In Part 1 of our webinar series on spinal cord injuries, Brad Dexter of QLI focuses on high cervical spinal cord injuries, covering injury classifications, the cost of spinal cord injuries, the type of body functions available, environmental modifications, and more.
Speakers: Brad Dexter, Tim Benak
Video Transcription
Introduction
Brad Dexter
Thank you everyone, for joining. You know, as I was thinking about this, we’ve done some spinal cord injury presentations in the past. We’ve done kind of an intro to spinal cord injury.
I think back to when I was a new clinician, even back in school and you hear, maybe some of you can relate to this as well, but you hear about a diagnosis, stroke, traumatic brain injury, spinal cord injury, right. In this case, we’re talking about spinal cord injury. But what you think of is pretty standardized in your mind. If you don’t have a lot of experience with it, you haven’t seen a lot of different cases, it seems a little more cut and dry than it actually is.
And so I wanted to put together a series that looks at just the vast array of different presentations that you can get after a spinal cord injury. And we’ve broken it into four parts. Part one is going to be the high cervical spinal cord injury. So we’re looking at the cervical levels one through four. Part two is going to be low cervical, spinal cord injury. So looking at C5, down to C8 T1 levels. And then part three is going to be thoracic level injuries, part four will be a lumbar level injuries.
And so I’m excited to kind of talk through part one today, the high cervical SCI, you know, going through not just how we determine level of injury, but then also what are you likely to experience after that? And why is it so different? So if you’ve viewed some of these webinars in the past, hopefully I’m expanding on some of the things that I’ve discussed previously.
We always kind of get into AIS scores, neurological level of injury, but we don’t always talk about the specifics of well, what does that actually look like? And again, you know, I remember back in school and if you if you had a C5 level injury, well, here’s exactly what you’re gonna see what the C5. If you had a T2 level injury, here’s exactly what you’re gonna see with with a T2 level injury. Well, that’s just not the case because of just the spectrum of recovery that can happen after each one of those spinal cord injuries.
So, my objectives today are to understand basic terminology behind classifying the SCI, being able to describe expected prognosis due to injury level and trend in progress, recognize the impact of SCI on annual lifetime costs, return to work, even marriage, and identify and apply appropriate goals based on injury classification.
Injury Classification –
Paraplegia Versus Tetraplegia
We’ll start off with just some of the basics in terms of classification and again, I don’t want to beat this to death because many of you are probably familiar with it or have at least heard me talk about it before, but very basically we talk about spinal cord injuries with the terms quadriplegia or paraplegia. Another word for quadriplegic is tetraplegia. Quad and Tetra both mean “four”. Different languages give us different prefixes though, right? So quadriplegia and paraplegia.
Quadriplegia
Quadriplegia, is an individual that has a cervical level injury. Because it’s a cervical level injury, it’s higher up the chain in the spinal cord, and so it’s going to affect everything down the chain down the stream. So you see all four limbs quadra/tetra being affected from that level of injury.
Paraplegia
Paraplegia, then is anyone that really has a thoracic level injury or below. Paraplegia is an individual that has full use of their upper extremities, but then varying degrees of use throughout their trunk, no use in their legs. Alright.
Now we talk about these two things. And I’ll tell you, I’m not going to get too deep into this, but I’ll tell you, it gets even more complex than that, right, because we can have a hemi-sided spinal cord injury where it’s more of like a Brown-Sequard Syndrome, one side of the spinal cord is functioning well with motor but it’s not with sensory. The other side isn’t functioning well with motor, but it is with sensory. And so it gets kind of confusing. You can have central cord injuries up in the cervical area as well, which have different presentations too.
For today, we’re gonna talk about tetraplegia and paraplegia.
Injury Classification – ASIA Impairment Scale
So our next step then, is to talk about the ASIA impairment scale. It’s a standardized neurological examination to assess sensory and motor levels affected by the SCI. So we use it to define and describe the injury extent and severity. We use it to determine future rehab and recovery needs. And there’s five classification levels. Here are the five classification levels.
So AIS, A, B, C, D, and E. You guys see on the screen, the writing there, but I want you to even just think about maybe a sliding scale. If you can visualize that off to the side, you know, moving from AIS, A to E, and you just have kind of these markers that help you transition from one to the next. So if we start out with an AIS A, that’s an injury where there’s nothing getting through the level of injury, there’s no movement, there’s no sensation.
It doesn’t mean that the cord is completely severed, it just means that the injury site there, the lesion to the spinal cord isn’t allowing for any sensation to get through.
I’m going to go off on a slight tangent here and just do a little education on what actually happens to the spinal cord when it gets hurt. Now, whether we have a subluxation dislocation of the vertebrae, where you end up with pressure compression on the spinal cord, or whether there’s a laceration to the spinal cord, or you have a bony tumor that’s pressing in on it. In any of those circumstances, what happens is we have loss of blood flow to nervous system cells, specifically in the spinal cord. And when we have loss of blood flow to those cells, we end up with cell death. And so you have this injury site that kind of happens. And the body’s response to any injury site is an inflammatory cycle.
On the nervous system that happens through a type of glial cell. And the glial cell is designed to come in, and it’s a little bit like Gorilla Tape, right? So it comes in and it patches up the area, and it tries to give the body a chance to heal it up. The problem with those glial cells, when they come in is they essentially form a scar within the spinal cord. And that tissue does not allow for the electrical signals to pass through that area.
So now all of a sudden, we don’t have movement signals coming from the brain going out to the body and we don’t have sensory signals coming from the body back up to the brain in the same way that they were because there’s a blockage formed by those glial cells.
Going off a little further on that tangent too that’s also why research right now is kind of aimed toward, how do we reprogram those glial cells? Are we able to instead make them shift towards cells that would transmit those electrical signals instead of going to their natural state of just blocking anything that’s coming through. So, that’s one area that research is heading right now.
I’ll step off of the tangents and come back to the AIS A injury. You can kind of think about that blockage, the glial cells that form that scar now in the spinal cord, and the size of that may vary, then the extent of of that glial cell deposit may vary, as we kind of slide through this scale of classification. So it may be a little bit larger widespread in that AIS A type of injury, resulting in the complete lack of motor and sensory function below the level of injury.
So we move to an AIS B. And those glial cells, maybe it’s not as widespread, it’s a little more condensed, and we still have some sensory information that’s able to pass through the injury side. There’s a shift between the AIS A and the AIS B that happens. So AIS A is considered complete. But we move to an AIS B, and below, those are all incomplete types of injuries.
And one of the key things that helps you make that jump to incomplete is not just the sensation below the level of injury, but also having some kind of sensation around the anus. So that’s, you know, the sacral portions of the cord. It’s telling us that, hey, there’s something getting through, and it’s not just going a little ways through, it’s making it all the way down to the bottom. So there’s some amount of pressure sensation in the rectum or motor control of the anus, or sensory kind of around the perennial area as well.
Again, going down that sliding scale to an AIS C. Now, we have sensory below the level of injury, we’re starting to get some movement below the level of injury too. So again, the extent the widespreadness of those glial cells that have laid down in the spinal cord is maybe a little bit less than in AIS B.
Keep moving down, we get into AIS D. Again, extent severity of those glial cells that have laid down and deposited themselves in the spinal cord is even less. And so we have more than 50% of the muscles below the level of injury, working strong enough to help us move against gravity. These are folks that are going to be able to move and do a little bit more for themselves.
The AIS E then is classification that I wish I was able to see more of, but you know, those people don’t need me at that point. Their neurologic function has already returned. So again, remember those glial cells, how they kind of deposit themselves in the spinal cord to wall off an area of injury and help it heal, and that they don’t transmit signals.
The extent to which those glial cells laid down how widespread they are also impacts the completeness or incompleteness of the spinal cord injury.
How QLI Determines the ASIA Score
All right, so we’re gonna jump into how we do that AIS scoring. We’re really looking at dermatomes and myotomes. If you’re not familiar with these dermatomes, it’s basically a sensory map of the body. And so you see, the picture on your left demonstrates that map very well for us. So we need to understand where the C5 nerve root is going to provide sensation to. You can see that’s on the outside of the shoulder. C6 moves down the outside of the arm, the thumb. C7, we can check on the backside of the middle finger. C8 does the backside of the pinky, so on and so forth.
So we would go through each one of these areas, and we would check different types of sensation, fine touch, light touch. And then we would shift to our myotomes. And we know key muscle groups are controlled by specific levels in the spinal cord as well. So we know that the biceps that bend the elbow, those are mainly controlled by C5, so we can test the integrity of C5 by checking strength at the elbow. Likewise, we can check the integrity of L3 by checking the strength of the knee extensors that straighten the leg out.
So we have all of this mapped out and it helps us then go through this exam and get a good idea of what the neurological level of injury is and what the AIS classification is for the individual.
Again, the purpose of doing that, it’s for education. It’s also for prognostic value as well. So we we can help determine, you know, if they’ve been moving pretty quickly through some of this and recovering pretty quickly, well, that’s a good trend and maybe we don’t need to get that power wheelchair down the line. Maybe we will be able to step away from that and go with a walker. Maybe we don’t need that shower chair for them. Maybe we could just go with a bench right. And that’s cost savings too.
Looking at this outcome measure here, a neurological level of injury is determined by figuring out what’s the lowest level that still has completely normal sensation for light touch and pinprick, and completely normal motor function. So a three or above on a zero to five scale. And that level then would determine the neurological level of injury.
So if I had someone, let’s say, if we’re looking at the sensory columns on the right and the left side, and they have two’s (sensory is defined as zero is absent, one is altered or diminished, two is normal). So they have all two’s through C6 on both sides. And then they have, let’s say, a four on a manual muscle test on their motor on both the right and the left sides through C6, but then below C6, maybe those numbers change, they go to a one or a zero on the sensory and and drop below a three on the motor, then that would help me determine that the neurological level of injury is a C6, because I have normal sensation, normal movement through that level. And it changes there, right.
Now the next step for me then is to determine what’s the AIS classification. And that’s where I need to look then below that neurological level of injury. And I need to figure out, do we have anything around the perineum in the anal area? If that’s a yes, I know it’s an incomplete, it helps me make the jump from an A to a B. And then if we do not, or sorry, if we have that and we have strength below the level of injury, we have to determine is it less than 50%? Or is it more than 50% of the muscle groups below that. And that’s going to help me determine if it’s a A, B, C, or D.
Injury Classification – Complete/Incomplete
This is one more way to just look at that sliding scale that we were talking about earlier. I talked to you about this in terms of those glial cells and the extent of them. Another simple way to think about it is a Styrofoam cup.
You have a Styrofoam cup…No holes in it as normal, you put that underwater, nothing’s getting through, that’s like a complete injury. But if we start to poke some holes in there, you can see just a few holes is gonna allow a little bit of water to leak out. But as we add more holes into that cup, more of that water is going to seep through the cup and make it through. So that’s very similar to the extent of those glial cells laying down. If there’s less glial cells, there’s more space for the information to get through. So just another helpful way for you guys to maybe think about completeness versus incompleteness of those spinal cord injuries and how, hey, add one more hole, and that allows a little more to get through. You add a lot of holes, a lot more to get through, right. And that’s what leads to a wide variety of what we see within a spinal cord injury.
Keep some of those images in mind because I’ll jump back to them as we’re going through some specifics later..
What Do Spinal Cord Injuries Really Cost?
I do want to just kind of throw this up on the screen for you guys to get a good understanding of some of the costs after spinal cord injury
Again, today, we’re talking about high Tetris high quads. So C1 through C4. But just in general, we’ll go through some of these areas, so we can kind of compare over time.
So length of initial hospitalization following injury and acute care units is around 11 days, the average day in rehab units is 31 days, so not a lot of time for people to kind of figure things out or get the equipment that they may need. It’s also not a lot of time for us to to look at the prognostic indicators that would allow us to make good determinations on what equipment would be appropriate. A C5 AIS B injury at 40 days post injury may look like a C5 AIS D five months later. And so the amount of equipment that they need, may drastically change over that amount of time.
And so that can be just from a therapist perspective, that can be something that is hard to determine right away, we have to look at trends and we have to kind of figure out like, how fast are they progressing? But honestly, there are people that come to us with very, very little sensation, and all of a sudden over time, they’ve gained enough movement to be up and using a walker. And maybe they don’t need the power chair anymore. Maybe they can move to a manual chair. So, key point there for you guys
Tim Benak
Kind of in line with that, we had somebody ask a question, how long after a spinal cord injury can you see improvement in a patient’s AIS level?
Brad Dexter
Yeah. I mean, you can see that within a week’s time, even just, you know, anecdotally talking to people. They’ll say, “Yeah, right after the injury, I didn’t feel anything in my legs, and maybe a week or two later, I started being able to move my foot and I could actually bend my knee.”
You have people that, you know, they have nothing right away, maybe they start to gain some sensation over the next few weeks. But it’s two months, three months down the line, where they begin actually starting to move a foot, an ankle, maybe a knee.
There’s so much variety. And that’s why the AIS scale is important. I think getting a good picture of where do you have sensation? Where do you have motor initially, within those first 72 hours? Doing that again, you know, four weeks later, having another picture to see how they’re trending. Doing that again, another four weeks later, to have a picture of how they’re trending.
It’s important to be able to see that not only from the educational value for the individual, but again, like I’ve said, to see the trend of them as well. Where have you gained motor? Where have you gained sensation? It’s very hard to say yep, in three months, you’re gonna have all of this back. If anyone does that, that’s a little out there.
It’s also really hard to say sorry, you’re never going to walk again. Because I’ve seen many people that have had that told to them and they walk again. And so that just goes to say, you know, a C 5 injury isn’t just a C5 injury because you have a C5 AIS A, AIS B, AIS C, AIS D. And so that classification really matters.
Tim Benak
We also somebody asked question, are you referring to, on what’s on the screen right now, are you saying, “acute”?
Brad Dexter
Acute. Yep.
And, all this information is taken from University of Alabama, Birmingham. Every year, it’s a model system site, they put out facts and figures that come out late January, early February, for the previous year, and it has all of these stats on there. So if you guys are interested, that’s a reference for all of this information.
So that initial hospitalization is is kind of just the acute stage, the acute rehab unit is 31 days. Alright, so first year expenses for para’s, looking at around $550,000. First year expenses for high quads like what we’re talking about today. $1.12 million. First year expenses for low quads at that $816,000 range. Lifetime costs for para’s, $2.45 million. Lifetime costs for high quads, again, this is a younger person that would that would be hurt, close to $5 million. Average lifetime costs for a lower quad $3.6 million. So you can even see the difference between a low quad and a high quad. Right there, you can imagine as we get into some of these details in a little bit here, you can imagine, just because of the equipment needs that some of those higher quads may need, the amount of care that they may need, some of those costs are going to be quite a bit higher.
Percentage of SCI individuals who recovered by private health insurance, close to 50% at the time of their injury, and percentage of SCI individuals unemployed 10 years after injury is 77%.
This is a really hot topic within the spinal cord injury world. How do we get people back into meaningful, purposeful work? How do they contribute to society again?
Certainly, there are ways to do that. But there are a lot of barriers to making that happen as well.
Body Function Available
Alright, so we’ll get into some of the nitty gritty now. Again, so we’re thinking about high level cervical injuries C1 through C4. For each one of these areas that we go through, I’m going to hit each classification level and kind of talk through what you may expect to see with that high quad at an AIS A or AIS B or AIS C, or AIS D.
Now, I will say I’ve been able to group a lot of these with AIS A and B together, and AIS C and D together. So as I talk about them, you may hear me just say in AIS A and B, this is what you’re going to get. AIS C and D is going to be a little closer to this. And so just to begin, we’re going to think about what body function do these individuals have available to them?
So a high quad C1 to C4, an AIS A or B, you’re looking at an individual that’s really only able to move their head and neck and perhaps has some shoulder shrug if they’re a C4 level injury, able to pick their shoulders up towards their ears.
For both of those, you’re going to have a weak breathers, right. So the diaphragm muscles, all the muscles throughout the ribcage are going to be impaired and probably be difficult for them to use.
AIS C and D, on the other hand, because we know that they start to get sensation and motor below their level of injury, they’re going to probably add on some different muscle groups.
So they’re going to have the head and neck movement, the shoulder shrug still, but for an AIS C, you have potential weak use of all muscle groups below the level of injury. They could all be less than a three, but you could have use of them. Those respiratory muscles may be coming back, the abdominal muscles that can help produce a cough and help them move a little bit more could be coming back. They may have some weak muscles in their upper extremities and even some weak muscles in their lower extremities that allow them to perhaps help with a transfer in a different way, or use a different type of wheelchair.
AIS D is where you’re going to see potentially stronger use of those muscle groups to a point where a person could be up walking, not using as much equipment. Again, you’re going to have the respiratory muscles, abdominals, upper and lower extremities coming back, and even stronger use of the bowel and bladder sphincters and having more potential for them to be able to use the restroom without assistive devices catheterization and the like.
Bowel/Bladder
So we’ll start off with bowel and bladder function. So just some general things to consider. For bowel management, we always have to consider what the individual’s routine looked like prior to their injury, regardless of their classification. What’s their diet look like, hydration, exercise, any additional medications or supplements being used. If we have people on pain meds, they’re more likely to have constipation, and so we need to always try to find the right balance of supplements that may help with softening stool. Timing of their program, morning versus night. Positioning on the support surface to position their pelvis correctly to allow for anal sphincter to relax a little bit more and any premorbid conditions that may impact the bowels too.
Things just in general they consider for bladder management, any neurological assessments that are ongoing, urodynamics to assess the bladder function, what is it able to do? What’s hydration look like? That’s a big deal. Many of us may admit, yeah, we probably don’t drink enough water during the day, and that’s much of our spinal cord injury population as well. But we know that if we push those fluids a little bit more, it can be helpful with helping to fend off UTIs and just continually kind of flush the ureters, the bladder, kidneys, and urinary tract as well.
You know, they may have to have regular monitoring of their kidneys over time, very high incidence of UTIs again, just because of the foreign objects that need to go into their body to help them empty their bladder. And so UTI prevention education needs are important there. And then prophylactics that we may need to consider as well.
So, again, AIS A and B pretty similar here with what we’re gonna see. For bowel, you’re looking at an upper motor neuron or a spastic type of bowel. That’s really any injury above the level of T 12 is going to be looking like that. And that’s going to drive how often we do a bowel program because of how things are kind of moving through there and having a tiny little sphincter which goes into your bowel program frequency.
So they may require medications, suppositories, enemas and digital stimulation to help clear their bowels. They’re going to be dependent for their bowel management and incontinence, not able to help with any of that. They’re going to need some kind of a specialty chair, tilting shower commode chair with pressure relieving seat where they can tilt back if they’ve been up for a while. These programs can take, some people get pretty regular and it can be 20 minutes, but sometimes it takes up to an hour, sometimes a little more to have results.
For bladder, they’re going to be dependent for bladder management unable to avoid volitionally. They may require alternate bladder management methods, right. So oftentimes we’ll start off with a fully or intermittent straight cathing but many of these folks may move to a super pubic catheter, just so that the catheter isn’t being changed out as often and you reduce the entry of a foreign object into the body. And certainly a higher risk of AD for these folks with an AIS A or B type of injury, and high cervical.
For an AIS C and D, again, we’re getting a little more function below the level of injury and so for bowel, you know, AIS C and D, you may have a formal program or maybe volitional, even with a specific program. Perhaps they need meds, they may need an upright shower commode chair. In the case of an AIS D injury, you might even get to a toilet, might be able to go over toilet or with a raised surface over a toilet. Perhaps they could be independent, depending on the amount of hand function they have, or again, just balancing function that they have.
For bladder, some of the same things. So an AIS C is probably going to need a little more assist to dependent. Same thing with an AIS D, maybe a little more assisted dependent, may be able to volitionally void. And this is just where that sliding scale comes into play. So you may have an AIS C at the beginning of an AIS C, and you may have an AIS C that’s slid down even more, gain more function and is closer to an AIS D and you see some of this stuff coming back, right.
So some of the same problems can still occur with an AIS C and D in this bowel and bladder area that we had with AIS A and B, where they may be a little more dependent for these things, just depends on so many things, from spasticity, to upper extremity movements, transfer needs.
Skin Considerations
I don’t want to go through all of this with you guys, but you can imagine A and B, they’re going to be high risk for pressure injuries, they’re lacking sensation below their level of injury. We need to consider the type of bed surfaces that they’re on, their seating and positioning to make sure that we are minimizing pressure that they’re getting, teach them how to pressure relieve throughout the day, help them understand an area of their body to figure out what the water temperature is before they take a shower and they don’t get any burns that way. Help them know the risks of having coffee right next to them, what happens if you spill a hot cup of coffee can be at risk for burns, right.
So we may need to make sure that their seating and positioning in order for them to be able to tilt on their own, that they have all the specialty equipment on their chairs needed. You know switches, sip and puffs to allow them to more modified independently get themselves to a point where they can do those pressure reliefs on their own.
For your C and D. Again, you may have a little bit more movement here below the level of injury. And so still at a higher risk depending on the amount of sensation, they still need to understand the importance of pressure relieving regularly, doing that for one to two minutes every 15 to 30 minutes in their chair. They still need to understand risks of burns and if they’re not moving as much and developing those sores, but they should have a little bit more ability to kind of move themselves around, and they may also be getting that feedback, just like you and I are to shift around in their chairs a little bit when they get uncomfortable.
Seating/Positioning
Alright, so our next kind of natural transition here from skin protection is seating and positioning. Our AIS A and B injuries for high cervical injuries really need a lot of equipment, they need power wheelchairs. Think of them as their prosthetics. Just like we give a prosthetic to someone that has limb loss, and that allows them to move again, a power wheelchair with all of the appropriate bells and whistles for that individual can give them a lot of freedom throughout their day to move and go where they need to go to be more independent.
So our A’s and B’s are going to be in power wheelchairs, they’re going to need all of the power seating functions, tilt and recline, elevating leg rests to allow them to reposition themselves. If you have all of those functions for these individuals, typically you can get a program on the chair where they can hit a switch, tap a few times and it’ll essentially put them in a position where they can shift their pelvis back in the chair just by using gravity and then go back into an upright position in the case that they’ve kind of slid out of their chair after a car drive, or after spasms throughout the day, things like that.
They’re oftentimes going to need some kind of a sip and puff, drive control, a head array, maybe a chin switch, that will allow them to move their chair. They’ll need switches around the sides of their heads that will allow them function or access into the functions of the chair itself, the controller on the chair.
I’m telling you, there’s so many things you can do through the controllers on these chairs now. There’s Bluetooth technology integrated with them that allows them to have a lot of access, not just to that device, to the chair, but also to their environment as well.
Our C and D injuries, and these high levels, it may be a bit of a toss up between a power wheelchair and a manual wheelchair. Probably looking more toward a power wheelchair with an AIS C, more potential to get to a manual wheelchair if necessary for your AIS D.
The manual wheelchair, you may be looking at needing a power add on of some kind. So those are your smart drives, Twion wheels, e-motion wheels, and there’s a number of other ones that are out there on the market now, as well just to give them a little bit more mobility a little more freedom. And you can do that a lower cost using a manual wheelchair with a power add on with these C’s or D’s.
With the C’s, you may still be looking at someone that needs all the bells and whistles that the A’s and B’s do as well. So again, this is a sliding scale we kind of have to be ready for anything with that classification and the high cervical injury.
With both of these levels, just like our A’s and B’s, are probably looking at different types of mounts on their chairs too, in addition to some of the other things to allow them access to hydration, maybe they need attendant drive control, just depending on their abilities. So if you have an individual that’s an AIS D, and they’ve gotten half of the muscles below their level of injury, say it’s a C4 level injury, maybe they have some strong leg movement, and that leg movement is strong enough to help them do a stand pivot transfer with assistance from another person. But maybe it’s not strong enough that they can walk a long distance and their arms may not have much control to them. So it may be really difficult for that person to even drive a power wheelchair with a hand or with their arm.
And so you may be dealing with a person that still needs a head array to drive but has good leg movement and has some good sensation. That’s the variety that we can we can get here. And that’s where it’s always helpful to know good therapists and make sure that what’s being recommended is necessary for that individual too.
Transfers and Bed Mobility
Our A’s and B’s are going to be pretty dependent. So they’re going to need a lift system to get out of bed, to allow their caregiver to help them out. Depending on size, they may need one or two people to assist. And that’s for the transfer in and out of bed to their power wheelchair to their shower chair. That’s also for rolling, sitting them up or even laying them back down again.
Some other alternatives to a Hoyer system like this, a mechanical lift system like this, would be a ceiling track system system. There are different levels of ceiling track systems, depending on an individual’s finances and what their needs are as well. You can do ceiling tracks that are built in to the house, you can do a wall to wall system where they build that track system in one spot and just go wall to wall and mount it into the studs. Or you can do more of a portable track lift system as well.
In any of those cases, if the individual has some hand use, there are controllers that would allow them to control the up and down or even the side to side function of those on their own. And those can also kind of ease caregiver burden a little bit as well. In any of these cases, and we’ll go into this a little bit later with our environment, but if you’re using a portable lift system like the one that you see on the screen there, hard floor surfaces are much easier than carpet surfaces to move those around on. And so those are recommendations that we make for people sometimes if they don’t have the finances to pull up carpet and put down hard floor. We may be looking at, well gosh, can we get a roll of laminate and put laminate down over the carpet or can we get access to some plywood and put that over the area where you’re going to be doing the majority of your transfers using that as well. So just things that we’re always kind of considering from a therapeutic aspect.
Our AIS C’s and D’s, again, because they have a little more movement down to the legs, maybe some more function in their arms, they may be able to help with a side board transfer, they may be able to do a stand pivot transfer. And then they may be able to do that with assistance from another person, or perhaps they’re able to complete it on their own if their balance is good enough, or if they’re able to use an appropriate assistive device.
In these cases, for bed mobility, they may be able to use bed ladders, bed rails to assist with turning themselves a little bit more, or even sitting themselves up in bed.
Walking
Our high level, AIS A’s and B’s are not going to be able to walk on their own, they don’t have any motor. It would only be with assistance of robotic therapy, and there’s plenty of that out on the market. But probably too expensive to get into the home for them, and they would always need assistance to complete the robotic walking. You may ask, why would you do that with them? Why would you get them into a robot? Well, you know, there’s benefits of just being up on your feet.
We know that from much of the research has been done in the last 30 to 40 years to reduce risks of osteoporosis, you know, stand people and get them up in an upright position. You can impact orthostatic hypotension by getting people out of a seated position and moving them into standing. So you can kind of strengthen the cardiovascular system a little bit more that way.
There are also benefits for spasticity, for range of motion, and even just the psychological benefits of getting people up and helping them to walk using some of the robotic therapy as well. Again, if they’re appropriate for that.
Your C’s and D’s, your C’s may require a robotic or bodyweight system for gait training, they’re probably not going to be walking on their own because half of those muscle groups below their level of injury will not be functioning strong enough.
Your D’s though, you’re gonna have a wide variety here, you may need that robotic system to get them going. That may be an on ramp to a body weight system, body weight support system. And you may get them to a point where they can walk with forearm crutches, with a platform type of walker or maybe even no assistive device at all. And then you’re looking at, well can that person walk household distances? Are they able to walk more community types of distances? Again, there’s a wide variety within that realm as well.
Grooming/Hygeine/Eating
This is going to depend on the amount of upper extremity use that comes back. So you would assume as we go down that sliding scale, the disbursement of those glial cells, the widespreadness of them, it’s less as we get down to AIS D. So maybe we have a little more hand use to use at that point. But your A’s, your B’s, even your C’s are probably going to need grip assists, adaptive equipment, like you see in that picture to help them with grooming, with hygiene, with eating.
Your D’s may need that as well. Or they may be able to get away from that a little bit more. They may be able to to feed themselves, grasp utensils, grasp some of the items they may need for grooming and hygiene more on their own.
If anything our OT’s are going to be looking at, well, how can we build up the grip surfaces to make it a little bit easier for them to hold on to those devices.
Assistive Technology
This is huge for this group of individuals, high cervical level. You know we were talking earlier about all the bells and whistles in their seating and positioning, their wheelchairs. We can integrate those things with smart home technology.
Some of the nice things that we have now are Amazon echo, your Google Home, your Apple home products, these are not designed just for individuals that have sustained a catastrophic injury and are in wheelchairs, right? These things available to the general public, it’s normal to use them. Perhaps some of these folks were using it before. And so it really helps assist them with accessing their environment, using those tools to turn on lights, shut off lights, to turn on outlets, turn off outlets, to close blinds, open blinds. If they have an automated door opener in their home ,to open the door for themselves as well, to open garage doors. There’s so many things that we can do with this stuff. And it’s important if you guys are working with individuals with these types of injuries that they’re getting access and have a trained individual that’s helping them get access to all of this.
Apple, you know, just within the last year released even more assistive technology tools within their products. And if you guys ever saw that commercial, there’s a gentleman with a high, high level cervical injury, AIS A that’s in those commercials. I encourage you to look those up if you’re curious about that. And you’ll hear a little bit more about how that product, just the accessibility they’ve built into the software, is allowing him to do more for himself, to work more freely and to access life more for himself as well as.
Environmental Modification
Your A’s and B’s most definitely because of their seating and positioning needs are going to need ADA accessible ramps, they’re going to need door thresholds on their homes, widened doorways to accommodate the size of those power chairs, automatic door openers, smart home setups for the thermostats, lights, blinds, electronics, so on and so forth. Trying to make open designs of living spaces or apartments wherever they’re living, if they’re able to. Doing more of like a wet bathroom where everything’s tiled, you can just go in and everything is kind of in there, the toilet’s open, the shower’s open, you have some more of that wet bathroom feel. Ceiling or portable trackless systems may be nice changes to ease the burden of care for a caregiver support system that’s helping them. Hard floors are important and elevators and chair lifts may be appropriate for their homes as well.
AIS C’s are probably going to need some of the same things just based on the seating and positioning needs that they have. But you get into an AIS D injury with a high cervical spinal cord injury, and you see there’s quite a bit less needs for them. And that just has do with their ability to move a little more freely. So they may be the folks that don’t need the wheelchair to get around their house, maybe they can do some residential walking and need the wheelchair for the community.
And so you may still be looking at the ramp or door thresholds even from a walking standpoint, you may need to consider the flooring so that there’s no tripping hazards, makes a little bit easier for them to move around. You may need a stair lift for them to get back upstairs again. But you may be able to get by with some cheaper modifications like offset door hinges, and finding ways to widen the doorways that way as well.
Driving and transportation
So for our AIS A’s and B’s, you can drive from a power wheelchair in a converted vehicle, van or appropriate SUV or truck. It’s a really high technology system. There are ways to do that, believe it or not with sip and puff control technology. There’s joysticks if they have any amount of upper extremity movement, but very, very expensive to spec these out and get them going.
You can see the gentleman in the picture there is in a truck. He’s in a manual wheelchair. He actually has a lower cervical level injury. But you can see how the door opens up like a Lamborghini, there’s a lift that slides out and drops down to the ground, there’s a different setup on his steering wheel, if you can see the tri pin on there. So there’s a lot of modifications that happen to allow that to work. But there are options out there.
Now, these folks, oftentimes the A’s and B’s, they may not be comfortable driving. It’s a lot just dealing with some of the technology that they have to deal with, and even though it offers a little more control, they don’t feel like they have a lot of control behind the wheel.
Obviously, there’s a lot of training that goes into this before they’re actually authorized to do it. But there is availability for it.
Your C’s and D’s, we may see them driving with an adapted setup similar to this. Or they may be able to actually access a vehicle without doing a lot of modifications to it, potentially a tri pin, maybe you have some kind of a push rock system that allows them to accelerate or decelerate in a vehicle as well. Perhaps they need some of the technology to change how the wipers or the blinkers or the horn work in their vehicle as well. But what I want you to hear is that there are possibilities here for these individuals to be able to access the community through driving and transportation.
Otherwise, for your A’s and B’s, you’re still looking at a converted vehicle to allow them to actually get into the vehicle. You need to consider the height of those vehicles much of the time because they’re in power wheelchairs. Those can be a little bit taller in the opening on the side of a van so to say or on the side of an SUV, maybe a little tight for them to get in. And so those are considerations that need to happen. They usually drop the floors in these vans to add a little extra space. But again, those modifications are still necessary for those A’s and B’s.
Caregiver Needs
You can imagine, just based off of everything that we’ve talked about our A’s and B’s, you’re looking at 24 hour care for them. Perhaps there’s a little bit of time that they can be left alone during the day, if they have a lot of those environmental modifications and their chairs are set up for them to be able to do whatever they need to do.
But in general, they’re going to need help with their meds, with all of their ADL’s, with their bowel programs, eating, so on and so forth.
Your C’s a lot of variety here, as we’ve talked about. So you may need anywhere from two to 23 hours of care. That’s helpful. Modified independent to assist with ADLs, potentially independent with adaptive driving controls, to dependent for transportation. So again, just a wide variety right there.
And similar with our AIS D’s too, just kind of depending on where they get those muscle groups back and how much of it they get back. They may vary from being modified independent throughout their day to needing up to 23 hours of care. Again, think about that individual that maybe has some movement in their legs, but nothing in their arms. That’s going to drive needing help with medications, needing help with dressing, needing help with showering so on and so forth.
Durable Medical Equipment
So our A’s and B’s pretty similar. Here you’re looking at power wheelchairs, patient lift systems of some kind, electric hospital beds, pressure relieving mattress or overlay for those beds, shower commode chairs that tilt, slide boards, portable ramps. And those are just some of the essentials. Obviously, we’ve even talked about more than that today, but those are some of the essentials that they would need.
Your C’s and D’s, you’re looking at power wheelchairs, or potentially manual wheelchairs, slide board, electric hospital beds, potentially a more normal bed, pressure relieving mattress or overlay, shower commode with tilt, no tilt, maybe a tub bench, maybe a normal toilet just depending on abilities, perhaps an assistive device for gait, if they’re able to get to that point close to an AIS D, even some portable ramps, if they’re using wheelchairs.
And similar for our AIS D’s as well, again, they would just have stronger muscles below that level of injury, which would allow them to move a little more freely and potentially decrease the amount of durable medical equipment or the kind of medical equipment that they would need.
Questions
That was a lot of information. It was meant to be that way. Hopefully just expanding on your knowledge of what does this actually look like? Give me some tangible examples of different areas that these folks are dealing with. And the content on there is meant, you know, as a resource for you guys, too. So in the future, you know, if you want to look back at that, that’s why it’s there. So hopefully, I didn’t get too wordy. Love to answer any questions that we have.
Tim Benak
It was fantastic. So to your point, we will be sharing this. So I’m going to be launching a poll question here in a second. If you do want to receive a copy of these slides, make sure you answer that. It will be included in the follow up email you receive after you complete the post webinar evaluation. So yes, they are going to be available, you just have to do a few things on your end to receive them.
Brad, we did have one question come through. And as Brad mentioned, this is the perfect time to ask some questions. I’m going to launch the poll here in about a minute. So please hang out with us for a little bit and ask questions if you have them.
Can you become an AIS D para due to a low back injury or neurological compression without an acute injury?
Brad Dexter
Yeah, absolutely. And I just to make sure I’m understanding this right. What I heard from that question is basically a traumatic spinal cord injury versus a non traumatic spinal cord injury.
So your traumatic ones obviously, you’re probably going to be involved more from a motor vehicle accident, from a fall, from violence, but your non traumatic ones can happen from aging, you can get some bone spurs that develop a start to cause some pressure on the spinal cord. It could be, maybe you’re outside playing with the grandkids or something and you happen to have a slip and just kind of come down and over time start to have this decrease in sensation or movement loss because of something that happened there. You could have a bony tumor that kind of grows in that area, right. So those are non traumatic types of examples. But the bottom line is you then get compression on the cord. What was the level lumbar?
Tim Benak
No level, just AIS D.
Brad Dexter
But then the key there is we identify, where’s the neurological level of injury. And then over time, they could become an AIS D if over half of those muscle groups below the level of injury return. So maybe initially after that injury, they’re very, very weak, maybe have nothing. But over time, those muscle groups gradually maybe strengthen back up, the signals are able to get through that area of the spinal cord again, and that’s when they would become classified as an AIS D because your muscle function has changed information getting through, that level of the spinal cord has changed.
Tim Benak
Again, keep asking questions. I’m going to go ahead and launch the poll right now. So everyone should see the poll on their screen now. Brad, we have 305 people on with us today. It’s awesome. Because that record for you that’s close to record for you. You don’t pull the quite the audience’s Dr. Snell. But you are in my mind. Just as interesting.
I’m totally kidding. You guys both bring in a lot of a lot of people to view your webinar. It’s fantastic education, fantastic information. So look at that. 245 people saying they’re gonna join you next time. Awesome. I’m excited for that. Okay, so another one. Another question here, a few of them actually coming through right now.
As patients improve, as you describe, at what point would you expect them to plateau in their functional capacity? i.e. one to two years? Like when do they hit that max?
Brad Dexter
Yeah, so one, I’m going to just say, I’m a big believer in learning, right? I’m a big believer in neuroplasticity, the ability of the brain, the spinal cord to change if the right ingredients are there to challenge the body to challenge the nervous system.
That being said, if you think about a graph and on the x axis is is time the y axis is progress, you look within the first 12 months and your rate of recovery, your rate of progress is going to be a lot higher in those first 12 months than it is in the second 12 months.
A lot of the research out there is going to tell you, you know within the first two years, this is first 24 months, this is kind of what that recovery graph looks like. And you have a steep incline the first 12 months and then it starts kind of tapering off a little bit more in the next 12 months. And so within two years time, you should have a good idea of how the body is going to be functioning and what movement, what sensation you have back.
Now the catch on this is that progress is going to keep happening beyond the two years. The rate of progress is going to be drastically slower than it was in the first 12 months, but it’s going to keep happening. And the reason it can keep happening, if the right ingredients are there, is because we can challenge muscle groups that are available, we can challenge what they have to try to strengthen it and try to improve it.
Now, with our with our high cervical level injuries, that may mean actually giving them access to more assistive technology to allow them to become more independent. So you may not make a change to their body, so to say, at the three year mark or the four year mark, but you may actually make them go from being dependent on someone all day to maybe they can stay home for two or three hours on their own because their environment is changed. So you know, that’s an example of how I would think about it with a high cervical level injury, AIS A or B. But, the C or D, maybe we’re looking at beyond that two year mark, we’re able to kind of strengthen different muscle groups and continue helping them improve function a little bit more too.
Tim Benak
Okay, I did go ahead and close the poll. So a few things just to touch on here real quick. No, the part 2 invite has not been sent out. It’ll be sent out following this webinar here. As always be on the lookout in the next few hours or so for your follow up email containing your evaluation or sign up for the next one. And please check us out on social media. We take a lot of pride in telling stories of the individuals that we serve. And so it is an extremely impactful way to gain some information about this population. So please go and check us out on social media QLIOmaha.com, teamQLI.com. We post a lot of blog stories on there that we would appreciate you looking at.
And also Brad’s contact information is up on the screen, so feel free to reach out to him if you have any other questions. Also, you can reach out to QLIWebinars@QLIOmaha.com. And Taylor and I can come forward on questions that Brad may need to answer.
Next one will be part 2. That’ll be on October 28. So again, look out for the invite there. We did have a few questions that we didn’t get to, so I’ll make sure to get those over to you.
Thanks, Brad. Thank you everyone for joining us, and we look forward to having you join next month. Take care.
Categories: Spinal Cord Injury