Spinal Cord Injury Assessment Guiding Principles

Original Editor - Ewa Jaraczewska based on the course by Melanie Harding

Top Contributors - Ewa Jaraczewska, Kim Jackson and Jess Bell  

Introduction

The physiotherapy assessment for individuals with spinal cord injury (SCI) provides "the vision of the possibilities [the] patient could attain in the perfect situation, and adapt it to the specific person's world".

International Classification of Functioning, Disability and Health Model (ICF)

A description of health can be found in the International Classification of Functioning, Disability and Health (ICF). It offers a standard language to be used among health providers to describe the health-related state. The use of ICF in the spinal cord injury assessment facilitates communication and understanding of team roles within an SCI multidisciplinary team. It challenges clinicians to think holistically. The following components of health conditions are included in the ICF: body functions and structures, activities, participation, environmental factors, and personal factors. The goal of the assessment is to collect information about disordered movement patterns, underlying impairments, activity restrictions, and societal participation, and to identify the structural or functional mechanisms influencing improvement for the purpose of intervention planning. The assessment should be ongoing so that clinicians can tailor-make treatment plans based on observed changes in the patient's function and behaviour.

Subjective Assessment

Body Functions and Structures

In this section, the physiotherapist asks questions and reviews the medical record, seeking information on current and past medical history, including:

• Mechanism of injury: traumatic vs. non-traumatic
• Presence or history of other injuries related to the primary reason for assessment
• Medical management and current precautions
• Progression of the condition
• Pre-morbid medical history
• Presence of complications related to the spinal cord injury, including myositis ossificans, syringomyelia, spasticity, pressure sores, autonomic dysreflexia, infections, postural hypotension

Activity

In the ICF model of functioning, difficulty in activity is defined as problems with performing physical actions or tasks. In this section, physiotherapists ask about and observe patients' current and past abilities to perform activities of daily living with or without the assistance of special equipment. Current equipment that the patient uses may facilitate or restrict mobility. Examples of equipment used include:

• Nasal gastric tube
• Suctioning machine
• Ventilator

Physiotherapists must notice the technology that the patient uses: assistive device, standard or special wheelchair, etc.

Participation

In the ICF, participation limitation is defined as a "limitation in performing socially defined life tasks and roles". It includes socialising (interpersonal interaction and relationship), travelling, working, taking care of one's own health, taking care of the members of the family, taking care of one's own finances, play and leisure. Limitations in participation can be due to functional impairments related to a spinal cord injury and / or its secondary complications. The physiotherapist must acknowledge the presence of the multidisciplinary team members who are involved in managing these limitations: speech-language pathologist, nutritionist, dietician, wound care nurse, or psychologist. For this domain, the patient is asked about previous therapy, patient goals and envisaged outcomes.

Environmental Factors

When discussing environmental factors, physiotherapists must include an assessment of the barriers and resources in the community. The following examples represent environmental factors:

• Accessibility of the patient's residence: mountainous, rural or urban area, sandy
• Weather conditions: hot, dry, snowy, windy
• Distance from healthcare services
• Access to specialised services or technology

Personal Factors

Understanding a patient's personal factors allow the physiotherapist to determine the individual's level of function and to design patient-specific interventions. Examples of personal factors include:

• Degree of functioning
• Socio-economic status
• Mental well-being including forgetfulness, beliefs, and attitude
• Lack of knowledge about healthcare and prevention
• Lifestyle choices and practising prevention care
• Self-awareness, stress management, and help-seeking behaviour
• Household: amenities, access, support structures

You can read more about the spinal cord injury subjective assessment here.

Objective Assessment

The spinal cord injury objective assessment includes observing and analysing a patient's attempts at completing a movement or activity to determine which part of the task the patient is having difficulty with. This assessment guides treatment and it provides an objective way to monitor improvement over time. The timing of the assessment and communication among team members are key to the objective assessment. An objective assessment should begin with the International Standards for Neurological Classification of SCI-ASIA, and this must be completed within 4 to 72 hours after the injury.

Body Functions and Structures

Observe:

• Presence of O₂ mask, ventilator support
• Placement of drips or drains, NG tube, catheter
• Patient positioning in bed or wheelchair
• Vital signs at rest and during activities
• Surgical or other wounds or scars, wound dressing
• Skin condition, skin temperature
• Presence of oedema
• Type of wheelchair the patient uses
• Wearing of an abdominal binder and / or trunk, lower or upper extremities orthoses
  • Abdominal binder - may indicate postural hypotension
  • 
    Universal cuff - refers to hand function                   
  • Wrist extension splint - indicates weak wrist extension
• Patient's engagement during the assessment
• Breathing pattern, cough effectiveness, cough productiveness
• BMI / body shape and body weight
• Autonomic nervous system function includes the presence of autonomic dysreflexia (hypertension) or postural hypotension, bladder and bowel and sexual function / dysfunction, and impaired temperature control especially in lesions above T6

Measure:

• 

  ASIA Form
  ASIA Motor Score
• Range of motion: during the exam, the physiotherapist must differentiate between spasticity and contracture. The following should be considered:
  • A minimum of 110 degrees of hamstrings length for balance and stability is needed in a long sitting position
  • 5 degrees of ankle dorsiflexion is needed for foot placement in a wheelchair
  • Hip external rotation range of motion will assist with dressing and perineal cleanliness
  • Shoulder external rotation assists with locking the elbows during transfers
  • Tenodesis grip will require a functional shortening of the long finger flexors in the hands of patients with C5, C6, and C7 spinal cord injuries

• Upper and lower extremities neural mobility assessment

• Manual muscle testing
• Clinical sensory testing
• Muscle tone assessment:
  • The Modified Ashworth Scale for elbow and / or knee flexors and extensors: the instrumented stretch-reflex test is performed by the clinician. The therapist moves the forearm or lower leg slowly through elbow flexion or knee flexion, and then rapidly through extension to stretch the elbow flexors or the knee flexors. Spasticity is rated as indicated by Bohannon and Smith:
    • 0: No increase in tone
    • 1: Slight increase in tone, manifested by a catch / release, when the limb is moved into flexion or extension
    • 1+: Slight increase in muscle tone, manifested by a catch with minimal resistance throughout the remaining range of motion (this should be less than half the total range)
    • 2: More noticeable increase in tone through most of the range of motion, but the limbs are still easily moved
    • 3: Significant increase in tone and passive movement is difficult
    • 4: The limb is rigid in flexion or extension
  • The Wartenberg pendulum test can be used for an assessment of knee tone: the patient is sitting with their legs hanging freely over the edge of a plinth and torso reclined to approximately 30°. The therapist slowly raises the lower leg to passive full extension and holds the leg in a horizontal position until the patient is completely relaxed. The patient's lower leg is released and allowed to oscillate until coming to rest.

• Pain level to determine whether the pain is neurogenic or nociceptive.

Transfer

Activity

• Sitting / standing balance assessment
  • Long sitting
  • Short sitting
  • During a functional task (transfers)
• Assessment of functional tasks of reaching, feeding, grooming
• Turning, bed mobility, and transfers assessment
• 

  Wheelchair Pressure Relief
  Ability to perform pressure relief, including instructions given by the patient on how to assist
• Sit to stand transition assessment
• Gait assessment with or without assistive devices or assistance provided
• Toileting and bladder and bowel function assessment

Participation

Cognitive function can affect participation in socially defined life tasks and roles. Current research suggests that individuals with SCI should be evaluated for cognitive impairment as there are reports that there is a high incidence of impaired cognitive functions in individuals with SCI. 30% of tetraplegics have associated head trauma or hyponatremia which can lead to impaired cognition. In addition, the following factors can contribute to this problem:

• Concomitant brain injury
• Psychological or somatic comorbidities
• Decentralised cardiovascular control

To evaluate participation, clinicians must understand the specific needs and problems of an individual with an SCI. In the literature, it is referred to as a person–perceived participation or handicap. The following measures of participation are currently available:

Craig Handicap Assessment and Reporting Technique (CHART)

• Based on 6 domains: physical independence, cognitive independence, mobility, occupation, social integration, and economic self–sufficiency
• Collects information about if and how the respondent fulfils the roles typically expected from people without disabilities
• The score range from the minimum (0) to the maximum (100) where 100 corresponds to a role fulfilment at the level of the person without a disability

You can read more about this tool and you can download the worksheet here.

The Assessment of Life Habits (LIFE–H)

• Self-reported assessment of life habits across 12 domains from activities of daily living to social participation
• Life habits are referred to as "regular activities (eating, communication, moving around, etc) and social roles (working, studying, practising leisure activities, etc)

You can read more about this assessment here.

The Impact on Participation and Autonomy Questionnaire (IPAQ)

• Self-administered questionnaire
• Measures perceived participation and the experience of problems for each aspect of participation

You can read more about this tool and you can download the worksheet here.

You can find more information on the participation after spinal cord injury here

You can read more about spinal cord injury objective assessment here

Outcome Measures

The physiotherapist has access to a number of accurate and sensitive outcome measures in an SCI assessment. No single outcome measure exists that monitors all changes and is applicable for the assessment of all individuals with spinal cord injury. It is important to choose the most appropriate ones, and to consider which ones correspond with the stage, level of the patient and the patient's goals. When assessing the patient at different stages of rehabilitation, the physiotherapist may need to use alternative outcome measures.

When using outcome measures, the physiotherapist must remember that "outcome measurement tools do not take into account how a functional improvement was achieved ". This statement gives an important message about the compensatory mechanisms that can develop over the course of rehabilitation and which can alter the true effect of a therapeutic intervention.

Upper Extremity Outcome Measures

• The Nine-Hole Peg Test is used to measure finger dexterity in patients with various neurological diagnoses
• Dynamometer grip strength measure
• The Modified Ashworth scale helps to determine upper and lower-extremity spasticity in patients with SCI
• The Action Research Arm Test (ARAT) or the modified Action Research Arm Test (mARAT) assesses upper limb function based on the ability to complete functional tasks
• The Grasp and Release Test is used to evaluate the ability to open and close the hand by a person with a SCI

Lower Extremity Outcome Measures

When the focus is on locomotion, the following lower extremity outcome measures may be appropriate:

Non-ambulatory measures

• International Standards for Neurological Classification of Spinal Cord Injury includes a motor (manual test of arm and leg key muscles) and a sensory (light touch, sharp) evaluation
• Lower extremity motor score (LEMS) is a measure of the voluntary muscle strength of 10 key leg muscles, 5 on the left and 5 on the right side. Each muscle is assessed on a scale from 0 to 5, where 5 is normal. The patient can receive a maximum combined score of 50 points (5 x 10 muscles)
• Berg Balance Scale (BBS) is a balance measure validated for people with SCI
• Mini-BESTest is used to assess balance in higher-functioning patients with SCI
• Community Balance and Mobility Scale assesses balance in higher-functioning patients with SCI
• The Modified Ashworth scale helps to determine upper- and lower-extremity spasticity in patients with SCI
• Penn Spasm Frequency Scale (PSFS) is a self-assessment tool for muscle spasm frequency and severity applied in the SCI population
• Wheelchair Propulsion Test (WPT) assesses the ability to propel a wheelchair over 10m at a comfortable speed

Ambulatory measures

Ambulatory outcome measures are available when gait speed, endurance, turns and position changes from sitting/standing to walking need to be quantified. Other variables can be assessed during the performance of these tests, but it depends on their complexity. For example, safety while crossing the street at a crosswalk can be evaluated. It has been established that walkers need to have a walking speed of 0.6 m/s to safely cross. However, the evaluator must also consider the region where the task will be performed (rural vs city), as the demand for speed may vary. Another example is general walking speed. Walking above 1.0 m/s for elderly people correlates with independent living.

The following are examples of the ambulatory outcome measures:

• 10-metre walk test (10MWT) for a gait speed assessment
• Six-minute walk test (6mWT) is used to assess endurance, fatigability and cardiovascular fitness
• Timed up and go test (TUG) looks at the time required for an individual to stand up from a chair, walk 3m, turn around, walk back to the chair and sit down
• Two-minute walk test (2mWT) is a variation of the 6mWT and assesses the distance covered during a 2 minute walk. This assessment IS NOT well-established in SCI
• 3D gait analysis is the gold standard for assessing gait
• Instrumented walkways are portable devices that offer gait analysis, including speed, step length, stance time, swing time, single support time and base of support
• Walking Index for Spinal Cord Injury (WISCI) is used to measure impairment in ambulation after spinal cord injury (SCI)

Information on the strength and limitations of the lower extremity outcome measures can be found here.

Functional Performance Outcome Measures

• Spinal Cord Independence Measure III (SCIM III) assesses the ability of a person with SCI to perform activities of daily living and is used for a comprehensive assessment of functional recovery
• Functional Independence Measure (FIM) helps to determine a person's functional capacity and independence
• Quadriplegia Index of Function (QIF) is a functional assessment instrument for use with patients who have a high level SCI (i.e. quadriplegia)
• Canadian Occupational Performance Measure (COPM) is used to assess a person's perceived performance of daily activities and his or her satisfaction with the performance

Additional Outcome Measures

• Montreal Cognitive Assessment (MoCA)is a screening tool for cognitive impairment
• The Visual Analogue Scale (VAS) is used for pain assessment

You can read more about spinal cord injury outcome measures here.

Team Communication / Team Roles

The interdisciplinary team in a SCI unit typically consists of rehabilitation physicians, residents, rehabilitation nurses, physiotherapists, occupational therapists, leisure therapists (recreational therapists), social workers, and psychologists, but the number and speciality of the team members can vary depending on the country, medical systems, socioeconomic status, etc. The staff should be available 5-7 days a week and should be supported by other healthcare professionals including pharmacists, dietitians, speech-language pathologists, respiratory therapists, orthopaedic surgeons, or infection control specialists.

You can find information on the interdisciplinary management of spinal cord injury here.

Goal Setting

Good assessment and choosing the most appropriate goals can lead to more functional outcomes; i.e. the patient would have a better chance to return to their home environment with the appropriate equipment and skills to re-integrate back into society and perform the roles they want to fulfil safely and effectively. When goal setting in SCI rehabilitation reflects only physical functioning goals, the individual with an SCI will not be adequately prepared for everyday life and emotional issues. Healthcare providers should address psychosocial components such as family issues and change of roles and include goals relevant to the person with the SCI and their everyday life.

One common method of goal setting is derived from the SMART Goal approach, which originated in the field of project management. The acronym SMART stands for specific, measurable, attainable or assignable, realistic, and time-related.

Example for short term goals:

1. Transferring to the wheelchair and eating breakfast in the dining room
2. Pushing the wheelchair to the gym for a physiotherapy session
3. Doing a car transfer and going out for a weekend at home

Examples for long term goals:

1. Getting into a taxi to attend an outpatient appointment
2. Driving to work for a meeting
3. Getting groceries to cook dinner

You can find information on prognosis and goal setting in spinal cord injury here.

Resources

• International Classification of Functioning, Disability and Health (ICF) https://www.who.int/classifications/international-classification-of-functioning-disability-and-health
• Spinal Cord Injury Research Evidence SCIRE. Available from: https://scireproject.com