A PROJECT

Entitled

“REHABILITATION IN PARAPLEGIA”

Submitted To

The Department Of Physiotherapy

I.T.S PARAMEDICAL COLLEGE

Affiliated To

CHAUDHARY CHARAN SINGH UNIVERSITY, MERRUT

In The Partial Fulfillment of Degree Of

BACHELOR OF PHYSIOTHERAPY

Guide Submitted By Dr Shubhra Narang Vishakha puri

March 2010

CERTIFICATE

This is to certify that the project work entitled “REHABILITATION IN PARAPLEGIA” by VISHAKHA PURI BPT 2006-2010 Batch , Enroll No._____________has been completed in the partial fulfillment for the degree of Bachelor of Physiotherapy from C.C.S. University, Meerut, U.P., India. I recommend him/her for the award of BPT Degree.

DR.C.S.RAM

DIRECTOR

DEPT. OF PHYSIOTHERAPY

I.T.S PARAMEDICAL COLLEGE

CERTIFICATE

This is to certify that the project work entitled “REHABILITATION IN PARAPLEGIA” is conducted by VISHAKHA PURI in the partial fulfillment for the degree of Bachelor of Physiotherapy under my guidance and supervision .

GUIDE

Dr SHUBHRA NARANG

MPT NEUROLOGY

(i)

CERTIFICATE OF ORIGINALITY

I hereby declare that the project work entitled “REHABILITATION IN PARAPLEGIA ”

embodies the original work by me . This work in part or full has not been submitted to any

other university for award of degree. I shall not publish the contents of this project in part

or full without the written consent of my guide and college.

VISHAKHA PURI

B.P.T 2006-2010 Batch

Enroll. No. ________

(ii)

ACKNOWLEDGEMENT

I would like to express my sincerest gratitude to the following individuals without whom this study would have been unattainable.

I offer my sincerest gratitude to Dr. Shubhra Narang (M.P.T) whose guidance constructive concel , unmatchable suggestions and unstinted encouragement enlightened me throughout the project.

I express my heartiest gratitude to Dr. C.S. Ram , H.O.D , Department Of Physiotherapy , I.T.S Paramedical college for kindly permitting us to pursue research work.

I am thankful to Dr. M Thangaraj , Dr. Stuti Sehgal , Dr. Tanu Shrivastava , Dr. Kanika Govil , Dr. Ekta for their constant inspiration and support in pursuing the study .

I would like to thank my colleagues Ashish gautam , Pooja sinha , Priyenka tyagi and Yukti sharma for their co-operation in my project .

Remarkable co-operation and dedication by the subjects laid milestone for the success of project completion.

And finally thanks to all those who have contributed directly and indirectly towards this study.

VISHAKHA PURI

(iii)

DEDICATED

TO

MY PARENTS

AND

ALL MY FACULTY

(iv)

TABLE OF CONTENTS

Certificate ( Guide) iCertificate Of Originality ii

Acknowledgement iii

Dedication iv

List of figures v-vi

List of Tables vii

1) INTRODUCTION

Anatomy – The basis of injury classification

Epidemiology

Mechanism of injury

Designation of lesion level

2) TYPES OF LESIONS IN SPINAL CORD

Complete injury

Incomplete injury a) Central cord syndrome b) Anterior cord syndrome c) Brown sequard syndrome d) Posterior cord syndrome e) Cauda equine syndrome f ) Sacral sparing

Stages after spinal cord injury a) Stage of spinal shock b) Stage of reflex activity c) Stage of reflex failure

3) CLINICAL MANIFESTATIONS

Direct Impairments a) Autonomic dysreflexia b) Impaired temperature regulation c) Orthostatic hypotension d) Bladder dysfunction e) Bowel dysfunction

Indirect impairments a) Pressure sores b) Deep venous thrombosis c) Contractures d) Heterotopic ossification e) Pain

4) HOSPITAL MANAGEMENT

Prehospital management

Immediate management of patient with spinal cord injury a) transfer from the site of emergency b) assessment of ABCDE c) neurological status examination d) skin inspection e) temperature examination f) bladder function

Investigations

Fracture stabilization

Pharmacological management

5) REHABILITATIVE MANAGEMENT

Acute phase rehabiltation

Active phase rehabilitation

Transition phase of rehabilitation

( 6 ) BIBLIOGRAPHY

(7 ) APPENDICES

Appendix A

Appendix B

Appendix C

Appendix D

LIST OF FIGURES

Figure 1) : Etiology of spinal cord injury

Figure 2) : Types of thoracolumbar fractures

Figure 3) : Central cord syndrome

Figure 4) : Anterior cord syndrome

Figure 5) : Brown sequard syndrome

Figure 6) : Cauda equine syndrome

Figure 7) : Stage of spinal shock

Figure 8) : Autonomic dysreflexia

Figure 9) : Pressure sore

Figure10) : Deep venous thrombosis

Figure11) : Heterotopic ossification

(a) Hip

(b) Knee

Figure12) : Harrington rod

Figure13) : Jewett brace

Figure14) : Phenol peripheral nerve block

Figure15) : Negative pressure vacuum technique

Figure 16) : Elastic support stockings

Figure 17) : Tilt table

Figure 18) : Rolling

Figure 19) : Supine to long sitting position

Figure 20) : Prone on elbow position

Figure21) : Prone on hand position

Figure22) : Quadruped position

Figure23) : Kneeling position

(v)

Figure24) : Push up weight shift

Figure25) : Bed to wheelchair transfer

Figure26) : Wheelchair to bed transfer

Figure27) : Wheelchair to car transfer

Figure28) : Car to wheelchair transfer

Figure29) : Wheelchair to toilet transfer

Figure30) : Toilet to wheelchair transfer

Figure 31) : Wheelchair to bath seat transfer

Figure 32) : Bathseat to wheelchair transfer

Figure 33 ) : Oswestry standing frame

Figure34) : Orthosis prescribed in case of paraplegics

a) Knee ankle foot orthosis

b) Scott craig orthosis

Figure35) : Standing from wheelchair with crutches

a) Forward technique

b) Sideway technique

c) Backward technique

Figure 36) : Crutch balancing

Figure 37) : Ambulation activities with crutches

a) Swing to gait

b) Swing through gait

c) Four point gait

Figure38) : Partial body weight support treadmill

Figure39) : Functional electrical stimulation

(vi)

LIST OF TABLES

Table 1 : Etiology

Table 2 : Mechanism of injury

Table 3 : Pharmacological management of spasticity

Table 4 : Pharmacological management of pain

Table 5 : Correlation of complete injury levels and orthosis prescription

ABBREVIATIONS USED

LMN - Lower motor neuron UMN - Upper motor neuron SCI - Spinal cord injury DVT - Deep vein thrombosis PaO2 - Partial pressure of oxygen BP - Blood pressure CT Scan-Computed tomographic scan MRI - Magnetic resonance imaging IM - Intramuscularly IV - Intravenously TENS - Transcutaneous electrical nerve stimulation KAFO - Knee ankle foot orthosis RGO - Reciprocal gait orthosis AFO - Ankle foot orthosis FES - Functional electrical stimulation Ft - Feet # - Fracture N - Normal I - Intact PT - Performance timeRep - Repetitions Sec - Seconds H - Hold Res - Resistance

(vii)

CHAPTER 1

INTRODUCTION

( SIMILARLY FOR OTHER CHAPTERS)

Spinal cord injury is a central neurological disorder1 . It occurs due to damage to neurological

components in spinal cord occurring as a result of primary or secondary effects of disease or trauma 2. Spinal cord injury is a low incidence , high cost disability requiring tremendous changes in an individuals

life style3 . Normal events of life driving a car, diving into lake or walking down stairs can suddenly

results in life changing injury with physical and lifestyle constraints that totally refigure the realities of

daily life .

SPINAL CORD INJURY ANATOMY – THE BASIS OF INJURY CLASSIFICATION

The term spinal column refers to the vertebral column bones and disc that collectively

encases and protects the soft tissue of the spinal cord .The spinal cord is made up of nerve tracts

carrying signal back and forth between the brain and rest of the body4 .

Rta Falls Violence Sports Others0

10

20

30

40

50

60

Etiology of SCI

On /before 1980

Since 2000

Cause

Perc

enta

ge o

f SC

I

Figure 1: Incidence of spinal cord injury

(2)

ETIOLOGY10

Trauma Road traffic accident , Gun shot wounds.

Non traumatic factors

Tumours

Meningioma , astrocytoma , metastatic

tumour in spinal cord

Ischaemia Arteriosclerosis , dissecting aortic aneurysms

Developmental disorders Spina bifida , meningomyelocele

Neurodegenerative disease Friedreich's ataxia , spinocerebellar ataxia,

Transverse myelities Resulting from stroke or inflammation.

Vascular Malformation Arteriovenous malformation , dural

arteriovenous fistula , spinal

hemangioma , cavernous angioma and aneurysm.

Demyelinating disease Multiple sclerosis

Table 1 : Etiology of spinal cord injury

(3)

(5)

Figure 2 : Thoracolumbar fractures

END OF CHAPTERS

BIBLIOGRAPHY

Books Referred

1. Susan B O’ Sullivan , Thomas J Schmitz : Physical Rehabilitation and Assessment and

Treatment (Fifthedition) : chapter 23 : Traumatic spinal cord injury : page 932-9

2. Cameron Monroe : Physical rehabilitation : chapter 20 : Non progressive spinal cord disorders : page

539-573

3. Ida Bromley : Tetraplegia and Paraplegia (fourth edition) : chapter 10-12 : Mat work , wheelchair

and wheelchair management , transfers : page 95 – 115.

4. Tidy`s Physiotherapy, Twelfth edition , Ann Thompson , Alison Skinner , JoanPrierly : chapter 7 : 229-

243

5. Darcy. A. Umphred : Neurological Rehabilitation : Fourth Edition :Chapter 16 : Page 477-

530.

6. Louis Solemom , Davi J. Warwick Silva Durai Nayagam : Apley`s System of orthopaedics and fractures

: The spine : page 1130-1135

7. Lorriane William Pedretti : Occupation Therapy Practice skills for physical Dysfunction 4 th edition :

Chapter 6 : 224-245

8. Kloth, Le and Feeder : Rehabilitaton in Occupational Physical Therapy : Page 334-356

9. Ebnezer : Essentials of Orthopaedics and applied Physiotherapy: Chapter 23 : page 143-147

10. Carolyn Kisner , LynnAllencolby : Theraputic exercises Foundation and techniques : section 2 : page

140 -174

11. McKinnis, LN: Fundamentals of orthopedic radiology : Chapter 12 : Spinal cord Fractures : Page

(1231-1268).

12. Daniel`s L ,Worthingham C , Muscle Testing : Techniques of Manual Examination, 5 th edition :

Chapter 3 : Page 35-60

13. Norkin`s CC, White DJ: Measurement of Joint Motion : A Guide to Goniometry : Chapter 4 : page

164-176

14. Morison, M.J. (Ed) . The Prevention and Treatment of Pressure Ulcers. St. Louis : Mosby, 2001

Chapter 31:The Prevention and Management of Pressure Ulcer : Page : page 636-647.

15. Arthur C. Guyton, John E. Hall : Textbook of Medical Physiology: Chapter 54 : Motor Functions Of

The Spinal Cord :The Cord Reflexes: Page 622-632.

16. Kenneth W. Lindsay, Ian Bone : Neurology and Neurosurgery Illustrated : 3 rd edition : Chapter 22 :

Spinal cord and Root compression. Page : 377-390.

17. Kissner Carolyn, Lynn Allen Colby : Theraputic Exercises Foundation and Techniques : Chapter 14,

Chapter 15 :The Spine : Subacute , Chronic and Postural Problems : Page 531-576.

Journals Referred:

1. Houte SV, Vanlandewijck Y (2006) Respiratory muscle training in persons in persons with

spinal cord injury : A systematic review: Respiratory medicine : 100 , (1886-1895).

2. Waters RL , Adkins Rh (1991) Definition of Weurmser LA (2007) Spinal cord injury medicine :

Epidemiology and classifications : Arch Phys Medical Rehabilitation : 88, (S49-S54).

3. Nobunga AI, Go BK : Recent Demographics and injury trend sin people served by model spinal cord

injury care system : Arch Physical Medicine Rehabilitation : 80,1372-1382.

4. Andrew Swain, David Grundy : ABC of spinal cord injury : Chapter 1 : At the site of accident : Page

(112-143).

5. Waters RL, Adkins RH : Definition of complete spinal cord injury: Paraplegia 29 , 573-581.

6.Comarr , AE : Autonomic Dysreflexia (Hyper reflexia) , Journal Spinal cord , 1997 : page

345-354

7.Erickson, RP : Autonomic Hyperreflexia : Pathophysiology and medical management.

Journal : Archives of physical medicime and rehabilitation, 1980 : 61:431

8.Lamount LS: A Comparison of two arm exercises in patients with paraplegia: Journal :

paraplegia : 1996, 61: Page 441-567

9.Hussey RW and Stauffer ES : Spinal Cord injury: Requirements for ambulation: Journal :

Archieves of Physical medicine and rehabilitation 1973 : 54:544.

10.Mikel berg R, Reid S : Spinal cord lesion and lower extremity bracing: An overview and

Follow up study : Paraplegia , 1999 : 379, 19.

11.Bernardi M, Et al : The Efficiency of walking of paraplegic patients using reciprocal gait

orthosis : Paraplegia : 2000 : 78 : 552-559

12. Sipski ML, Delisa JA : Functional electrical stimulation spinal cord injury rehabilitation A

review of literature. Journal : Physical therapy : 56 : 778-789.

Web site referred

1) http://www.google.com 2) http : // www.yahoo.com3) http:// www.searchi.com4) http:// www.meditech.com5) http://www.emedicine.com

6) http://www.medscape.com

7) http:// www.pubmed .com

8) http:// bartleyby.com

APPENDICES

APPENDIX- (a)

APPENDIX-(b)

FORMAT FOR CASE REPORT-1

(please note it is of a different project)

Name: Mrs. Kamlesh Age: 51 years Gender: Female

Occupation: House wife

Any other recreational activity: No

Address: Railway Road, New Defence Colony, Muradnagar, Ghaziabad

Chief Complaint: Patient complaints of Low back pain since 3-4 months with the pain on the left side of

buttocks.

History of Past Illness

A) History of Previous similar Problem: Same type of illness occurs 2 year back, but the intensity of

episode was less problematic then present.

Any Previous traumatic History: History of fall from the stairs 2 years back.

History of Present Illness:

A) Episode of illness: The illness started 8-9 years back. The episode is of recurrent low back pain

with aggravation of symptom since 3-4 months. This is second episode of illness.

B) Onset : (i) Pathological-

a) Sudden - N b) Gradual -Y

(ii) Traumatic-

Mechanism of injury-

C) Site of pain: Pain is in lower lumbar region and the left side of buttocks

D) Is there is any radiation of pain: Yes/No-

If yes: where it goes- It radiated form the lower back to the left side of buttocks till mid of

thigh.

E) Is any paraesthesia / numbness / tingling sensation:

F) Most preferred position of the patient: Lying in the supine position.

G) Sleeping position of the patient: Patient preferred to lie in the right side lying position.

H) Mattress used: Hard Surface

I) Any other history: No

Medical History

Diabetes Y/N√

Hypertension Y/N√

Yes

No

Y

No

Cardiac disease Y/N√

Cancer Y/N√

Tuberculosis Y/N√

Infection Y/N√

Repetitive Coughing Y/N√

Any other medical problem Y/N√

Drug History

Past drugs History: No

Present drug History: On Phase Medications - Analgesic

Allergic to any Drug: No

Surgical History

Any surgery: Hysterectomy has been done 5 years back.

Date of Surgery: Not known

Any complication after Surgery: No.

Bed stay after Surgery: 15 -20 days.

Occupational History: - Home maker.

Personal History:

Smoking: No

Alcohol: No

Dietary Habits: Regular

History of Constipation: No

Other Details:

Fever: N

Malaise: N

Any other joint problem: N

Any bladder/ bowel symptoms like incontinence or retention N

Any respiratory problem N

Symptoms suggestive of major neurological disturbances N

Frequency of episodes of pain: 1 attack before 8 years

2 attack before 2 years

3 attack before 3 months

Intensity (VAS) (On first visit) - 9 out of max. of 10

Type of Pain:

Superficial- X

Deep- √

Nature of Pain:

Sharp- X

Dull- √

Aggravating Factors:

Pain is aggravated by prolonged sitting, standing, and bending forward.

Relieving Factors:

Patient got relief after lying in right side lying position.

Does pain aggravates with coughing, sneezing: N

(But previously it was present)

On Observation:

Body type: Ectomorphic

Mesomorphic

Endomorphic

Gait: Patient walks with the lordotic posture and takes precautionary measures during walking

to avoid the jerk.

Assistive device: No

Attitude of patient: Normal Tense Bored

Lethargic Over anxious

X o

√

X

√

X X

XX

Spinal posture:

Standing: Patient was having protruded neck with excessive lumbar

Lordosis.

Lying: Patient lies in supine lying position and avoids bending forward

while getting up from bed.

Spinal curvature:

Lumbar spine: Normal lordosis

Excessive lordosis

Flat back

Scoliosis

Sway back

Thoracic spine: Normal Kyphosis

Excessive kyphosis

Scoliosis

Any Step off sign: No.

Any presence of tuft of hairs: No

Others: No

On Palpation

X

√ √

X

X

X

X

√

X

Muscle tone (Lumbar muscle): Tone Increased

Tenderness: Present

Site: Left PSIS and L3-L4 spinous process.

Odema: Absent

Swelling: Absent

On Examination:

MOVEMENTS:

JOINT MOVEMENTS ACTIVE PASSIVE

LUMBAR FLEXION P, TR P,TR

EXTENSION NP NP

SIDE FLEXION LEFT RIGHT LEFT RIGHT

NP P NP P

ROTATION LEFT RIGHT LEFT RIGHT

NP NP NP NP

P- PAINFUL

NP- NON PAINFUL

IR-INITIAL RANGE

MR- MID RANGE

TR- TERMINAL RANGE

RANGE OF MOTION:

JOINT MOVEMENTS ACTIVE PASSIVE

LUMBAR SPINE Flexion 0-74* 0-75*

Extension 0-18* 0-20*

Side Flexion RIGHT LEFT RIGHT LEFT

62-47 62-49 62-48 62-50

*- signifies taken from the inclinometer

END FEELS:-

Lumbar Flexion: Tissue Stretch

Lumbar Extension: Tissue Stretch

Lumbar Side Flexion: Right Tissue Stretch

Left Tissue Stretch

Lumbar Rotation: Right Tissue Stretch

Left Tissue Stretch

JOINT MOVEMENTS ACTIVE PASSIVE

Right Left Right Left

HIP JOINT Flexion 0-100 0-100 0-110 0-110

Extension 0-15 0-15 0-15 0-15

Abduction 0-35 0-35 0-40 0-40

Adduction 0-20 0-20 0-25 0-25

Internal Rotation 0-35 0-35 0-35 0-35

External Rotation 0-45 0-45 0-45 0-45

END FEELS:-

Hip Flexion: Right- Tissue Stretch

Left- Tissue Stretch

Hip Extension: Right- Tissue Stretch

Left- Tissue Stretch

Hip Abduction: Right- Tissue Stretch

Left- Tissue Stretch

Hip Adduction: Right- Tissue Stretch

Left- Tissue Stretch

MANUAL MUSCLE TESTING OF LUMBAR SPINE

1) Abdominals : 4

2) Lumbar Extensors : 4

MANUAL MUSCLE TESTINGOF HIP

1) Hip Flexors: Left- 4+

Right- 4+

2) Hip extensors: Left- 4+

Right- 4+

3) Hip Adductors: Left- 4+

Right- 4+

4) Hip abductors: Left- 4+

Right- 4+

5) Hip Internal rotators: Left – 4+

Right- 4+

6) Hip External Rotators: Left- 4+

Right- 4+

MUSCLE LENGTH TEST:

Hamstring test: Normal

Rectus femoris test/ Ely’s test: Normal

MYOTOMES:

Affected myotomes are: L3, L5

DERMATOMAL EXAMINATION:

Affected Dermatomes are: L3, L4, L5

SPECIAL TEST:

SLR: Negative for neural tissue

Slump test- Positive

Prone Knee Bending – Negative

Bowstring test – Positive

Valsalva maneuver- Negative

ANY OTHER FINDINGS:

PROVISIONAL DIAGNOSIS:

Lumbar PIVD (L3, L4, L5) WITH RADICULOPATHY

INVESTIGATIONS:

MRI FINDING:

MRI reveals: Disc Degeneration at L4-L5 levels

Diffuse Posterior disc herniations with extrusion at L5-S1

Diffuse Posterior herniations with annular tear at L4-L5 level

Disc bulge at L3-L4

DIAGNOSIS:

LUMBAR PIVD (L3- L4-L5) without radiculopathy to left buttocks.

PHYSIOTHERAPY TREATMENT:

Treatment A: (10 DAYS)

1) Hot pack for 15 minutes

2) Interferential Therapy- 10 minutes, Four pole vector 45 degree scan, square waveform

3) Traction: 20 Kg, intermittent traction with hold time 5seconds and relax time 20 second for the

duration of 10 minutes is given in straight leg position.

Treatment B: (Next 10 DAYS)

1) Hot pack for 15 minutes

2) Transcutaneous Electrical Nerve Stimulation- HI TENS, 2 channels, 1st at the nerve roots of L3,

L4, and L5. 2nd channel at the nerve course at left buttocks for 15 minutes

Treatment C: (Next 5 days)

1) Ultrasound at the L4-L5 level- pulsed 1.2W/cm2 for 5minute and at the left sacroiliac joint pulsed

0.8 W/cm2 for 5 minutes

2) Transcutaneous Electrical Nerve Stimulation- HI TENS, two channels, one at the nerve roots of

L3, L4, and L5. two channel at the nerve course at left buttocks for 15 minutes

HOME PROGRAM AND ERGONOMICS:

1) Patient is advised to use the lumbosacral orthosis to support the back during travelling.

2) Patient is advised for hot fomentation at home.

3) Patient is advised to lying in prone lying position for at least 15 minutes duration twice in

a day.

4) Patient is explained about the proper sitting, standing, lying, and lying to standing, doing

the household activities in a proper way.

5) Patient is advised to take rest and to avoid the forward bending as much as the patient can

avoid.

Exercises:

Protocol A:

Pelvic tilting

Hamstring Stretching

Spinal Rotation

Calf Stretching

Neck Raising

Knee Rolling

These exercises are advised to be done twice daily for the 10 seconds hold time and 10

repetitions.

Protocol B:

Lying in extension

Extension exercises

Back and Gluteal exercise

PROGRESS NOTE:

Pain Reduction Progress: Visual Analog Scale (VAS):

Dated:

0 5 10

No pain Mild Pain Severe Pain

4/3/10- 5 out of max 10

9/3/10- 3 out of max 10

17/3/10- 1out of max 10

The patient had the treatment A for 10 days continuous then the patient pain subsided to the lower lumbar

back and slightly to the left buttocks area. All the lumbar muscle spasm has been also reduced.

After 10 days the Treatment plan B started and continued for the 7 days. Now the pain was reduced to a

limit and patient was able to do her ADL’s. Along with the treatment plan B, the patient was advised to

start the exercise protocol A. But the patient had the slight tenderness at the lower lumbar spinous

process.

After that the treatment plan C was started for 5 days.

Pictures Of assessment:

Posture assessment:

Tenderness checking: Fig 1 & 2

Fig 1 Fig 2

Two tender points: Fig 3

Fig 3

Lumbar movement assessment:

Lumbar flexion and extension Fig 4 & 5

Fig 4 Fig 5

Measurement of lumbar range by inches tape (schobber’s test)

Measuring Lumbar Flexion: Fig 6

Fig 6 fig 7

Measuring Lumbar Movement by Inclinometer:

Fig 8 Fig 9

Special test:

PKB Fig 10 Slump Test Fig 11

SLR Test Fig 12

APPENDIX

ASSESSMENT SCALES

Scale For Assessment Of Spinal Cord injury

ASIA Scale Impairment Scale

Scale For Assessment Of Spasticity

Spasm Frequency Scale Modified Ashworth Scale

Scale for Assessment Of Pressure Sore Risk

Bradens scale

Scales For Assessment Of Activities of Daily Living

Barthel Index Scale Functional Independence Measure Scale

Scale For Assessment Of Ambulation

Walking Index Scale For Spinal Cord Injury

ASIA Scale ( Standard neurological classification of spinal cord injury )

Impairment Scale

A - Complete : No motor or sensory function is preserved in the sacral segment

S4 -S5 level

B - Incomplete : Sensory but not motor function is preserved below the neurological

level and includes the sacral segments 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 is preserved below the neurological level and at least

half of the key muscles below the neurological level have a grade of 3

or more

E- Normal : Motor and sensory function is normal

SCALES FOR ASSESSING SPASTICITY

Spasticity Rating Scale

Spasm Frequency Scale

0 - No spasms

1 - One spasm or fewer per day

2 - Between one and five spasms per day

3 - Between five and nine spasms per day 4 -

Ten or more spasms per day

Modified Ashworth Scale

0 - No increase in muscle tone

1 - Slight increase in muscle tone, manifested by a catch and release or by minimal

resistance at the end range of motion when the part is moved in flexion /extension

abduction or adduction

1+ - Slight increase in muscle tone, manifested by a catch, followed by minimal

resistance throughout the remainder (less than half) of the ROM

2 - More marked increase in muscle tone through most of the ROM, but the affected

part is easily moved

3 - Considerable increase in muscle tone, passive movement is difficult

SCALE FOR ASSESSING PRESSURE SORE RISK

Braden Scale

Patients Name _____________________________________

Evaluators Name

Name________________________________ Date of Assessment

Sensory perception

Ability to respond meaningfully to pressure-related discomfort

Completely Limited

Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished .level of consciousness or sedation / limited ability to feel pain over most of body

Very Limited

Responds only to painful stimuli . Cannot communicate discomfort except by moaning or restlessness / has a sensory impairment which limits the ability to feel pain or discomfort over 2 of body.

Slightly Limited

Responds to verbal commands, but cannot always communicate discomfort or the need to be turned / has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities.

No Impairment

Responds to verbal commands . Has no sensory deficit which would limit ability to feel or voice pain or discomfort .

Moisture

Degree to which skin is exposed to moisture

Constantly Moist

Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned.

Very Moist

Skin is often, but not always moist .Linen must be changed at least once a shift.

Occasionally Moist

Skin is occasionally moist, requiring an extra linen change approximately once a day.

Rarely Moist

Skin is usually dry, linen only requires changing at routine intervals.

Activity

Degree of physical activity

Bed fast

Confined to bed.

Chair fast

Ability to walk severely limited or non-existent . Cannot bear own weight and/or must be assisted into chair or wheelchair.

Walks Occasionally

Walks occasionally during day, but for very short distances, with or without assistance . Spends majority of each shift in bed or chair

Walks Frequently

Walks outside room at least twice a day and inside room at least once every two hours during waking hours .

Mobility

Ability to change and control body position

Completely Immobile

Does not make even slight changes in body or extremity position without assistance

Very Limited

Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.

Slightly Limited

Makes frequent though slight changes in body or extremity position independently .

No Limitation

Makes major and frequent changes in position without assistance.

Nutrition

Usual food intake pattern

Very Poor

Never eats a complete meal . Rarely eats more than a of any food offered . Eats 2 servings or less of protein (meat or dairy products) per day . Takes fluids poorly . Does not take a liquid dietary supplement /or maintained on clear liquids or IV for more than 5 days.

Probably Inadequate

Rarely eats a complete meal and generally eats only about 2 of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement / receives less than optimum amount of liquid diet or tube feeding

Adequate

Eats over half of most meals . Eats a total of 4 servings of protein (meat, dairy products per day . Occasionally will refuse a meal, but will usually take a supplement when offered / is on a tube feeding or TPN regimen which probably meets most of nutritional needs

Excellent

Eats most of every meal . Never refuses a meal . Usually eats a total of 4 or more servings of meat and dairy products . Occasionally eats between meals . Does not require supplementation.

Friction and shear

Problem

Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance . Spasticity , contractures or agitation leads to almost constant friction.

Potential Problem

Moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair, restraints or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down.

No Apparent Problem

Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move . Maintains good position in bed or chair.

SCALES FOR ASSESSING ACTIVITIES OF DAILY LIVING

Functional Independence Measure ( FIM SCALE )

The Functional Independence Measure (FIM) scale assesses physical and cognitive disability.

Fim scale

Self-care

1. Eating

2. Grooming

3. Bathing/showering

4. Dressing upper body

5. Dressing lower body

6. Toileting

7. Swallowing

Sphincters

1. Bladder management

2. Bowel management

Mobility

1. Transfers : bed/chair/wheelchair

2. Transfers : toilet

3. Transfers : bathtub/shower

4. Transfers : car

5. Locomotion : walking/wheelchair

6. Locomotion : stairs

7. Community mobility

Barthel index

Activity Score

Feeding

0 - unable

5 - needs help cutting, spreading butter, etc., or requires modified diet

10 - independent ______

Bathing

0 - dependent

5 - independent (or in shower) ______

Grooming

0 - needs to help with personal care

5 - independent face/hair/teeth/shaving (implements provided)

Dressing

0 - dependent

5 - needs help but can do about half unaided

10 - independent (including buttons, zips, laces, etc.) ______

Bowels

0 - incontinent (or needs to be given enemas)

5 - occasional accident

10 - continent

Bladder

0 - incontinent, or catheterized and unable to manage alone

5 - occasional accident

10 - continent ______

Toilet use

0 - dependent

5 - needs some help, but can do something alone

10 - independent (on and off, dressing, wiping) ______

Transfers ( bed to chair and back )

0 - unable, no sitting balance

5 - major help (one or two people, physical), can sit

10 - minor help (verbal or physical)

15 - independent ______

Mobility (on level surfaces)

0 - immobile or < 50 yards

5 - wheelchair independent, including corners, > 50 yards

10 - walks with help of one person (verbal or physical) > 50 yards

15 - independent (but may use any aid; for example, stick) > 50 yards ______

Stairs

0 - unable

5 - needs help (verbal, physical, carrying aid)

10 - independent ______

TOTAL (0–100): ______

SCALE FOR ASSESSING AMBULATION

Walking index scale for spinal cord injury (WISCI II)

Physical limitation for walking secondary to impairment is defined at the person level and indicates the

ability of a person to walk after spinal cord injury. The development of this assessment index required a

rank ordering along a dimension of impairment, from the level of most severe impairment (0) to least

severe impairment (20) based on the use of devices, braces and physical assistance of one or more

persons.

Level Description

0 - Client is unable to stand and/or participate in assisted walking.

1 - Ambulates in parallel bars, with braces and physical assistance of two persons,

less than 10 meters.

2 - Ambulates in parallel bars, with braces and physical assistance of two persons,.

10 meters.

3 - Ambulates in parallel bars, with braces and physical assistance of one person,

10 meters.

4 - Ambulates in parallel bars, no braces and physical assistance of one person

10 meters.

5 - Ambulates in parallel bars, with braces and no physical assistance

10 meters.

6 - Ambulates with walker, with braces and physical assistance of one person,

10 meters.

7 - Ambulates with two crutches, with braces and physical assistance of one person

10 meters.

8 - Ambulates with walker, no braces and physical assistance of one person,

10 meters .

9 - Ambulates with walker, with braces and no physical assistance, 10 meters.

10 - Ambulates with one cane/crutch, with braces and physical assistance of one

person , 10 meters

11 - Ambulates with two crutches, no braces and physical assistance of one

person , 10 meters

12 - Ambulates with two crutches, with braces and no physical assistance

10 meters

13 - Ambulates with walker, no braces and no physical assistance, 10 meters.

14 - Ambulates with one cane/crutch, no braces and physical assistance of one

person , 10 meters

15 - Ambulates with one cane/crutch, with braces and no physical assistance

10 meters

16 - Ambulates with two crutches, no braces and no physical assistance, 10 meters.

17 - Ambulates with no devices, no braces and physical assistance of one person,

10 meters

18 - Ambulates with no devices, with braces and no physical assistance, 10 meters.

19 - Ambulates with one cane/crutch, no braces and no physical assistance

10 meters

20 - Ambulates with no devices , no braces and no physical assistance, 10 meters.