Spinal Cord Injury Assessment Guiding Principles

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Introduction[edit | edit source]

Physiotherapy assessment of spinal cord injury (SCI) is "the vision of the possibilities patient could attain in the perfect situation, and adapt it to the specific person's world".[1]

The 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 healths-related state.[2] The use of ICF in the spinal cord injury assessment facilitates communication and understanding of team roles within a spinal cord injury multidisciplinary team. It challenges clinicians to think holistically. [3][4]The following components of health condition are included in the ICF: body functions and structures, activities, participation, environmental factors, 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 the improvement for the purpose of intervention planning. [5][6][2]The assessment should be ongoing to tailor-make treatment plan based on observed changes in patient's function and behaviour.

Subjective Assessment[edit | edit source]

Body functions and structures[edit | edit source]

In this section physiotherapist asks questions and review 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 myocitis ossificans, syringomyelia, spasticity, pressure sores, autonomic dysreflexia, infections, postural hypotension

Activity[edit | edit source]

Activity is defined as difficulty in performing physical action or tasks. In this section, physiotherapist ask about and observe patient's current and past abilities to perform activities of daily living with or without assistance of special equipment. Current equipment that patient uses may facilitate or restrict mobility. It includes:

  • nasal gastric tube
  • suctioning machine
  • ventilator.

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

Participation[edit | edit source]

The ICF defines participation as a "limitation in performing socially defined life task and roles".[7]It includes socialising (interpersonal interaction and relationship), traveling, working, taking care of own health, taking care of the members of the family, taking care of own finances, play and leisure. [8]The limitations can be due to functional impairment related to a spinal cord injury and/or its secondary complications. 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 a psychologist. For this domain patient is asked about previous therapy, patient's goals and envisaged outcome.

Environmental factors[edit | edit source]

When discussing environmental factors, physiotherapist must include assessment of the barriers and resources in the community.[1] 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
  • access to specialised service or technology

Personal factors[edit | edit source]

Understanding patient's personal factors allows the physiotherapist to determine the individual's level of function and to design patient-specific interventions. [9]The examples of personal factors include:

  • degree of functioning
  • disability socio-economic status
  • mental well-being including forgetfulness, beliefs, attitude [9]
  • lack of knowledge about health care and prevention [9]
  • lifestyle choices and practising prevention care [9]
  • self-awareness, stress management, help-seeking behaviour[9]
  • household: amenities, access, support structures[1]
You can read more about spinal cord injury subjective assessment here.

Objective Assessment[edit | edit source]

Body functions and structures[edit | edit source]

You can read more about spinal cord injury objective assessment here

Outcome Measures[edit | edit source]

The physiotherapist has access to a number of accurate and sensitive outcome measures in a spinal cord injury assessment.[2] No single outcome measure exists that monitor changes and is applicable for the assessment of all individuals with spianl cord injury. It is important to choose the most appropriate ones which corresponds 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. [1]

When using outcome measures, the physiotherapist must remember that "outcome measurement tools do not take into account how a functional improvement was achieved ".[2] This statement gives an important message about the compensatory mechanism that can develop over the course of the rehabilitation which can alter the true effect of a therapeutic intervention.

Upper Extremity Outcome Measures[edit | edit source]

Lower Extremity Outcome Measures[edit | edit source]

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). It is a voluntary muscle strength of 10 key leg muscles, 5 on the left and 5 on the right side, and each muscle is assessed on the scale from 0 to 5, where 5 is normal. 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.[11]
  • Mini-BESTest is used for balance assessment in higher-functioning patients with SCI.[12]
  • Community Balance and Mobility Scale assess balance in higher-functioning patients with SCI.[13]
  • Modified Ashworth scale

Ambulatory measures

Ambulatory outcome measures are available when gait speed, endurance, turns and the position changes from sitting/standing to walking needs to be quantified. Other variables can be assessed during the performance of these tests, but it depends on its complexity. [14] For example safety with street crossing at the crosswalks can be evaluated, as it is defined by the walking speed of 0.6 m/s, however the evaluator must consider region where the task will be performed (rural vs city), as the demand for the speed may vary. Another example is a walking speed. Walking above 1.0 m/s for elderly people correlates with independent living. [15]

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 for endurance, fatigability and cardiovascular fitness assessment.[16][17]
  • Timed up and go test (TUG) is looking at the time required for the patient to stand up from a chair, walk 3 m, 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 during 2 min walk. This assessment IS NOT well-established in SCI.
  • 3D gait analysis is the gold standard for the assessment of 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. [18]

Functional Performance Outcome Measures[edit | edit source]

Team Communication/Team Roles[edit | edit source]

Goal Setting[edit | edit source]

Resources[edit | edit source]

  • bulleted list
  • x

or

  1. numbered list
  2. x

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 Harding M. Spinal Cord Injury Physiotherapy Assessment, Prognosis, and Goal Setting Course. Physioplus 2022.
  2. ↑ 2.0 2.1 2.2 2.3 Bolliger M, Blight AR, Field-Fote EC, Musselman K, Rossignol S, Barthélemy D, Bouyer L, Popovic MR, Schwab JM, Boninger ML, Tansey KE. Lower extremity outcome measures: considerations for clinical trials in spinal cord injury. Spinal cord. 2018 Jul;56(7):628-42.
  3. ↑ Sykes C. Health Classifications 1 - An Introduction to the ICF. WCPT Keynotes. World Confederation for Physical Therapy. 2006.
  4. ↑ Rauch A, Cieza A, Stucki G. How to Apply the International Classification of Functioning, Disability and Health (ICF) for Rehabilitation Management in Clinical Practice. Eur J Phys Rehabil. 2008;44(3):329-42.
  5. ↑ Ryerson S. Neurological Assessment: The Basis of Clinical Decision Making. In: Lennon S, Stokes M, editors. Pocketbook of Neurological Physiotherapy. Elsevier Health Sciences; 2008 Oct 10.
  6. ↑ Bernhardt J, Hill K. We Only Treat What It Occurs to us to Assess: The Importance of Knowledge-based Assessment. Science-based Rehabilitation: Theories into Practice. 2005:15-48.
  7. ↑ Jette AM, Haley SM, Kooyoomjian JT. Are the ICF Activity and Participation dimensions distinct? J Rehabil Med. 2003 May;35(3):145-9.
  8. ↑ Alve YA, Bontje P. Factors Influencing Participation in Daily Activities by Persons With Spinal Cord Injury: Lessons Learned From an International Scoping Review. Top Spinal Cord Inj Rehabil. 2019 Winter;25(1):41-61.
  9. ↑ 9.0 9.1 9.2 9.3 9.4 Pilusa S, Myezwa H, Potterton J. 'I forget to do pressure relief': Personal factors influencing the prevention of secondary health conditions in people with spinal cord injury, South Africa. S Afr J Physiother. 2021 Mar 15;77(1):1493.
  10. ↑ Wilson N, Howel D, Bosomworth H, Shaw L, Rodgers H. Analysing the Action Research Arm Test (ARAT): a cautionary tale from the RATULS trial. Int J Rehabil Res. 2021 Jun 1;44(2):166-169.
  11. ↑ Lemay JF, Nadeau S. Standing balance assessment in ASIA D paraplegic and tetraplegic participants: concurrent validity of the Berg Balance Scale. Spinal Cord. 2010 Mar;48(3):245-50.
  12. ↑ Jørgensen V, Opheim A, Halvarsson A, Franzén E, Roaldsen KS. Comparison of the berg balance scale and the mini-BESTest for assessing balance in ambulatory people with spinal cord injury: Validation study. Phys Ther. 2017;97:677–87.
  13. ↑ Chan K, Guy K, Shah G, Golla J, Flett HM, Williams J, et al. Retrospective assessment of the validity and use of the community balance and mobility scale among individuals with subacute spinal cord injury. Spinal Cord. 2017;55:294–9.
  14. ↑ van Hedel HJA, EMSCI Study Group. Gait speed in relation to categories of functional ambulation after spinal cord injury. Neurorehabil Neural Repair. 2009;23:343–50.
  15. ↑ Zörner B, Blanckenhorn WU, Dietz V, Curt A. Clinical algorithm for improved prediction of ambulation and patient stratification after incomplete spinal cord injury. J Neurotrauma. 2010;27:241–52.
  16. ↑ Barbeau H, Elashoff R, Deforge D, Ditunno J, Saulino M, Dobkin BH. Comparison of speeds used for the 15.2-meter and 6-minute walks over the year after an incomplete spinal cord injury: The SCILT Trial. Neurorehabil Neural Repair. 2007;21:302–6.
  17. ↑ Dobkin BH. Short-distance walking speed and timed walking distance: Redundant measures for clinical trials? Neurology. 2006;66:584–6.
  18. ↑ Nair PM, Hornby TG, Behrman AL. Minimal detectable change for spatial and temporal measurements of gait after incomplete spinal cord injury. Top Spinal Cord Inj Rehabil. 2012;18:273–81.
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