LEVEL OF SPINAL CORD INJURY & FUNCTIONAL LOSS

Sagar Naik, PT

LEVEL OF SPINAL CORD INJURY & FUNCTIONAL LOSS

Sagar Naik,

PT

Sensory testing is performed at the following levels:

C2 - Occipital protuberance C3 - Supraclavicular fossa C4 - Top of the acromioclavicular joint C5 - Lateral side of antecubital fossa C6 - Thumb C7 - Middle finger C8 - Little finger T1 - Medial side of antecubital fossa T2 - Apex of axilla T3 - Third intercostal space (IS) T4 - 4th IS at nipple line T5 - 5th IS (midway between T4 and T6) T6 - 6th IS at the level of the xiphisternum T7 - 7th IS (midway between T6 and T8) T8 - 8th IS (midway between T6 and T10) T9 - 9th IS (midway between T8 and T10) T10 - 10th IS or umbilicus T11 - 11th IS (midway between T10 and T12) T12 - Midpoint of inguinal ligament L1 - Half the distance between T12 and L2 L2 - Mid-anterior thigh L3 - Medial femoral condyle L4 - Medial malleolus L5 - Dorsum of the foot at third metatarsophalangeal joint S1 - Lateral heel S2 - Popliteal fossa in the midline S3 - Ischial tuberosity S4-5 - Perianal area (taken as one level)

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4a

C5 - Elbow flexors (biceps, brachialis) C6 - Wrist extensors (extensor carpi radialis longus and brevis) C7 - Elbow extensors (triceps) C8 - Finger flexors (flexor digitorum profundus) to the middle finger T1 - Small finger abductors (abductor digiti minimi) L2 - Hip flexors (iliopsoas) L3 - Knee extensors (quadriceps) L4 - Ankle dorsiflexors (tibialis anterior) L5 - Long toe extensors (extensors hallucis longus) S1 - Ankle plantar flexors (gastrocnemius, soleus)

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The following key muscles are tested in patients with SCI, and the corresponding level of injury is indicated:

LEVEL OF SPINAL CORD INJURY & FUNCTIONAL LOSS

Sagar Naik, PT

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Skeletal muscles and their major spinal segments

4a

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LEVEL OF SPINAL CORD INJURY & FUNCTIONAL LOSS h Functionality of C1, C2, C3 Quadriplegic Mobility & Movement

Sagar Naik, PT

Respiratory System

Personal Care

- Complete personal assistance is required. The person will need assistance with washing, dressing, and assistance with bowel and bladder management.

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Domestic Care Communication

- Complete domestic care is required, such as household cleaning, washing of clothes and kitchen duties, preparation of meals and general household duties.

- A computer may be operated using iris recognition, mouth stick or voice recognition. Telephone can be used using voice recognition and headset.

4a

- Inability to breathe using chest muscles or diaphragm, therefore the person will be dependant on a ventilator to breathe. A portable ventilator can be attached to the back of a wheelchair during transport. - Oxygen and humidification may be required. - Assistance required to clear secretions from trachea, and assistance in coughing will be required. - Patient may use phrenic nerve stimulator during the day time.

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- Limited head and neck movement depending on muscle strength. - Muscles spared include face and neck muscles and muscles supplied by cranial nerves. - Available movements include talking, mastication, sipping and blowing. - Complete paralysis of arms, body and legs. - Sympathetic nervous system will be compromised, possibility of Autonomic Dysreflexia. - Electric wheelchair may possibly be controlled by either a chin or "sip and puff" controller, this will vary depending on dexterity. - The person will require total assistance when transferring from a bed to a wheelchair and from a wheelchair into a car. A hoist will have to be used, possibly by two assistants for safety. - Complete assistance required during mealtimes.

LEVEL OF SPINAL CORD INJURY & FUNCTIONAL LOSS h Functionality of C4 Spinal Cord Injury Mobility & Movement

Sagar Naik, PT

Respiratory System

Personal Care

- Complete personal assistance is required. The person will need assistance with washing, dressing, and assistance with bowel and bladder management. Domestic Care

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Communication

- Complete domestic care is required, such as household cleaning, washing of clothes and kitchen duties, preparation of meals and general household duties.

- A computer may be operated using iris recognition, mouth stick or voice recognition. Telephone can be used using voice recognition and headset.

4a

- Able to breathe without a ventilator using diaphragm. - Assistance required to clear secretions and assistance in coughing will be required.

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- Full head and neck movement depending on muscle strength. Limited shoulder movement. - Muscles spared include all above + diaphragm and trapezius. - Available movements include above all + respiration and scapular elevation. - Complete paralysis of body and legs. No finger, wrist or elbow flexion or extension. - Sympathetic nervous system will be compromised, possibility of Autonomic Dysreflexia. - Electric wheelchair may be controlled by either a chin or "sip and puff" controller, this will vary depending on dexterity. - The person will require total assistance when transferring from a bed to a wheelchair and from a wheelchair into a car. A hoist will have to be used, possibly by two assistants for safety. - Complete assistance required during mealtimes.

LEVEL OF SPINAL CORD INJURY & FUNCTIONAL LOSS h Functionality of C5 Spinal Cord Injury Mobility & Movement

Sagar Naik, PT

- Able to breathe without a ventilator using diaphragm. Low stamina. - Assistance required to clear secretions and assistance in coughing will be required. Personal Care

- Complete personal assistance is required. The person will need assistance with washing, dressing, and assistance with bowel and bladder management. - Ability to shave and brush hair may be possible with palm straps.

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Domestic Care Communication

- Complete domestic care is required, such as household cleaning, washing of clothes and kitchen duties, preparation of meals and general household duties.

- A computer may be operated using a typing stick or voice recognition. Telephone can be used using voice recognition and headset.

4a

Respiratory System

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- Full head and neck movement with good muscle strength. Good shoulder movement. - Muscles spared are all above + biceps, brachialis, brachioradialis, deltoid, infraspinatus, rhomboids (major & minor) and supinator. - Available movements include above all + elbow flexion and supination, shoulder external rotation, shoulder abduction to 90 and limited shoulder flexion. - Complete paralysis of body and legs. No finger or wrist movement. No elbow extension, good elbow flexion. - Sympathetic nervous system will be compromised, possibility of Autonomic Dysreflexia. - Electric wheelchair can be controlled with a hand control for uneven surfaces. A manual wheelchair may be used for short distances on flat surfaces. - The person will require total assistance when transferring from a bed to a wheelchair and from a wheelchair into a car. A hoist will have to be used, possibly by one to two assistants for safety. - Ability to feed self using feeding strap and fork or spoon during mealtimes. Food will need cutting.

LEVEL OF SPINAL CORD INJURY & FUNCTIONAL LOSS h Functionality of C6 Spinal Cord Injury Mobility & Movement

Sagar Naik, PT

Respiratory System

- Able to breathe without a ventilator using diaphragm. Low stamina. - Assistance required to clear secretions and assistance in coughing may be required. Additional coughing techniques can be applied to assist in coughing by leaning forward whilst exhaling.

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Communication

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Domestic Care

Personal Care

- Personal assistance is required. The person will need assistance with washing, dressing, and assistance with bowel and bladder management. Ability to empty own legbag will depend on dexterity and strength. - Ability to partially dress upper body, however, assistance may be required to dress lower body. - Ability to shave, brush hair and brush teeth is possible with palm straps.

- Complete domestic care is required, such as household cleaning, washing of clothes and kitchen duties. - Ability with adapted equipment to prepare simple meals and simple general household duties.

- A computer may be operated using a typing stick or voice recognition. Telephone can be used using voice recognition and headset.

4a

- Full head and neck movement with good muscle strength. Good shoulder movement. - Muscles spared include all above + extensor carpi radialis, infraspinatus, latissimus dorsi, pectoralis major (clavicular head), pronator teres, serratus anterior and teres minor. - Available movements include all above + shoulder flexion, extension, internal rotation and adduction; scapular abduction and upward rotation; forearm pronation; wrist extension (tenodesis grip). - Complete paralysis of body and legs. No finger movement, no elbow extension, no wrist flexion. Good wrist extension, good elbow flexion. - A passive key grip may be present by flexing the wrist backwards, but will be weak. - Sympathetic nervous system will be compromised, possibility of Autonomic Dysreflexia. - Electric wheelchair can be controlled with a hand control for uneven outdoor surfaces. A manual wheelchair may be used for short distances on flat surfaces. - The person will require total assistance when transferring from floor to chair. Assistance will vary for transfer from bed to wheelchair, and wheelchair to car. A sliding board may be used in assisting with the transfer - Ability to feed self using feeding strap and fork or spoon during mealtimes. Food will need cutting. Able to make hot drinks with adapted kettle using a "kettle tipper".

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LEVEL OF SPINAL CORD INJURY & FUNCTIONAL LOSS h Functionality of C7 - C8 Spinal Cord Injury Mobility & Movement

Sagar Naik, PT

Respiratory System

- Able to breathe without a ventilator using diaphragm. Low stamina. - Assistance required to clear secretions and assistance in coughing may be required. Additional coughing techniques can be applied to assist in coughing by leaning forward whilst exhaling.

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Communication

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Personal Care Domestic Care

- Ability to manage bladder and bowel independently will vary depending on strength and dexterity. - Independent in upper body showering and dressing, lower body dressing and showering may need assistance. - Independent in grooming, usually without palm straps.

- Partial domestic assistance is required, such as heavy household cleaning, home maintenance, and complex preparation of meals. - Ability to prepare simple meals and simple general household duties independently.

- A computer may be operated using a typing stick or voice recognition. Telephone can be used using voice recognition and headset.

4a

- Full head and neck movement with good muscle strength. Good shoulder movement. - Muscles spared include all above + extensor pollicis longus and brevis, extrinsic finger extensors and flexors, extensor carpi radialis, extensor carpi ulnaris, triceps, flexor pollicis longus and brevis. - Available movements include all above + elbow extension, wrist flexion, finger extension. - Complete paralysis of body and legs. Partial finger movement, full elbow extension and flexion, full wrist extension and flexion. - A C7 injured person will have movement in the thumb. - Sympathetic nervous system will be compromised, possibility of Autonomic Dysreflexia. - May use an electric wheelchair for long independent travel or uneven outdoor surfaces. - A manual wheelchair may be used for short distances on flat surfaces. - Ability to transfer independently from bed to chair, and chair to car. Car transfers may need assistance depending on upper body strength. - Ability to drive a car adapted with hand controls. Assistance may be required to load wheelchair into car independently. - Ability to feed self independently during mealtimes. Food may need cutting. Able to make hot drinks, may require an adapted kettle using a "kettle tipper".

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LEVEL OF SPINAL CORD INJURY & FUNCTIONAL LOSS h Functionality of T1 - T4 Paraplegic Mobility & Movement

Sagar Naik, PT

Respiratory System

- Ability to breathe normal, although respiration capacity and endurance may be compromised. Personal Care

- Should be independent in personal care as long as no other factors are involved, ie, additional injuries, severe spasticity etc.

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Domestic Care Communication - Normal communication skills apply.

- Partial domestic assistance is required, such as heavy household cleaning and home maintenance. - Ability to prepare complex meals and general household duties independently.

4a

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- Full head and neck movement with normal muscle strength. Normal shoulder movement. Full use of arms, wrists and fingers. - Complete paralysis of lower body and legs. Upper body strength will vary depending on level of injury, but the lower the level, the stronger the upper body strength and balance. - A T4 injured person will have good strength in the chest muscles; however this will get progressively weaker the higher up the injury. - Sympathetic nervous system may be compromised, possibility of Autonomic Dysreflexia. - May use an electric wheelchair for long distance independent travel or uneven outdoor surfaces. A manual wheelchair may be used for everyday living, with the ability to go over uneven ground for short distances. - Ability to transfer independently from bed to chair, and chair to car. Car transfers may need assistance depending on upper body strength. - Ability to drive a car adapted with hand controls. Assistance may be required to load wheelchair into car. - Ability to feed self independently during mealtimes.

LEVEL OF SPINAL CORD INJURY & FUNCTIONAL LOSS h Functionality of T5 - T9 Spinal Cord Injury Mobility & Movement

Sagar Naik, PT

Respiratory System

- Ability to breathe normal, although respiration capacity and endurance may be compromised. Personal Care

- Should be independent in personal care as long as no other factors are involved, ie, additional injuries, severe spasticity etc. Domestic Care

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Communication - Normal communication skills apply.

- Partial domestic assistance is required, such as heavy household cleaning and home maintenance. - Ability to prepare complex meals and general household duties independently.

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- Full head and neck movement with normal muscle strength. Normal shoulder movement. Full use of arms, wrists and fingers. - Muscles spared include all above + top half of intercostals, long muscles of back (sacrospinalis & semispinalis). - Available movements include all above + improved trunk control, increased respiratory reserve and pectoral girdle stabilized for lifting objects. - Complete paralysis of lower body and legs. Upper body strength will vary depending on level of injury, but the lower the level, the stronger the upper body strength and balance. - A manual wheelchair may be used for everyday living, with the ability to go over uneven ground. - Ability to transfer independently from bed to chair, and chair to car. Car transfers may need assistance depending on upper body strength. - Ability to drive a car adapted with hand controls. Assistance may be required to load wheelchair into car.

LEVEL OF SPINAL CORD INJURY & FUNCTIONAL LOSS h Functionality of T10 - L1 Spinal Cord Injury Mobility & Movement

Sagar Naik, PT

Respiratory System - Normal respiratory system. Personal Care

- Should be independent in personal care as long as no other factors are involved, ie, additional injuries, severe spasticity etc. Domestic Care

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Communication - Normal communication skills apply.

- Partial domestic assistance is required, such as heavy household cleaning and home maintenance. - Ability to prepare complex meals and general household duties independently.

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- Full head and neck movement with normal muscle strength. Normal shoulder movement. Full use of arms, wrists and fingers. - Muscles spared include all above + lower abdominals and all intercostals. - Available movements include all above + improved trunk control and increased endurance. - Partial paralysis of lower body and legs. Upper body strength and balance will vary depending on level of injury, but the lower the level, the stronger the upper body strength and balance. - A manual wheelchair may be used for everyday living, with the ability to go over uneven ground. - Ability to transfer independently from bed to chair, and chair to car. It may be possible to transfer from floor to chair depending on upper body strength. It may also be possible to transfer from sitting position to standing frame independently. - Ability to drive a car adapted with hand controls. Ability to load wheelchair into car independently.

LEVEL OF SPINAL CORD INJURY & FUNCTIONAL LOSS h Functionality of L2 - S5 Spinal Cord Injury Mobility & Movement

Sagar Naik, PT

Respiratory System

- Normal respiratory system. Personal Care

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Domestic Care Communication - Normal communication skills apply.

- Should be independent in personal care as long as no other factors are involved, ie, additional injuries, severe spasticity etc.

- Partial domestic assistance is required, such as heavy household cleaning, home maintenance. - Ability to prepare complex meals and general household duties independently.

4a

- Full head and neck movement with normal muscle strength. Normal shoulder movement. Full use of arms, wrists and fingers. - Muscles spared include all above + gracilis, iliopsoas, quadratus lumborum, rectus femoris, sartorius, extensor digitorum, low back muscles, medial hamstrings (weak), tibialis posterior, quadriceps and tibialis anterior. - Available movements include all above + strong hip flexion, hip abduction; strong knee extension, weak knee flexion, improved trunk control. - Full upper body control and balance. - Some hip, knee and foot movement depending on the level of injury. The lower the injury, the more control over movement. - A manual wheelchair may be used for everyday living, with the ability to go over uneven ground. - Ability to transfer independently from bed to chair, and chair to car. It may be possible to transfer from floor to chair depending on upper body strength. - Depending on the level of injury, walking may be possible with assistance or aids. Walking will be slow and difficult though. - Ability to drive a car adapted with hand controls. Ability to load wheelchair into car independently.

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