Spinal Cord Injury Assessment Guiding Principles

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Introduction

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".

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. 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. 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. The assessment should be ongoing to tailor-make treatment plan based on observed changes in patient's function and behaviour.

Subjective Assessment

Body functions and structures

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

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

The ICF defines participation as a "limitation in performing socially defined life task and roles".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. 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

When discussing environmental factors, physiotherapist must include 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
• access to specialised service or technology

Personal factors

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

• degree of functioning
• disability socio-economic status
• mental well-being including forgetfulness, beliefs, attitude
• lack of knowledge about health care and prevention
• lifestyle choices and practising prevention care
• self-awareness, stress management, help-seeking behaviour
• household: amenities, access, support structures

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

Objective Assessment

Spinal cord injury objective assessment includes observing and analysing a patient's attempts to complete movement or activities to determine which part of the task the patient is having difficulties with. This assessment allows to guide treatment and it provides an objective way to monitor improvement over time. During the assessment the timing and communication among the team members are the keys. Objective assessment should begin with the International Standards for Neurological Classification of SCI-ASIA which must be completed within 4-72 hours after the injury.

Body functions and structures

Observe:

• presence of O2 masks, ventilator
• 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, dressing
• skin condition, skin temperature
• presence of oedema
• type of wheelchair the patient uses
• wearing of braces, abdominal binder and/or orthosis
• patient's engagement during assessment
• breathing pattern, cough effectiveness, cough productiveness

Test:

• 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
  • A 5 degrees of ankle dorsiflexion is needed for a foot placement in the 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 on long finger flexors in the hands of a patient with a C5, C6, and C7 spinal cord injury.
• Manual Muscle Testing
• Clinical sensory testing
• Muscle tone assessment
  • • • • Tone: usually flaccid during spinal shock which can last for up until 6 weeks. (if patient shows early increased tone this shows the end of spinal shock and may indicate incompleteness too). Spasticity can have both advantages and disadvantages.
        • Muscle strength as the ASIA only does a few and this in required in a quad and incomplete injury especially
        • Balance: sitting (long or high) and in standing in an appropriate patient
        • Pain: where and whether neurogenic or nociceptive
        • BMI/body shape  and weight (affects functional outcomes)
          • Neural mobility: both upper and lower limbs
          • Autonomic nervous system
            • Cardiovascular function: Autonomic dysreflexia (hypertension) or postural hypotension
            • Bladder and bowel and sexual function/dysfunction
            • Impaired temperature control especially in lesions above T6. Beware of over or under heating and taking on the temperature of the environment.
          • Cognitive function: 30% of tetraplegics have associated head trauma or it could be physiological for example hyponatremia

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 a spinal cord injury assessment. No single outcome measure exists that monitor changes and is applicable for the assessment of all individuals with spinal 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.

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 mechanism that can develop over the course of the rehabilitation which can alter the true effect of a therapeutic intervention.

Upper Extremity Outcome Measures

• 9 hole Peg test is used to measure finger dexterity in patients with various neurological diagnoses
• Dynamometer
• 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 abilities to open and close the hand by a person with 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 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
• Mini-BESTest is used for balance assessment in higher-functioning patients with SCI
• Community Balance and Mobility Scale assesses balance in higher-functioning patients with SCI
• 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 10 m at a comfortable speed.

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. 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.

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.
• 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.
• Walking Index for Spinal Cord Injury (WISCI) is used to measure impairment in ambulation after spinal cord injury (SCI)

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 patient with high level of a spinal cord injury (quadriplegia)
• Canadian Occupational Performance Measure (COPM) is used to assess 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
• Visual Analogue Scale (VAS) is used for pain assessment.

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

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