anxiety, difficulty breathing, and
chest tightness

d. What is the VERY FIRST THING THAT YOU DO
AS AN OT in response to autonomic dysreflexia
Stop whatever activity you're doing, sit the patient fully
up, and remove any abdominal binder or ted hose to
help drop the blood pressure

Orthostatic hypotension. Symptoms
light-headed, pallor, faint, fuzzy-headed, visual
changes. Cause: usually due to lack of muscle
contraction in body/limbs, but may have an ANS
component

Autonomic Dysreflexia vs. Orthostateic Hypotension
quick way to remember what to do:
If your face is red, raise your head (Autonomic
Dysreflexia)
If your face is pale, raise your tail (Orthostatic
Hypotension)

Types of sitting
short sitting, long sitting, circle/frog/ring sitting (wide
BOS for balance and easy to reach feet)

o Substitution pattern for elbow extension (for
persons with C5-C6 tetraplegia)
 No triceps yet, so use shoulder adduction and ER to
substitute for triceps (lock elbows out) for
propping/balance

SCI Level C1-C3
Heand and Neck Control
Muscles:
+Sternocleidomastoid
-Upper Trapezius
-Levator Scapulae
-Diaphragm (C3-C5)

SCI Level C4
Shoulder Elevation
+Trapezius (superior, middle, and inferior)

-Levator Scapulae
-Rhomboids
-Rotator Cuff
-Diaphragm (C3-C5)

SCI Level C5
Elbow Flexors
+Diaphragm (C3-C5)
+Levator Scapulae

-Rhomboids
-Rotator Cuff
-Pectoralis Major
-Deltoids
-Biceps Brachii
-Brachialis
-Brachioradialis
-Supinator

SCI Level C6
Wrist Extensors
+Rhomboids
+Deltoids
+Biceps Brachii
+Brachialis
+Supinator

-Serratus anterior (partial but significant innervation)

-Latissimus dorsi
-Pectoralis major
-Rotator Cuff
-Triceps
-Pronator teres
-Extensor carpi radialis longus & brevis

SCI Level C7
Elbow Extensors
+Rotator Cuff
+Pectoralis Major

-Pectoralis Minor
-Latissimus Dorsi
-Triceps Brachii
-Flexor Digitorum Superficialis
-Extensor Digitorum
-Flexor Carpi Radialis
-Extensor Carpi Ulnaris
-Extensor Pollicis Longus & Brevis
-Abductor Pollicus Longus

SCI Level C8
Finger flexors (distal phalanx of middle finger)
+Latissimus Dorsi
+Triceps
+Flexor Digitorum

SCI Level T1-T6
T1: Finger abductors (little finger)
*All of the muscles of the UE are now fully innervated
+Pectoralis Minor (T1)
+Abductor Digiti Minimi (T1)

-Erector Spinae
-External Obliques
-Rectus Abdominus (T5-T12)

Which is better random or massed practice
Random

Which is better knowledge of performacne or
knowledge of results
Knowledge of results

Name some standardized or non-standardized
assessments to consider with SCI patients
Pain
ASIA: Impairment Scale; Light touch and pin prick;
MMT
Braden Scale; for skin integrity
ADL=>FIM, 
QOL: SWLS, COPM
Cognition
Vision

Spinal precautions: 
What is BLT? 
What is BAT?
Bending, lifting, or twisting
Bending, arching, or twisting

What is an important component to start in the acute
phase and should be addressed every day?
UE ROM and Strengthening Program

For a C5 SCI what should you really worry about?
muscle imbalance due to biceps; elbow extension
without triceps

Should you work on depression or scapular
elevation?
Depression!

At what level do you get Tenodesis?
C6-C7

When should pressure relief be completed?
Every 15-30 minutes

Tetraplegia
impairment or loss of motor and/or sensory function
in the cervical segments of the spinal cord; resulting in
impairment of function in the arms, trunk, legs, and
pelvic regions

Paraplegia
impairment or loss of motor and or sensory function in
the thoracic, lumbar or sacral regions

Incomplete injury
partial preservation of sensory and or motor functions
is found below the neurological level and includes the
lowest sacral segment

Complete injury
If there is an absence of sensory and motor function in
the lowest sacral segment

Zone of partial preservation (ZPP)
Dermatomes and myotormes caudal to the
nerurological level that remain partially innervated

What are the 3 criteria for determining the
neurological level using the ASIA?
Motor level, Sensory level, and anal sphincter
control/sensation

When completing the ASIA should you test sensory
or motor first?
Sensory on both sides first, then motor.

Neurological Level
the lowest level at which key muscles grade 3 or above
and sensation is intact for this leve

A= complete
No sensory or motor function is preserved in the sacral
segment s4-S5

B= Incomplete
Sensory but no motor function is preserved below the
neurological level and includes S4-S5

C=Incomplete
Motor function is preserved below the neurological
level, and more than half of the key muscles below the
neurological level have a muscle grade less than 3

D=Incomplete
Motor function preserved below neurological level and
at least half of key muscles have grade greater than or
equal to 3

E=
normal

Brown-Sequard Syndrome
half of the cord damaged causing ipsilateral
proprioceptive and motor loss and contralateral loss of
pain and temperature sensation

Central cord syndrome
incomplete injury most common to the cervical region
in which the center part of the cord is damaged
resulting in weakness in the upper limbs than in the
lower limbs with sacral sparing

Anterior cord syndrome
a lesion with variable motor and sensory loss and
preservation of proprioception

lesion to the sacral cord and lumbar nerve roots
within the spinal canal; commonly resulting in
reflexic bladder, bowel, and lower limbs
Conus Medullaris Syndrome

What are the 10 Key muscles tested to determine SCI
classification
Upper limb 
Elbow flexors C5
Wrist extensors C6
Elbow extensors C7
Finger flexors C8
Finger abductors T1
Lower Limb
Hip flexors L2
Knee extensors L3
Ankle dorsiflexors L4
Long toe extensor L5
Ankle plantarflexors S1

What are the 6 components of a goal
Timeframe: how long
Subject; patient
Functional behavior: will do what
Condition of observation: using what or in what setting
Criterion (safely or with stable vitals)
Measure: with supervision or at what FIM level

What are the primary impairments most likely to be
with persons with SCIs?
Absent or decreased strength/force production
Absent or decreased sensation
Spasticity
Decreased balance
Decreased activity tolerance/endurance
Psychosocial issues (grief, adjustment to new life roles)
Decreased physiological tolerance to activity (vitals)
Body functions: bowel and bladder, sexual functions

Is sitting at EOB an optimal position to work on
bathing, dressing, feed, or grooming?
No, it is rarely used for SCI other than transitioning
between bed and w/c
Why? It takes a great degree of trunk control, a motor
component most person with SCI don't have.

What level is the hip hiker innervated
T12-L1
What is the muscle? Quadratus lumborum

How can you work on lateral weight shifts in a
compensatory sense
Have pt move from sitting down to lateral propping on
elbow

At what level can pts. with SCI potentially live alone
C6

C1, C3 movements____
chew, swallow, talk, blow

C1, C3 techniques/ equipment for self care____
ventilator

Long term goals for self care C1, C3____
Directs other for all applicable care, including pressure
relief, skin, precautions, upper extremity ROM
techniques, equipment maintenance, activity and
equipment s/u proceedures, upper extremity
positioning in bed and w/c

C1, C3 techniques/ equipment for mobility____
-w/c (electronically controlled electric wc can use sip
and puff or head control, appropriate seating system
for positioning and safety)
-pressure relief (electronically controlled recline or tilt
mechanism

C1, C3 communication techniques/ equipment____
-word processing- computer using infrared head
pointer, single or dual action switches, or mouth stick
-telephone-speaker phone, adapted for automatic
dialing

C1, C3 long term goal for communication___
minimal assistance, maximal assistance for mouthstick
with only limited use

C1, C3 recreation equipment/ techniques____
-games- computer/ electronic
-art- mouthstick painting with s/u
-reading-electronic page turner or turn pages with
mouth stick
-invironmental control unit
-vocation- computer with head point, switches, or
mouthstick

C1, C3 long term goals for recreation____
min A with all devices/ techniques

C4 movements patient can do____
respiration, scapular elevation

C4 techniques or equipment for self care____
-feeding- long straw with straw holder

C4 techniques or equipment for mobility___
-w/c- electronically controlled wc using sip and puff,
cin switch, or head control
-pressure relief- electronically controlled wc with
power recline/tilt mechanism

C4 Long term goals for mobility_____
Independent with w/c propulsion inside on hard level
surfaces, independent with supervision outdoors on
hard surfaces, dependent/directs others for assist with
architechtural barriers, independent with power
recline/tilt wc

C4 long term goal for self care____
minimal assistance for drinking, directs others for all
applicable care

C4 fully innervated level and key muscles____
diaphragm and trapezius

C5 last fully innervated level and key muscles____
biceps, brachialis, brachioradialis, supinator,
infraspinatus, deltoid

C5 movements patient can do____
elbow flexion and supination, shoulder external
rotation, shoulder abduction to 80-90, gravity provides
shoulder adduction, pronation, and internal rotation

C5 self care techniques/ equipment for feeding____
mobile arm support or suspension sling, dorsal wrist
splint with ucuff, dycem to stabilize plate, plate guard
or scoop dish, stablized cup or cup holder, long straw
with straw holder, angled spoon or fork,

C5 long term goals _____
a ratchet splint can be used to increase level of
funcitonal independence

C5 long term goals for self care____
minimal assistance for these tasks

C5 Long term goals for dsg
mod assist with UE, max A with LE

C5 grooming/bathing techniques/equipment
wash mits, quad grip hairbrush, makeup for ucuff, LH
sponge

C5 mobility techniques and equipment ____
-w/c-hand controlled power w/c, manual w/c with
projection knobs
-pressure relief- power recline or tilt wc with use of
elbow or head switches

C5 Long term goals for mobility___
independent with propulsion inside on hard level
surfaces, I/S outdoors on hard surfaces, D/ directs
others for assist with architctural barriers

C5 communication techniques and equipment____
-word processing- typing stick placed in dorsal wrist
splint with ucuff
-writing- long writing orthosis
-phone-push button speaker,typing stick to press
buttons
-reading- turn pages manually using book holder and
typing stick in dorsal wrist splint with ucuff

Communication Long term goals____
min A with these tasks required

C6 last fully innervated level and key muscles___
pectoralis major, serratus anterior, lattisimus dorsi,
pronator teres, radial wrist extensors

C6 movements pt can do_____
shoulder flexion, reach outward, shoulder internal
rotation and extension, shoulder adduction, more
respiratory reserve, pronation, wrist extension
(tenodesis grasp)

C6 Feeding techniques or equipment_____
ucuff, rocker knife or sharp paring knife, does not need
long handled straw, may use cup with long handle,
does not need plate guard (mod I)

C6 Grooming techniques or equipment____
tenodesis grasp with adaptive equipment (mod I)

C6 bathing techniques or equipment____
bench, must reach facet (min A)

C6 bowel and bladder care techniques or
equipment____
insert suppositories with ae, adaptive handles, Ind with
toilet transfers, applying condom, self cath, adaptive
clamp for drainage bag (male- min A, female- max A)

C6 dressing techniques or equipment____
Dressing in bed, uses button hook, uses zipper pull,
clothes should be correct size or larger (UE- mod I, LE-
min-max A)

C6 w/c mobility techniques or equipment____
pushes manual wc with friction material or rims or
projection knobs, an electric w/c may be required for
long distances (Independent in propelling on level
surfaces, min A on uneven surfaces)

C6 transfer techniques and equipment____
uses a transfer board and partial depression or swivel
transfer (independent)

C6 bed transfer techniques and equipment____
possible loops at bottom of bed

C6 long term goals for bed transfers____
mod I for rolling supine to long sitting, mod A for
proning, paddling, and positioning

C6 vehicle techniques and equipment____
drive using hand controls with adapted steering wheel
(mod I)

C6 pressure relief goals___
independent side to side

C6 communication techniques____
-word processing- ucuff for tenodesis grasp to hold
typing stick
-writing-uses tenodesis grasp to hold pen or short
writing orthosis
-telephone- uses any phone or phone holder or uses
tenodesis grasp to hold receiver
(mod I with all tasks)

C6 recreation techniques and equipment_____
-can turn on and off radio/ TV
-can play table games with adaptations
-can participate in some w/c sports

C6 vocation techniques and equipment_____
-cannot use hand tools that require strength
-electronic office machines are well suited to these pts
-homemaking can do light cooking and cleaning, needs
a wc accessable kitchen (light work min A, heavy work-
max A)

C7 fully innervated level and key muscles____
tricips, extrinsic finger extensors, flexor carpi radialis

C7 movements patients can do____
elbow extension, active finger extension (tenodesis
grasp), wrist flexion

C7 dsg, bathing, bowel/ bladder techniques and
equipment_____
-button hook only, wc dressing
-same as C6 only is easier

C7 mobility techniques/ equipment_____
manual w/c, uses modified car

C7 long term goals for mobility____
-Independent with propulsion over flat surfaces and
inclines, Ind/S for rough terrain
-Doors: mod I, 
-Independnet with pushups for pressure relief
-min A with padding and positioning
-independent for transfers
-mod I for modified car transfers

C8, T1 key muscles_____
Intrinsics, including thumb, ulnar wrist flexors and
extensors, extrinsic finger and thumb flexors, extrinsic
thumb extensor

C8, T1 movements_____
full UE control, including FMC and grasp

C8, T1 self care, mobility, and communication
tehcniques and equipemtn _____
same as C7, but easier- mod I

T6 key muscles_____
top half of intercostals, long muscles of the back

T6 movements patient can do___
increased endurance due to larger respiratory reserve,
pectoral girdle stablized for heavy lifing

T6 mobility techniques and equipment____
uses full braces and standing aid for physiological
standing only, can ambulate with great difficulty, on
level surfaces (independent)

T6 vocation techniques and equipment____
can work with tools and do fairly heavy lifting and
sedentary position

T12 key muscles____
full innervation of intercostal, abdominal muscle

T12 movements patients can do_____
better endurance, better trunk control

T12 self care and mobility techniques or
equipment_____
-work, sports, and housekeeping
-mobility- uses wc for energy conservation, ambulates
with difficulty using long leg braces and crutches, can
use ride on snow plow, grass cutter, etc, with hand
controls (independent)

L4 key muscles_____
low back muscles, hip flexors, quadriceps

L4 movements patiet can do____
hip flexion, knee extension

L4 mobility techniques and equipment____
uses canes to prevent deforming effects of degenerate
arthritis, w/c might be convenient at home

L4 bowel and bladder info____
control is not voluntary

Ranchos Los Amigos and

interventions
Level I
No response: unresponsive to sounds, sights, touch
and movement.

Level II
Generalized Response: Begin to respond slowly,
inconsistently, delayed, non-specific and non-
purposeful. Responds to stimuli only through
physiological changes, gross body movement, or
vocalization.

Level III
Localized Response: Responds inconsistently and with
delays to specific stimuli and would not be capable of
intelligibly responding to simple commands.
May follow simple command (squeeze my hand, look
at me). May be awake on & off throughout the day.
May begin to recognize familiar people.

Level IV
Confused Agitated: Bizarre, non-purposeful,
incoherent and inappropriate behavior; no short term
recall, atn is short and non-selective; confused and
frightened, overreact, focused on basic needs, difficulty
following directions. Recognize family and friends
sometimes

Level V
Confused Inappropriate, Non-agitated: Random and
fragmented and non-purposeful responses to complex
stimuli. Highly distractible and displays severe
memory impairment, new information is not retained.
Can respond to simple commands. Need step-by-step
instructions for daily events.

Level VI
Confused Appropriate: Gives appropriate context. Has
goal-directed responses and depends on external
guidance for direction. Can carry over relearned tasks
but not new information. 30 minute attention span.
Aware of physical problems but not cognitive.

Level VII
Automatic, Appropriate: Behaves appropriately in
familiar settings and daily routine. Has limited
distractibility and is capable of carrying out an
intelligible conversation despite minimal confusion.
Retains new learning but at lower than normal rates.
Initiates social interaction but judgment still impaired.

Level VIII
Purposeful, Appropriate: Oriented and responds to
environments but abstract reasoning in decreased from
pre-morbid condition; compensates for problems and
people who didn't know them before may not notice
anything wrong with them.

Level I, II, III Interventions
Positioning, ROM, Multi Podus boot. Mobility is
bedside sitting. Co-treat with OT. Reclining w/c.
Sensory stimulation. Monitor responses.

Level IV Interventions
Work near current level of function. Remember pt
lacks capacity for new learning. Behavioral
modification; offer consistency, expect no carry-over
from previous learning, model calm behavior. Keep
environment quiet, less than 3 people at a time. Be
flexible, follow pts lead w/i safety limits. Reassure pt
they are safe. Remind them where they are.

Level IV Family Education
Allow safe mvt, don't force them. Allow for breaks and
change activities. Quiet and calm environment.
Familiar, calming activities. Family pictures in room.
Explain why they're in the hospital, w/c rides or walk
in safe environment.

Level V and VI eval
more precise examination possible; examine functional
abilities in different environments; may use some
standardized tests; begin thinking about DC

Level V and VI intervention
watch for signs of mental and physical fatigue, practice
should be distributed, explicit feedback, may try a
variety of treatment approaches

Family education level V and VI
repeat, help, encourage, short & sweet, make
connections

Level VII and VIII intervention
frequently DC from IP rehab at this point, may be in
day treatment setting, treatment focus on reintegrating
back into the community

Family education level VII and VIII
feel as normal as possible, don't joke, discourage drugs
and alcohol, talk about feelings

Positioning for Level I, II, III
head in midline, UE out of tone as much as possible,
LE: hips and knees slightly flexed, no pressure on ball
of foot to prevent stretch reflex, pillow between legs if
strong adduction, neutral rotation

General Guidelines for Rehab
get family involved from day 1, always assume the pt
can understand you, give the pt time to respond, avoid
sarcasm and use concrete communication

Occupational therapy therapeutic groups

Group Development Stages

1. Orientation
2. Intermediate
3. Conflict
4. Cohesion
5. Maturation
6. Termination

Orientation Stage
members learn what group is about, connect with
members

Intermediate Stage
members develop interpersonal bonds, group norms,
roles

Conflict Stage
members challenge group structure, purpose and
process

Cohesion Stage
involves group members using their energy to be
productive for goals

Termination Stage
dissolution of group due to lack of engagement,
inability to resolve conflicts, goal attainment or task
accomplishment

Types of groups
1. Evaluation Group
2. Thematic Group
3. Topical Group
4. Task Oriented Group
5. Developmental Group
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Evaluation Group
the goal is to enable client and OT to assess clients
skills, assets, and limitations regarding group
interaction. The OT must observe the person in a
setting where the skills can be demonstrated. 

* The group focus is NOT intervention*

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Thematic Group
goal is to assist members in acquiring the knowledge,
skills and or attitudes needed to perform a specific
activity. 

* activities must involve active doing of the

specific task in a real or simulated
environment*
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Topical Group
goal is to discuss specific activities that members are
engaged in outside of group to enable them to engage
in activities in a more effective, need-satisfying
manner. 

* purpose is to DISCUSS activities, task

completion is not the primary focus*
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Task-Oriented Group
goal is to increase clients awareness of their needs,
values, ideas, feelings, and behaviors as they engage in
a group task. To improve intra and inter psychic
functioning by focusing on problems which emerge in
the process of choosing, planning, an implementing a
group activity. 

*activities are selected to help members

examine their behaviors to increase self
understanding*
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Developmental Group
a continuum of groups consisting of:
1. parallel groups
2. project groups
3. egocentric-cooperative groups
4. cooperative groups
5. mature groups
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Parallel group
enables members to perform individual tasks in the
presence of others

Project group
goal is to develop the clients ability to perform a
shared, short term activity with another member in a
comfortable cooperative manner

Egocentric-cooperative group
goal is to enable members to select and implement a
long range activity which requires group interaction to
complete.
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Cooperative group
goal is to enable members to engage in a group activity
which facilitates free expression of ideas and feelings,
and develop a sense of trust, love and belonging

Mature Group
goal i sto enable all members to assume all functional
socio-emotional and task roles within a group
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Directive leadership
takes place when the therapist is responsible for the
planning and structuring of much of what takes place
in the group.
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Facilitative Leadership
occurs when the therapist shares responsibility for the
group and for the group process with the members 

* this style is advised when members skill levels and

engagement are moderate (egocentric cooperative or
cooperative)
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Advisory Leadership
takes place when the therapist functions as a resource
to the members who set the agenda and structure the
groups functioning. 

*this style is assumed when members skills and

engagement are high ( mature groups)
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Moseys Taxonomy of activity groups
provided a standard classification to identify major
types of activity groups. 
(evaluation, thematic, topical, task oriented,
developmental , instrumental)