CHAPTER 20 Traumatic Spinal Cord Injury 921

Table 20.5 Functional Expectations for Patients With Spinal Cord Injury*
Motor Level and Available Equipment and Assistance
Key Muscles Movements Functional Capabilities Required
C1, C2, C3, C4
Face and neck
muscles, cranial
nerve innervation,
diaphragm (partial
innervation at C3
and C4)
C5
Biceps
Brachialis
Brachioradialis
Deltoid
Infraspinatus
Rhomboid (major
and minor)
Supinator
Dependent
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
Independent with power
wheelchair
Typical components include adap-
tive controls such as head, chin,
tongue, or sip-and-pu control
Electronically controlled seating sys-
tem (tilt and/or recline)
Wheelchair cushion and head/trunk
support
Portable ventilator (depending on
innervation of diaphragm)
Dependent with positioning in
wheelchair
Dependent
Adjustable bed with pressure reduc-
ing mattress
Directs care provided by attendants
Dependent, attendants use me-
chanical lift
Directs care provided by attendants
Unable
Unable
Some assistance and/or setup
required depending on the
activity
Mobile arm supports, deltoid aid
Adapted utensils and splinting
Adapted equipment (wash mitt,
adapted toothbrush, and so forth)
Dependent
Adapted computer keyboard
Hand splints
Adapted typing sticks
ECU
Part-time attendant required, directs
care provided by attendants
Dependent, directs care provided by
attendants
Talking
Mastication
Sipping
Blowing
Scapular elevation
Elbow exion and
supination
Shoulder external
rotation
Shoulder abduction
and exion to ~90
Activities of daily living (ADL)
Dependence in basic ADL
(BADL)
Activation of computer, light
switches, page turners, call
buttons, electrical appliances,
and speaker phones
Bowel and bladder
Wheelchair mobility and
pressure relief in wheelchair
Bed mobility
Transfers
Ambulation
Driving
ADL
Feeding
Grooming, washing face, and
oral hygiene
Bathing and dressing (depen-
dent)
Activation of computer, light
switches, page turners, call
buttons, electrical appliances,
and speaker phones
Bowel and bladder
Continued
922 SECTION II Intervention Strategies for Rehabilitation
Table 20.5 Functional Expectations for Patients With Spinal Cord Injurycontd
Motor Level and Available Equipment and Assistance
Key Muscles Movements Functional Capabilities Required
C6
Extensor carpi
radialis
Infraspinatus
Latissimus dorsi
Pectoralis major
(clavicular portion)
Pronator teres
Serratus anterior
Teres minor
Independent to some assist with
manual wheelchair on level surfaces
Requires plastic-coated hand
rims/extensions
Benet from power-assist wheel-
chair
Independent with power wheelchair
using handheld joystick
An electronically controlled seating
system (tilt and/or recline)
Wheelchair cushion and trunk sup-
port, dependent with positioning in
wheelchair
Assistance to dependent
Adjustable bed with pressure reduc-
ing mattress
Bed rails and loops
Directs care provided by attendants
Dependent, attendants use me-
chanical lift
Directs care provided by attendants
May be able to perform with assis-
tance and transfer board
Unable
Independent with van with adaptive
controls
Assistance to independent with
setup and/or equipment
Universal cu, adaptive utensils
Adaptive equipment, universal cu
Upper body: independent with
adaptive equipment
Lower body: assistance with adap-
tive equipment
Assistance with adaptive equipment
Assistance, may be independent
with certain tasks with adaptive
equipment (e.g., light meal prep)
Part-time attendant required
May be able to be independent with
adaptive equipment, likely to require
assistance/dependent
Independent with manual wheel-
chair on level surfaces
May require power wheelchair in
community
Requires plastic coated hand rims/
extensions
Benet from power-assist wheelchair
Independent with pressure relief in
wheelchair
Shoulder exion, ex-
tension, internal rota-
tion, and adduction
Scapular abduction,
protraction, and
upward rotation
Forearm pronation
Wrist extension
(tenodesis grasp)
Wheelchair mobility and
pressure relief in wheelchair
Bed mobility
Transfers
Ambulation
Driving
ADL
Feeding
Grooming, washing face, and
oral hygiene
Dressing
Bathing
Home management
Bowel and bladder care
Wheelchair mobility and
pressure relief in wheelchair
CHAPTER 20 Traumatic Spinal Cord Injury 923
Table 20.5 Functional Expectations for Patients With Spinal Cord Injurycontd
Motor Level and Available Equipment and Assistance
Key Muscles Movements Functional Capabilities Required
C7
Extensor pollicus
longus and brevis
Extrinsic nger
extensors
Flexor carpi
radialis
Triceps
C8
Extrinsic nger exors
Flexor carpi ulnaris
Flexor pollicis longus
and brevis
Intrinsic nger exor
Independent to some assistance
with adaptive equipment (e.g., bed
rails, loops, and so forth)
Independent to some assistance
with transfer board
Assistance with uneven transfers
Unable
Independent with car/van with
adaptive controls
Independent
Independent with most ADL with
adaptive equipment (e.g. shower
chair, hand rails, button hook,
adaptive utensils) and wheelchair-
accessible environment
Likely to require assistance with
heavy household tasks
Independent with adaptive
equipment
Independent with manual wheel-
chair in home and community with
plastic-coated hand rims
May need some assist with ramps,
curbs, and uneven terrain
May benet from power assist
Independent with pressure relief
Independent, may require adap-
tive equipment (i.e., bed rails, leg
loops)
Independent, may require assistance
between uneven surfaces
Unable
Independent with car with adaptive
controls
Independent
Independent in all ADL, may require
adaptive equipment (e.g., shower
chair, hand rails, reacher, adaptive
utensils) for some tasks and wheel-
chair-accessible environment
Better able to perform with less
need for adaptive equipment due to
improved hand function compared
to higher cervical level injuries
Independent with adaptive
equipment
Elbow extension
Wrist exion
Finger extension
Finger exion
Bed mobility
Transfers
Ambulation
Driving
ADL
Feeding
Grooming, washing face, and
oral hygiene
Dressing
Bathing
Home management
Bowel and bladder care
Wheelchair mobility and
pressure relief in wheelchair
Bed mobility
Transfers
Ambulation
Driving
ADL
Feeding
Grooming, washing face, and
oral hygiene
Dressing
Bathing
Home management
Bowel and bladder care
Continued
924 SECTION II Intervention Strategies for Rehabilitation
Table 20.5 Functional Expectations for Patients With Spinal Cord Injurycontd
Motor Level and Available Equipment and Assistance
Key Muscles Movements Functional Capabilities Required
T1 to T12
Intercostals
Long muscles of
back (sacrospinalis
and semispinalis)
Abdominal
musculature
(~T7 and below)
Independent with manual wheel-
chair in home and community
Better able to propel on ramps,
curbs, and uneven terrain due to im-
proved hand function compared to
higher cervical level injuries
May benet from power assist
Independent with pressure relief
Independent, may require adaptive
equipment (i.e., bed rails, leg loops)
Independent, may require assistance
between uneven surfaces
May be able to transfer from oor
into wheelchair
Unable
Independent with car with adaptive
controls
Independent
Independent in all areas
Generally tasks become easier and
require less adaptive equipment
to perform with improved trunk
control with more caudal SCI
Independent with adaptive
equipment
Independent with manual wheel-
chair in home and community
Independent on ramps, curbs, and
uneven terrain
Independent with pressure relief
Wheelchair mobility becomes easier
and more ecient with improved
trunk control with more caudal SCI
Bed mobility skills become easier
and more ecient with improved
trunk control with more caudal SCI
Independent
Able to transfer from oor into
wheelchair
Transfers become easier and more
ecient with improved trunk con-
trol with more caudal SCI
Independent with physiological
standing and ambulation for exer-
cise over short distance in the home
Assistive devices (e.g., forearm
crutches)
Orthoses: hip-knee-ankle-foot-ortho-
sis (HKAFO), knee-ankle-foot orthosis
(KAFO)
Improved trunk
control with more
caudal SCI
Increased respiratory
reserve
Pectoral girdle stabi-
lized for lifting objects
Wheelchair mobility and
pressure relief in wheelchair
Bed mobility
Transfers
Ambulation
Driving
ADL
Bowel and bladder care
Wheelchair mobility and
pressure relief in wheelchair
Bed mobility
Transfers
Ambulation
CHAPTER 20 Traumatic Spinal Cord Injury 925
Table 20.5 Functional Expectations for Patients With Spinal Cord Injurycontd
Motor Level and Available Equipment and Assistance
Key Muscles Movements Functional Capabilities Required
L1, L2, L3
Gracilis
Iliopsoas
Quadratus lumborum
Rectus femoris
Sartorius
L4, L5, SI
Quadriceps (L4)
Anterior tibialis (L5)
Hamstrings (L5S1)
Gastrocnemius (S1)
Gluteus medius
and maximus (L5S1)
Extensor digitorum,
posterior tibialis,
peroneals, exor
digitorum (L5, S1)
*This table presents general functional expectations at various lesion levels. Each progressively lower motor includes the
muscles from the previous levels. Although the key muscles listed frequently receive innervation from several spinal
levels, they are listed here at the key neurological levels where they add to functional outcomes. Although intact
musculature plays a main role in determining functional capability, many other factors inuence function, including
concomitant injuries, premorbid health status, age, body type, and psychosocial factors. Individuals with an incomplete
injury will likely have greater functional abilities.
Independent with car with adaptive
controls
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)
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
Hip exion
Hip adduction
Knee extension
Strong hip exion
Strong knee extension
Knee exion
Ankle dorsiexion
Ankle plantarexion
Ankle eversion
Toe extension
Driving
Ambulation
Ambulation
rehabilitation team, and patient can use these expected
outcomes to establish goals and outcomes. However, as
mentioned above, factors other than motor level may
aect functional recovery.
Goals should reect what is important and meaning-
ful to the patient. Tis will increase motivation, promote
achievement of goals, and enhance patient autonomy.
Early after injury patients are not likely to fully under-
stand the consequences of a SCI and are still in the
process of adjusting to the injury. It is important to
educate patients on the impact of SCI and review the
ndings of the initial examination and all reexamina-
tions. Potential functional goals should be discussed and
the patient encouraged to suggest his or her own goals
as well. Long-term goals should focus on activity and
social participation, not body structure and function im-
pairments. Goals should be specic in what the patient
will achieve. Te level of assistance, the environment/
conditions, and the length of time to achieve the goal
should all be documented.
Examples of general goals and outcomes for patients
with SCI (Practice Pattern 5H) as adapted from the
Guide to Physical Terapist Practice
207
are presented in
Box 20.5.
For patients with high cervical SCI who may not be
able to physically perform certain functional mobility
tasks, goals should be directed toward the patient being
able to independently direct an attendant caregiver to
perform the task appropriately.
Recovery of Walking Ability
Recovery of walking ability is one of the most common
goals expressed by people with SCI.
208
Individuals with
complete (ASIA A) UMN injuries are not likely to re-
gain the functional LE strength required to become in-
dependent ambulators.
209
In patients with iSCI (ASIA
B, C, and D) the prognosis for recovery of walking abil-
ity is more complex. For individuals with ASIA B (sen-
sory incomplete) the preservation of pinprick sensation
is an important prognostic indicator of the recovery of