Spinal Cord Injury Rehabilitation Functional ... - Shepherd Center

Spinal Cord Injury Rehabilitation 

Functional Expectations and 

Ambulation Potential 

• Diane Johnston, MSPT

Objectives for the course 

• Participants will have a general understanding of the 

epidemiology of Spinal Cord Injury (SCI). 

• Participants will better understand the levels of Spinal 

Cord Injury and their functional implications 

• Participants will have an awareness of the American 

Spinal Injury Association (ASIA) Impairment Scale 

• Participants will have a better understanding of incomplete 

SCI clinical syndromes and their relationship to 

ambulation potential.

Demographics - SCI 

• Incidence: 12,000 cases 

per year 

• Prevalence: 231,000 to 

311,000 

• Mean age 40.2 since 2005 

(28.7 years 1973-1979) 

• Gender: 80.8% male, 

19.2% female 

• Race: 66.2% Caucasian, 

27.0% African American , 

7.9% Hispanic, 2% Asian 

Source: National Spinal Cord Injury Statistical Center, February 2010

Etiology 


Neurological Level 

• Tetraplegia 55.1% 

• Complete 16.9% 

• Incomplete 38.3% 

• Paraplegia 44.4% 

• Complete 22.9% 

• Incomplete 21.5% 

• Less than 1% experience full 

recovery 


Neurological Level By Age 

PC 

PI 

TC 

TI 

16-30 46-60 61-75 76+

Average Yearly Expenses 

2009 dollars 

Severity First Year Each 

Subsequent Yr 

C1-4 $829,843 $148,645 

C5-8 $535,877 $ 60,887 

Para $303,220 $ 30,855 

Motor 

Incomplete 

$244,562 $ 17,139 


Life Expectancy 

Age at injury Para C5-C8 C1-4 Vent 

Dependent 

20 years 45.8 41.0 37.4 23.8 

40 years 28.2 24.2 21.2 11.4 

60 years 13.2 10.4 8.6 3.2 


Estimated Lifetime Costs 

Severity 

C1-4 $3,273,270 

Assuming 25 years old 

at time of injury 

C5-8 $1,850,805 

Para $1,093,669 

Motor Incomplete $729,560 


Number of SCI Patients Served 

• Overall 1,761 SCI persons 

served per year 

• Inpatient: 402 patients 

• Outpatient: 

• Day Program: 319 

• Single Service: 473 

• Beyond Therapy: 30 

• Promotion Wellness: 537 

• UE Clinic: 297 

• Numbers lead to 

expertise! 

Shepherd Data: 04/01/2009-03/31/2010

Then and Now 

• LOS 

• Acute care 

• 1974: 25 days 

• 2010: 15 days 

• Rehab 

• 1974: 115 days 

• 2010: 36 days 

• Average age at injury 

• 1973-1989: 28.7 years 

• 2005-present: 40.2 years 

• Injuries at 60 yo+ 

• 1979: 4.7% 

• 2010: 26.8% 

• Severity of injury 

• ↓in complete injuries (41%) 

• ↑in incomplete injuries (53%) 

• Plasticity of the spinal cord!!!

Functional Expectations

Definition: 

Complete vs/Incomplete Injury 

• Complete Injury: An absence of sensory and motor function in 

the lowest sacral segment.* 

• Incomplete Injury: Partial preservation of sensory and/or motor 

function is found below the neurological level and includes the 

lowest sacral segment. 

• Zone of Partial Preservation: Used only with complete injuries 

and refers to those dermatomes and myotomes caudal to the 

neurological level that remain partially innervated. 

• *Water, R.L., Adkins, R.H., Yakura, J.S.: Definition of Complete spinal cord 

injury. Paraplegia 1991; 9:573-581.

Neurological Categories 

at Discharge 

• Incomplete tetraplegia 30.61% 

• Complete paraplegia 25.3% 

• Complete tetraplegia 20.0% 

• Incomplete paraplegia 18.6% 

• No deficits 0.6% 

• Unknown 3.4% 

National Spinal Cord Injury Statistical Center 2009-2010

C1-3 

• Respiratory: Vent 

• Bowel: 1 

• Bladder : 1 

• Bed Mobility : 1 

• Transfers: 1 

• Pressure Relief: 6 

• Eating: 1 

• Grooming: 1 

• Bathing: 1 

• Wheelchair Prop: 6 

• Communication: 5 

• Transportation: 1 

• Home making: 1

C1-3 Assistance Required 

• 24-hour attendant care 

to include 

homemaking 

• Able to instruct all 

aspects of care

C4 

• Respiratory: No vent 

• Bowel: 1 

• Bladder : 1 

• Bed Mobility : 1 



• Eating: 1 


• Bathing: 1 

• Wheelchair Prop: 6 



• Home making: 1

C4 Assistance Required 

• 24-hour care to include 

homemaking 

• Able to instruct all 

aspects of care

C5 

• Bowel: 1 

• Bladder: 1 

• Bed Mobility: 2-3 

• Transfers 1-2 


• Eating: 5 

• Dressing: 

• Upper body: 4 

• Lower body: 1-2 

• Grooming: 1-3 

• Bathing: 1-3 

• Wheelchair prop: 6 



• Home making 1

C5 Assist Required 

• Person care: 10 hours 

per day 

• Home care: 6 hours per 

day

C6 

• Bowel: 3-5 

• Bladder: 3:6 

• Bed mobility: 3-6 

• Transfers: 3-6 


• Eating: 6 

• Dressing 

• UE 6 

• LE 3-6 



• Wheelchair: 6 

• Communication: 6-7 


• Home making: 

• Light meals:5-6

C6 

• Personal Care: 6 hours 

per day 

• Homecare: 4 hours per 

day

C7-8 

• Bowel: 6 


• Bed mobility: 6-7 


• Pressure relief: 6 

• Eating: 7 

• Dressing: 6-7 



• Wheelchair prop: 

• Manual: 6 

• Power: 6 



• Homemaking: 

• Meal prep: 6 

• Heavy housecleaning: 4-6

Assist Required C7-8 

• Personal Care: 2-4 

hours per day 

• Homecare: 2 hours per 

day

Para (T1-9) Para (T10 and ↓) 

• Bowel: 6 


• Bed Mobility: 6 


• Transfers: 6-7 

• Eating:7 

• Dressing: 7 


• Wheelchair: 6 


• Home making: 6-7 

• All the same 

• Add: 

• Ambulation 

• Bracing 

• Assistive Devices 

• Different levels of 

community ambulation 

• Below L2 generally 

independent at community 

level

Para Assist Required 

• Personal care: 0 hours 

per day 

• Homemaking 0-2 

hours per day

Statistically the percentage of 

incomplete spinal cord injured (SCI) 

persons has continued to increase as 

emergency medical care has improved.

The variability seen 

in neurological 

recovery challenges 

the clinician in 

planning for these 

clients functional 

needs.

5 Most Common Levels of Injury 

• C5: 14.9% 

• C4: 13.6% 

• C6: 10.8% 

• T12: 6.7% 

• C7: 5.3% 

Source: National Spinal Cord Injury Statistical Center

MRI 

• Hemorrhage with median 

length of 10.5 mm 

associated with complete 

spinal cord injury 

• Hemorrhage of less than 4 

mm associated with 

incomplete spinal cord 

injuries with good 

prognosis 

http://bjr.birjournals.org/cgi/content/full 

/76/905/347 

Source: Boldin C, et al. Spine. 2006;31(5):554-559.

ASIA Impairment Scale (AIS) 

AIS Changes Admission No Change Improved Declined 

A 48.0% 86.7% 11.3% 0% 

B 13.1% 46.9% 45.6% 4.5% 

C 14.7% 41.9% 52.7% 3.0% 

D 18.0% 90.1% 4.8% 2.1% 

A= Complete Injury 

B= Incomplete, sensory only 

C= Incomplete, motor (non functional) 

D= Incomplete, motor (functional) 

Source: National Spinal Cord Injury Statistical Center, January 2008

ASIA and Walking Outcomes 

• Attained independent walking by inpatient DC 

• AIS A: 6.4% 

• AIS B: 23.5% 

• AIS C: 51.4% 

• AIS D: 88.6% 

Morganti et al, 2005

Clinical Syndromes 

• Central cord Syndrome 

• Anterior Spinal Artery Syndrome 

• Brown-Sequard Syndrome 

• Posterior Cord Syndrome 

• Cauda Equina Syndrome 

• Conus Medullaris Syndrome 

• Other diagnoses: Multiple sclerosis, 

transverse myelitis, spinal cord tumors, 

Gillian Barre’ Syndrome, peripheral 

neuropathies, and amyotrophic lateral 

sclerosis

Central Cord Syndrome 

• Hyperextension injury 

• Impairment of function 

greater in upper 

extremities than lower 

extremities 

• Majority of incomplete 

lesions result in this 

syndrome. 

• 77% of these clients will 

ambulate. 

Bosch A et al, 1971

Anterior Spinal Artery Syndrome 

• Flexion injury 

• Loss of motor 

functions, pain and 

temperature sensation 

• Prognosis poor for 

ambulation. 

Bosch A et al, 1971

Brown-Sequard Syndrome 

• Caused by penetrating injures 

(gun shot or stabs wounds) 

• Hemi section of the spinal cord 

• Loss of movement and position 

sense on the same side 

• Loss of pain and light touch on 

opposite side 

• Nearly all regain some level of 

ambulation 

• Prognosis for recovery is good 

• 80% regain hand function 

• 80 – 100% gain bowel and 

bladder function 

Bosch A et al, 1971

Posterior Cord Syndrome 

• Very rare 

• Caused by compression from a 

tumor or infarction 

• Motor function is preserved 

• Sensory modalities are lost 

below the level of injury 

• Functional ambulation is 

difficult despite having strong 

muscles 

Bosch A et al, 1971

Cauda Equina Syndrome 

• Injury to the L1 vertebral 

level and below 

• Lower motor neuron 

lesion 

• In most cases it is a 

complete lesion 

• Ambulation is probable 

due to the injury being 

low (quadriceps muscles 

are spared)

Conus Medullaris 

• Injury to the sacral cord 

and lumbar nerve root 

within the neural canal 

• Lower extremity motor 

and sensory loss 

• Areflexic bladder and 

bowel 

• Can usually ambulate

Motor Indicators 

• Lower extremity motor scores (Waters et al, 1994): 

• 20 or less use a wheelchair as their primary mode 

of locomotion 

• 30 or more can become community ambulators 

• Walked at community level by 1 year if (Gittler et al, 

2002): 

• Tetra plegia with LEMS of 20+ 

• Paraplegia with LEMS of 10+ 

• Initial muscle grade of 1/5 (trace) recovered to 

muscle grade of 3/5 (fair) within 3 months of the 

initial injury (Ditunno et al, 1992)

Sensory Indicators 

• Baseline lower extremity pin prick 

preservation and sacral pinprick 

preservation at 4 weeks post injury are 

associated with an improved prognosis 

for ambulation (Oleson et al, 2005) 

• Muscles that initially scored 0/5 (Poynton 

et al, 1997) 

• Dermatomes with spared pin prick, 85% 

regained ≥3/5 strength 

• Dermatomes without spared pin prick, 1.3% 

regained ≥3/5 strength

Age 

• Regaining walking function: 

• If younger than 50 2x more likely 

to walk at discharge (Burns et al, 

1997) 

• Younger subjects more likely to 

regain walking (Scivoletto et al, 

2003)

Active Weight Bearing 

Tilt Table/Standing Frame 

• Combine with E-stim/vibration 

• Angle footplates for tight ankles. 

Incorporate US/STM 

• Adjustable knees, seat and chest 

positions for therapeutic exercise

Pool 

• Shallow (aerobic steps, sitting, 

standing therapeutic exercise, 

walking all directions with device or 

buoy bars) 

• Deep water (inner tubes, foam 

noodles, etc) 

• Lap swim (supine with inflatable 

neck support, ski belt, ankle floats, 

½ flippers to increase 

proprioceptive awareness and 

resistance)

Initiating Gait with Body-Weight 

Support Treadmill Systems 

• Robotic 

• Lokomat® (Hocoma) 

• Autoambulator (Health South) 

• Manual 

• TheraStride, Biodex, etc 

• Lite Gait® (with or without treadmill)

Video With Trainer AFO

Video Scott Craig Orthoses

Para Step Video

Fillauer Stance Control Knee Joint 

www.fillauer.com

Patient Video: Stance Control Brace

Patient Video: Stance Control Brace 

on Stairs

Video with Malleolocs 

Treadmill with Beach Ball 

Balance Board w/ Hoola Hoop

So Much Available to Us 

Think Outside The Box

Questions?

Spinal Cord Injury Rehabilitation Functional ... - Shepherd Center

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