Spinal Cord Injury

By. Ainun Ma’rufa

Program Studi Fisioterapi

Fakultas Ilmu Kesehatan
Universitas Muhammadiyah Malang
 TOPIK BAHASAN:

1. Anatomi dan fisiologi Spinal Cord

2. Definisi dan Patologi Spinal Cord Injury

3. Pemeriksaan dan Diagnosa Fisioterapi Pada Kasus Spinal Cord Injury

4. Intervensi Fisioterapi Pada Kasus Spinal Cord Injury

5. Evaluasi dan Dokumentasi Fisioterapi Pada Kasus Spinal Cord Injury

ANATOMI AND PHYSIOLOGY

The spinal cord is located inside the spinal column;

extends from the foramen magnum inside the brain to
the first or second lumbar vertebral level.

• Cylindrical structure
• vital link between the brain
and the body
• 40 to 50 cm long and 1 cm to
1.5 cm in diameter

https://nba.uth.tmc.edu/neuroscience/m/s2/chapter03.html
 The Spinal Cord
uniformly organized and is divided
into four regions

Comprised of several segments

Contains motor and sensory nerve

fibers to and from all parts of the body

Innervates a dermatome

A dermatome is an area of skin supplied

by peripheral nerve fibers originating
from a single dorsal root ganglion

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DEFINITION
Spinal Cord Injury (SCI)

Damage of spinal cord or specific nerves

located at the spinal canal’s end.
The actual damage can vary in severity, World Health Organization:
depending with the cause. • 250.000-500.000 new SCI cases/year
• Traumatic SCI is lead compared
to non-traumatic SCI (Canada,
USA and Australia)

flaccid paralysis, limbs, bladder

and anal muscle atrophy

spinalcure.org.au/research/sci-facts/.png
Spinal Cord Injury (SCI) Incidences
7

Canada,
85.000 cases
USA,
243.000-347.000
cases

spinalcure.org.au/research/sci-facts/.png
 TYPE OF SCI
Spinal cord injury can be classified based on causes of injury, extent of
injury, presentation after injury and level of injury.

Classification

• Paraplegia refers to loss of

Presentation after motor power in lower limbs

The Cause Injury Extent Level of Injury
Injury
but the upper limbs are
unaffected.
Spine Level
Traumatic Complete (Cervical, Thoracic, Tetraplegia • Tetraplegia refers to loss of
Lumbar, Sacral)
motor power in lower limbs
and complete or partial loss
Non-traumatic Incomplete Paraplegia
of motor power in upper
limbs.
 TYPE OF SCI
The most standard method of classifying a spinal cord injury is
American Spinal Injury Association's (ASIA)

• Dermatome: These are specific areas on the skin that are selectively
innervated by only one nerve root.
• Myotome: These are specific group of muscles innervated by a single
nerve root. Specific movements are suggestive of these myotomes.
SYMPTOMS AT DIFFERENT LEVEL OF INJURY

Cervical Level Injury

• Can cause weakness of diaphragm and all the body muscles
including arms, trunk and legs causing inability to breath and
complete loss of movement in the body.
• If the injury is complete, loss of normal bowel and bladder
control is seen.
• If the injury is incomplete, partial sensations, partial motor power
and bladder and bowel function may be preserved.
• Spasticity and autonomic dysreflexia are a common feature.
SYMPTOMS AT DIFFERENT LEVEL OF INJURY

Thoracic Level Injuries

• Injuries to the high thoracic spinal cord lead to sensory and
motor impairment in trunk and lower limbs whereas upper limbs
are unaffected.
• Bowel and bladder control is also impaired.

Lumbo-Sacral Level Injuries

• Loss of motor power and sensations, spasticity rarely is seen in
these injuries. Instead of spasticity there is flaccidity of the
muscles which means loss of tone and flabby muscles in the
lower limbs.
ANOTHER SYMPTOMS
INCOMPLETE SCI
• Bowel and bladder, sensation and control may also be present.
• There are some patterns of the sensory, motor, bowel and bladder preservation in incomplete spinal
cord injury

CENTRAL CORD SYNDROME

• Weakness in upper more than lower limbs with sacral sparing and some sensory loss below the level of
the injury.
• It occurs due to damage to the central part of the cord damaging the cervical fibers and sparing the
dorsal, lumbar and sacral fibers.

BROWN-SEQUARD SYNDROME
• Loss of sensation with flaccid paralysis in the ipsilateral side of the injury.
• All the superficial and deep sensations except for pain and touch are impaired on the ipsilateral side.
• Pain and touch are impaired on the contralateral side.
ANOTHER SYMPTOMS
ANTERIOR CORD SYNDROME
• Due to the damage to the anterior part of the spinal cord
• Motor power is impaired below the level of lesion and superficial sensations like pin prick may be
impaired but deep sensations like proprioception and deep pressure may be preserved.

CAUDA EQUINA SYNDROME AND CONUS MEDULLARIS SYNDROME

SCI ASSESSMENT
Observation before examination:
1.Bony prominences and vulnerable area of skin.
2.Scar tissue.
3.Pressure sores.
4.Secondary bad postures because of pressure sores.
5.Any external appliances like urinary catheters

Sensory Examination:
ASIA classification only the superficial touch and pin
prick tests are used on the dermatomal map of the body.
SCI ASSESSMENT
Motor Examination
1. Tone assessment

Intrinsic tonic spasticity evaluation

• Technique: Move the joints through 1 or 2 quick
movements through the whole range of motion.
• Scale: Modified Ashworth Scale
Intrinsic phasic spasticity assessment
• Technique: With a knee hammer gently tap on the tendon and observe the joint movement.
• Interpretation:
a. Absent: No response
b. Diminished: A slight but definitely present movement
c. Normal: Movement through partial range of motion
d. Brisk: Movement through the same range as that of normal reflex but with higher speed
e. Exaggerated: Increased speed and range of movement with a sudden explosive movement after the tap
SCI ASSESSMENT
Motor Examination
2. Strength assessment

• Technique: The muscle strength is assessed using

manual muscle testing observing the range of the
movement and if it is performed in gravity assisted
or eliminated plane.
• Scale: MMT
• Although the manual muscle testing is used for the
muscles the muscles are tested in the myotomal
pattern to identify the muscle weakness
3. Range of Motion assessment

• In case of restricted AROM and restricted PROM pay

attention to the endfeel. Springy endfeel is suggestive muscle
tightness or contractures,
SCI ASSESSMENT
Motor Examination
4. Balance Assessment 5. Respiratory Assessment

• Start with assessment of postural alignment and • Chest expansion

identify the factors that may affect the balance. Maximum inspiratory volume
• Once the postural alignment has been assessed ask • Forced exhalation
the patient to maintain a posture for 30 seconds in • Coughing ability
sitting and standing, for assessing static balance. • Range of motion of rib joints
• perform various movements of trunk and arm to • Range of motion of shoulder joints
assess the dynamic balance
• Identify limiting factor, such as poor strength, poor
ROM and poor proprioception.
SCI ASSESSMENT
Occupational Therapy Assessment
1. Assessment of ADL
• Modified Barthel Index is used to measure the level of functional independence. The areas focused
are personal hygiene, bathing, feeding, toilet use, stairs, dressing, bowel, bladder mobility, transfers,
• Spinal Cord Injury Independence Measure (SCIM): this tool is used to assess traumatic,
nontraumatic, acute, chronic SCI patients.
• Canadian Occupational Performance Measure (COPM): this tool assesses an individual's
perceived occupational performance and identification of problem areas in self-care, productivity and
leisure activities.
• Quality of Life (QOL): The QOL tool is to used to assess the quality of life (QOL) within the
context of an individual's culture, values, systems, personal goals, standards and concerns. It
addresses the 4 QOL domains like physical health, psychological health, social relationships, and
environment.
SCI ASSESSMENT
Occupational Therapy Assessment
2. Environmental Assessment for evaluation of home work and work place 6. Hand Function

• Home: it is important for safety factors, accessibility, architectural includes measurement of

barriers and restrictions that affect the participation of an SCI motion, sensation and
individual. function of the hand
3. Worksite Evaluation functions using standardized
• Assess job demands assessment tools
• Assess ergonomic consideration
• Assess the worker’s physical and psychological difficulties
4. Wheelchair Evaluation
5. The need of splint and assistive device
List of Instrumental Assessment
1. Neurological Impairment and Autonomic Dysfunction
• American Spinal Injury Association Impairment Scale (AIS): International Standards for
Neurological Classification of Spinal Cord Injury
2. Spasticity
• Ashworth and Modified Ashworth Scale (MAS)
• Penn Spasm Frequency Scale (PSFS)
3. Pain
• Classification System for Chronic Pain in SCI
• Brief Pain Inventory (BPI)
4. Lower Limb & Walking
• 6-Minute Walk Test (6MWT)
• 10 Meter Walking Test (10 MWT)
• Berg Balance Scale (BBS)
• Timed Up and Go Test (TUG)
• Walking Index for Spinal Cord Injury (WISCI) and WISCI II
List of Instrumental Assessment
5. Upper Limb
• Hand-Held Myometer
• Jebsen Hand Function Test (JHFT)
6. Self Care & Daily Living
• Lawton Instrumental Activities of Daily Living scale(IADL)
• Spinal Cord Independence Measure (SCIM)
• Quadriplegia Index of Function Modified (QIF-Modified)
7. Quality of Life and Health Status
• Short Form 36 (SF-36)
8. Skin Health
• Spinal Cord Injury Pressure Ulcer Scale (SCIPUS) Measure
COMPLICATION OF SCI

• Complications may require re-hospitalization and • Autonomic Dysreflexia

are most often the cause of morbidity and death. • Pulmonary Embolism
• They significantly hamper the quality of life and • Deep Vein Thrombosis
functional abilities and independence of the • Postural Hypotension
patients. • Edema
• Prevention, early identification and immediate • Pain
treatment of these complications is important for • Abnormalities of temperature regulation
improving quality of life and lifespan of the spinal • Contractures
cord injury patients. • Osteoporosis
PRINCIPLE MANAGEMENT OF ACUTE SCI

• Post operative physiotherapy starts immediately after • Respiratory care,

the surgery and is continued during the convalescent • Prevention of indirect impairments and
complications
period.
• Range-of-motion (rom) exercises and
• Respiratory management plays a very important role
initiating active exercises in available
to prevent post operative complications.
musculature
• Restorative physiotherapy starts immediately after the
• Normalization of tone
patient is stabilized. • Early strength training
• Goals during this phase should focus on prevention of • Gaining upright tolerance,
secondary complications and preparing the client for • Out-of-bed activities

full rehabilitation participation. • Sensory reeducation,

• Skin-management education
THE EDUCATION AGAINTS SCI PATIENT
For Sensory Issue
Modalities for sensory reeducation Things need to avoid:
include the following: • Handle sharp object
• Blunt end of pencil • Hot temperature
• Dowels of different textures • Gripping for long duration
• Different fabrics
The principle:
• Objects of different rough/
• Safety first
smooth edges
• Increase awareness of deficit
• Games
• Minimize risk of tissue damage
• Performing adlswith vision
occluded
MANY THANKS!