In Part 2 of our webinar series on spinal cord injuries, Brad Dexter of QLI focuses on low cervical spinal cord injuries and covers 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
Tim Benak
All right, good morning, everyone. Welcome to another webinar Wednesday here in studio Q. I’m Tim Benak. And I’ve got Brad Dexter here with me this morning as well to continue our series on spinal cord injuries.
So this is part two, managing the diverse needs of an individual with an SCI. And this is low cervical spinal cord injury.
So I hope you had the opportunity to join us for the first one. And if you didn’t, you can always reach out to us and request a recording of it and we can get that sent over to you. But we do have two more coming after this too. I know Brad knows that. He put them all together.
Brad, welcome back to studio Q. Appreciate you being here.
It’s good to have you. Coordinator of therapy therapy services here at QLI. Been here. How long?
Brad Dexter – 00:53
Coming up on 10 years.
Tim Benak – 00:55
10 years. Man. I’m coming up on five years. I feel old. You look old too. I’m totally kidding. I do have a lot more gray hair than you do. You give it to me. I’m blaming it on you. And Steve.
You know, I always like to touch on the fact that you’ve been here 10 years. Over the last two years, you’ve kind of made a transition over to our telerehab team, extremely involved still in our inpatient side.
But just to kind of really show off your wide range of expertise, you know, you’ve been able to take what you learned in eight years, nine years, now 10 years on the inpatient side and transitioned over to the telerehab side but as well as continued to be involved in so I know the teams are super happy to still have you there. It would be a loss to have a completely disconnect from that program.
Brad Dexter – 01:40
Yeah, well, I mean, spinal cord injury has kind of been something that that I’ve really enjoyed working with as a physical therapist over the years, but have also loved getting to work with your stroke population and traumatic brain injury as well. And so you know, get it I get to do some of that with the telerehab but still getting to pass on some of my my knowledge, do some coaching on the inpatient side with the spinal cord injury team.
Tim Benak – 02:05
Absolutely. Well, I won’t take up too much time. I do want to just touch on a few things for everyone. If you’re familiar with our webinars, you know that there will be a poll question towards the end. Please answer that. That lets us know that you’re wanting your credit for attending, as well as we do like this to be a conversation.
Brad and I get to sit here and stare at each other. And that gets pretty old pretty quickly. totally kidding, right?
But no, please ask questions along the way, I’ll make sure to be monitoring the chat. And then we’re also going to engage you guys a few times throughout. So we would like some participation. That way we kind of know, if we need to, you know, touch on a few things that maybe aren’t built into the presentation, add them in there and we’ll make sure to get them over to Brad, and we’ll try to answer them all live. There will be a question answer at the end. So that being said, it’s all you.
Brad Dexter – 02:56
Yeah. All right. So Tim hit on the title, obviously, we’re going through a series on managing the diverse needs of the individual with a spinal cord injury.
So if you’re able to catch the last one, we covered high cervical spinal cord injury. And so when we say high cervical, we’re looking at level C, one through C4. So part two today is low cervical spinal cord injury.
And when we say low cervical, we’re referring to the level C5 through C8. So that’s kind of going to be our jumping off point today.
If you did join the last session, you’ll see that we have some repeat information in this presentation. I want to hit on it again. I think repetition is key, one of the key parts of learning. And so you heard it once you’re going to hear it again, you’ll probably hear it a couple more times from me in terms of going through ASIA scoring, levels of injury and just doing some basic education in those regards, but excited to present this topic today and just share some of what I’ve learned over the years with you guys as well.
Objectives of the Spinal Cord Injury Webinar
So with that, let’s proceed. Objectives.
- Making sure you guys understand basic terminology behind classifying the spinal cord injury.
- Be able to describe expected prognosis due to injury level and trend in progress
- Recognizing the impact of spinal cord injury on annual lifetime cost, return work marriage
- Identifying and applying appropriate goals based on injury classification.
Injury Classification – Paraplegia Versus Tetraplegia
So starting out with the basics again, paraplegia versus tetraplegia. Just a reminder.
Paraplegia
Paraplegia generally your upper extremities will not be affected if an individual has paraplegia. Varying amounts of the trunk and the lower extremities will be affected.
Tetraplegia
If an individual has tetra, or quadriplegia. That means all four of the limbs are going to be affected from the spinal cord injury, and quadriplegia or tetraplegia, is going to take place with a cervical type of injury because the higher up the injury, the more of the spinal cord is going to be affected.
So everything downstream from that injury level is going to be affected. And we know that the cervical region is higher up than thoracic, lumbar, and sacral. So that’s why more of the body gets affected.
Injury Classification – ASIA Impairment Scale
So then we want to jump into the injury classification. We talked last time about the ASIA impairment scale. And again, we’re just going to revisit that the reason we like to use the ASIA pyramid scale.
It’s a way to kind of define describe the extent of the injury and the severity. It helps us understand and determine future rehab and recovery needs.
And ultimately, there’s five classification levels that kind of help us understand that progress, and predict kind of what’s going to happen down the line.
So here are the five injury classifications that we we generally talk about. So there’s A, B, C, D, and E. And if you guys are just reading this off of the screen, that’s okay. But what I want you to do is try to visualize with me just a sliding scale, right? Maybe even from 0 to 100. And at 0, that’s kind of where AIS A is at. And 100 is where that AIS E is at.
So AIS E is basically everything is returned to normal. AIS A though, is a type of injury where there’s a pretty severe lesion and there’s no information getting through that level of the lesion. You have a complete lack of movement and sensory function below the level of injury.
Now, in between 0 to 100. Obviously, we have a sliding scale there. And as we move through these, you know B, C and D, you can kind of think about those as different points along that sliding scale.
So, an AIS B type of injury is one where you’re starting to get some sensation below the level of injury particularly around the anus, the anal area. And that area is identified solely because it’s related to sake the sacral part of the spinal cord, which is the lowest part of the spinal cord.
So, you know, if the lowest part of the spinal cord is still getting some amount of information through, you can start to then classify the injury as incomplete, and it becomes AIS B. Complete is AIS A. Incomplete then is everything else below that, on this slide.
AIS B injuries, we start to introduce some amount of motor, so some amount of movement is present below the level of injury, but not quite enough movement to be able to fully move against gravity, right.
So maybe there’s a little bit of toe wiggle, or maybe that individual has started to be able to voluntarily contract the anal sphincter to help with bowel control a little bit. Perhaps, they they can kind of pump their ankle up and down.
So those types of movement showing up below the level of injury starts to classify someone in that AIS C realm.
AIS, D, then you have more movement present below the level of injury, more sensation present, whether it’s normal or diminished. But what you start to see is the individuals able to push themselves up against gravity. So this might be a person that’s able to start standing on their own, perhaps they’re most likely they’re able to start doing some amount of walking on their own as well.
So their muscle strength is, is adequate enough to hold up their body weight against gravity. That doesn’t mean that balance, and some of the other components are all there as well. But it does mean that they’re able to start using that movement a little more functionally.
So again, coming back to that sliding scale, 0 on that sliding scale is kind of like the AIS A. 100 on that sliding scale is like the AIS E. And then in between there, you can kind of put on the B, C and the D.
How QLI Determines the ASIA Score
So I want to talk a little bit about how we carry out this exam. This is the exam that we actually do. So we look at key sensory points on the body, we look at key movement points, key motor points on the body.
We can identify all those points through dermatomes, and myotomes.
- Dermatomes are basically a map of the body of where sensation is taken from and carried back up to the brain, from the body.
- Myotomes are a muscle map of the key nerves or the key levels of nerves that provide innervation to specific muscle groups.
And so, you know, if I’m working with an individual for the first time, I think it’s really helpful to go through an exam like this and to get an accurate picture of what’s going on.
It’s one thing for me as a clinician to say, well, where can you feel and what can you move. That’s kind of that’s a screen, that’s not good objective measurement.
This is much better objective measurement to tell exactly where we still have sensation and where we have movement, and then to start educating the individual, the family, case managers on where the injury currently is, where it has been, and potentially, where it could go in the future based off of how they have been trending.
So on the body here, the colorful picture on the dermatome map, you can see that we have specific areas of the body that are related to specific levels of the spinal cord.
So, for example, C4, we can test out on the tip of the shoulder, C5, we can get kind of down on the the outside of the elbow, C6 is the back of a thumb, C7 is the middle finger, C8 is the pinky finger, T1, on the inside of the elbow, L3, you know kind of down on the inside of the knee, L4s inside of the ankle, and so on and so forth, right so you can kind of see that map.
We would go through pinprick and we would go through light touch types of sensation, because those types of sensation are carried in different parts of the spinal cord. The pinprick type of sensation is carried on the backside of the spinal cord and the light touch part of the sensation is carried over on the sides a little bit more. And so it helps us also identify different areas that may still be intact.
Likewise with the myotomes, we know that if we test the bicep…So we have someone bend their elbow and hold that, that’s checking C5. If we have them bend their wrist back, that’s going to check C6. C7 is tricep. So having them extend their elbow and and essentially having a tug of war against them, not letting us bend their elbow at that point.
Down in the legs, if they’re able to extend their knee or straighten their knee out, that’s L3. L4 is kind of picking up their ankle. L five is picking up their big toe. And so again, you can just see that we can identify those specific areas through those means.
So we come back to this and we enter all that data. And it helps us analyze, where is the lowest level where we still have normal sensation, and normal motor. And that would be the level that we identify as their injury level, the neurological level of injury.
That’s different than the vertebrae that were broke in an accident. So oftentimes, I may hear someone say, Yeah, I was a, C5, a C5 and C6 done, but I think I’m functioning more like a C7 now.
Well, let’s talk about that a little bit more. C5 and C6 were the vertebrae that were fractured in your accent, or even a C5 kind of sub blocks or moved over C6, and so you had an injury site there. But Gosh, we’ve we’ve had enough recovery now that you are kind of functioning as a as a C7 level injury, right?
So the C5 and the C6 were the levels of the bones that were broken, but C7 is the level that we have normal sensation, normal movement function through.
So that’s that’s a really important differentiator when it comes to completing these types of tests too.
So we identify that neurological level of injury, and then we’re looking at, is there any sensation or any motor below the level of injury? If not, that’s an AIS A. If we do have some sensation, well, do we have it down in the perennial area and the anal area? If so, then they would shift to an AIS B.
If they don’t have any sensation in the anal area, they’d still be considered in AIS A with some sparing of sensation below the level. So the key indicator that shifts them to an AIS B type of injury is the sensation in that annual or perennial area.
AIS C then we’re looking for well, do we have obviously sensation in the anal area? That’s going to be a yes. Now, do we have any kind of motor below the neurological level of injury? If the answer is yes to that, How much motor? Is it less than 50%? Or is it more than 50%? If it’s less than 50%? It’s an AIS C.
If it’s more than 50%, then that bumps up to the AIS D category.
So again, we’re looking at all of this and after I’ve taken in that information, I’m starting to think well, where was this person three months ago? If they had this test done a month ago, where were they? And how much have they changed? Because then we can start to look at how are they trending? If an individual was in AIS B at their initial assessment early on after their injury? And, you know, four to six weeks later, they’re at an AIS C, well, that’s really positive. That’s a lot of progress. A lot of sensory and motor gain, within a relatively short period of time, right?
Spinal cord injury, we’re always thinking long game. We have to expect that recovery can keep happening over a long period of time, right? Four to six weeks, that’s an ankle injury type of recovery. That’s not spinal cord injury, full recovery. That’s just the beginning of it, right.
And so, if a person is trending like that, I’m thinking, in the back of my mind, I’m thinking to myself, wow, this person has a lot of potential, I want to see what we can get out of them.
On the flip side, if someone’s had, let’s say they’ve been out in AIS B, and they’ve been there for, you know, nine months, and there hasn’t been a lot of change. Well, we’re starting to think this might be what we have to work with moving forward.
That doesn’t mean that we can’t gain strength. We can’t gain functional mobility, that we can’t gain independence through compensatory means or compensatory strategies. All of those things require the the eyes of a skilled therapist and a skilled rehab team to help identify and start to pull out those goals and work toward them.
But it does mean that hey, if you’re a C6 AIS B for nine months, well we’re probably looking at C6 AIS B moving forward. Right?
So those are the types of things that we’re kind of looking at when we are going through this type of testing and helping to educate all of the parties involved.
Injury Classification – Complete Vs Incomplete
All right, so I talked to you about kind of that sliding scale earlier. That’s one analogy I like to use. Another analogy I like to use if you want to keep this in the back of your mind is the styrofoam cup analogy, right.
So if you have a styrofoam cup, you put it underneath the sink, turn the faucet on, there’s not going to be any water that gets through. That’s like an AIS A type of injury, you know, there’s no information getting through that level in the spinal cord
However, you start to poke a couple holes in there and you get varying amounts of fluid that starts to come through. If you put that under the sink, water is going through starts trickling through.
Think about a spinal cord injury and the incompleteness of that injury in the same way.
If you poke a couple holes in that cup, that’s kind of like an AIS B, you start to get some sensory information trickling through. But the more holes you poke in, you start shifting to an AIS C, AIS D, and more information is getting through that site in the spinal cord.
A quick aside, when when an injury to the spinal cord happens, the body has a mechanism where it sends specific cells to the area to kind of wall off that area and to help it start healing right. The problem is those cells don’t transmit the electrical signals that are going through the spinal cord.
Those cells are called glial cells. They come in, they add structure, and they add support, but they don’t allow for the neuro transmission of those electrical signals. So over time, you can kind of see the size of that start to kind of shrink. You think about a target, right? And that target going from the outer layers that inner layer. That’s what that’s what’s left of the scar, the glial scar and the spinal cord over the long term.
And so that’s also another way that you see progress or changes in sensation and motor over the course of time with an individual who’s had a spinal cord injury. There’s just kind of levels to that area as it’s trying to heal, that start to wake up a little bit more for lack of better terms.
What do Spinal Cord Injuries Really Cost?
Well, one thing I showed last time, and I’m going to reiterate it again today, just to compare is the cost of spinal cord injuries. And I’m going to put all these numbers up here for you guys.
One thing to note, the health care system has changed, obviously, over time. That’s no surprise to anyone. We used to have individuals with a spinal cord injury have really long lengths of stay within rehab before they re entered life within the community again, and that time has really shrunk, the time in the acute setting and then the acute rehab stay has shrunk to under two months on average.
And that’s lumping in cervical or quadriplegic and paraplegic types of injury. So cervical, thoracic, and lumbar all together. Okay, so you might imagine that a cervical level injury is going to have a longer length of stay than than a thoracic or lumbar level injury, just because of the amount of help that they are going to need.
But a couple things I want to point out on this slide, those high touches the high quadras first year expenses for them looking at $1.12 million. First year expenses for a low quad, what we’re talking about today is C5 through C8, a little lower than that. So $816,000.
The average lifetime costs for those high quads. If they’re injured at a younger age, it’s close to $5 million. And for the lower quads, it’s closer to $3.6 million. And as we start to go through some of these specific areas of function through the rest of this presentation, you’re just going to see that the caregiver support needed for those lower quads, the level of independence is going to be different than the higher quads. And so that’s going to be a part of that cost differential there.
Tim Benak – 21:48
All right. Got a question for everybody. Brad, ready for it? All right. So Brad and I were talking yesterday, and we’re just curious, for anyone who’s had experience in managing these injury classifications. What’s something that’s been confusing or surprising to you?
Pretty timely, just after the the cost slide. It could be about anything, doesn’t have to be about cost, but that kind of made us think of asking you at that time. So if you can put that in the chat. And we will give everyone a couple seconds here to put your comments and then we’ll discuss a little bit.
Someone said how medicine has advanced and an SCI does not mean a wheelchair for the life of an individual.
People are talking about just the quicker discharges, that’s been surprising or something that they’ve experienced with significant injuries through, you know, obviously, you mentioned healthcare changing. That’s definitely something we’ve seen as well, quicker discharges, especially from that acute setting, pretty quick turnarounds there with healthcare lately.
Another one we have, how the scores can change and different providers give different scores. That’s something to touch on. We’ve talked about that internally, too. And you touched on having make sure a specialized therapists looking at these individuals.
Brad Dexter – 23:32
Yeah, so a couple thoughts based off of those comments, Tim. One of them was, one of the comments that you read was that, you know, just a spinal cord injury doesn’t mean wheelchair necessarily.
And, you know, that’s actually one of the reasons why I was interested in doing this series of presentations, is because I remember as a new clinician, and having been a clinical instructor for students for almost 10 years too, you know, I think the common perception for a spinal cord injury is, well, if it’s a C5, it’s a C5. C5 is a C5 is a C5. That’s not entirely true, right.
And we see why as we go through the AIS scores. There are going to be different levels of function and mobility present in an individual’s body based off of, to another comment on there, perhaps the quickness of the attention that they received after they had their spinal cord injury.
So how quick, you’re able to get into the hospital and relieve inflammation early on is also going to impact the level of the severity or the extent of the severity of that injury in the spinal cord too. Those things are tied together.
And then the difference between providers. That was an interesting comment, too. In the statistics world, there’s terms called intertester reliability versus intratester reliability. And what it says is essentially, if one person is completing the same test over and over, that testing or the outcomes of that testing is going to be more reliable than the intertester reliability. Because that person is going to do it the same way, they’re going to carry it out the same way.
And so there are certain tests that they’re going to look at, inter and intratest reliability before they push those out. And, this is one of those tests that the intertester between practitioners, that reliability is slightly lower than what it could be.
There are some factors, you know, if someone has a broken arm on one side, you can’t test that. Well, it’s it’s as part of their injury, right? It’s hard to completely get a good testing as you go through through that. And then if they shift to another provider, I know personally, I’m always looking at, well, where did they test before? How am I based off of what I’m seeing? I don’t want to bias myself necessarily, but based off of what I’m seeing, how well does that match up? And why if there are differences, why are there differences between our testing?
So just being smart about how you do that.
Tim Benak – 26:20
I mean, in line with that someone mentioned, AIS scores are not being reevaluated as the injured worker progresses. Do we see that? Or is that something you’ve seen? I guess that would probably change if they are switching providers to your point, right. Typically, those those evaluations are being redone. But if someone stays in the same system, how often are they being done?
Brad Dexter – 26:43
I think ideally, what’s been talked about is if it can be done within the first 72 hours after an injury, it can be done within the next two weeks, four week mark, three month mark, then I know some of the model systems centers are going to test at the six year, annual and then at the two year mark, as well.
And I think it’s generally done like that, because, in general, I think the two year mark is kind of, well, you know, we’ve gotten to a point where we’ve probably accumulated the majority of our progress. That doesn’t mean that progress can’t keep happening, but in terms of the maturation of the healing of injury site, we’ve probably reached a point where the spinal cord healing has matured.
Tim Benak – 27:25
Absolutely. Okay. There’s a few more, but we’ll touch on them later on.
Body Function Available
Brad Dexter – 27:28
So we’re gonna jump into just some specific areas. You know, whether it’s eating, grooming, hygiene, ADLs, transfers, walking, we’re going to start to get into some of that, here next. But I want to highlight body function available with these low cervical injuries. I’ve broken this down, and C, five, C, six, C7, C8.
So last time, we talked about C, one through C for injuries, that’s that’s pretty high up. You’re looking at folks that just basically have some shoulder shrug. If they’re a complete injury, right, you get into the C’s and the D’s, and maybe they get some more movement below that level of injury.
But some key areas, key muscle groups that are going to come into play, and we have so much so much variance between a C5 and a C8, and you guys are going to kind of hear that theme as I go through and progress through the the coming slides here.
But at a C5, you start to get deltoids those shoulder muscles that kind of help you do the chicken dance if you guys do the chicken dance, right. So the deltoids and the biceps, which bend your elbow.
So those are key muscle groups that come into play, they’re really helpful the biceps especially, are going to be really helpful for for eating, getting the hand up to the mouth, and even helping to get hand up onto a joystick to drive a power wheelchair. So those are those are big things.
And then we can start to train the biceps for some other intentional movements to help people compensate to do different things, whether it’s pushing a manual wheelchair, or even potentially helping with their transfers a little bit rolling in bed.
C6 level injury you add in muscles that help with extending the wrist. So if you have your palm facing down and you kind of lift your hand up, those are the muscles on the backside of your forearm that allow you to do that. That one’s going to help a lot more with eating. If you get those muscles back.
Serratus anterior is another muscle, it’s called the boxers muscle. So you think about a boxer kind of reaching out to punch someone, that’s the muscle that does that movement, but that muscle can help with a person if they kind of fall over in their chair. So they have their seat belt on they flop forward, it can help them kind of push themselves back up into a seated position, gives them a little bit more independence during their day. And it also can help them with their sideboard transfers and the pushing movement to get across the sideboard into a wheelchair.
C7 is a game changer. And I’m not speaking in hyperbole at all with that. You get triceps back and you’re able to extend the elbow and it gives so much more independence to an individual.
It allows them to transfer so much more easily in and out of bed over onto a shower chair a shower bench. That impacts the environmental modifications you need to make and the help that they may need in the long term.
C8 level injury, now you’re talking about someone that has the ability to make a fist. So we’re getting fine motor movement back. The one thing that you may see with a C8 level injury is the inability to kind of spread their fingers out. So they may have that ability to make the fist still, but T1 is actually the level that gives them the ability to spread their fingers or if you guys can make a Spock hand which is what I’m doing right now and so as Tim, I’m proud of him, you know it can do that type of movement to a T1.
So if you remember C8, you can’t do a Spock with a C8. There you go.
Alright, so just a little more functionally your AIS A’s, they’re going to have head neck movement, shoulder shrug, and gross upper extremity use. B’s are going to be the same.
AIS C’s, you’re going to start to add in some weak use of all of the muscle groups below the level of injury. So you’re starting to pull in respiratory muscles, abdominal muscles, you know more strength probably in your upper extremity muscles and lower extremity muscles.
And then AIS D as we go along that sliding scale right? stronger use of all of those muscle groups below the level of injury available.
Bowel/Bladder
Bowel and bladder. I’m going to fly through this one. It was in my presentation last time too. Just in general, things with this population. So low cervical spinal cord injury that we want to consider. What did their routine look like before their injury? What was their diet? What is their diet currently? What’s their hydration look like? How much are they exercising? Are they using medications that that might be hardening their stool a little bit more or softening their stool too much which could lead to accidents.
What’s the timing of their program look like? Is it after a meal, is it before a meal? Is it in the evening? Is it in the morning? When is that happening. We always want to think about what’s going to disrupt your day the least. If you’re going to need caregivers in the long run, when are you more likely to be able to get those caregivers to come in? And so looking and considering those things as you’re setting up a bowel program.
Positioning on the support services is always impactful as well. Any pre morbid conditions, that could impact the bowels need to be taken into consideration.
Bladder management, you know, as we add in more fine motor function with the 7’s and the well actually 6’s, 7’s and 8’s was some tenodesis at C6. Those folks may be able to intermittent cast themselves a little bit more. The C5s, you’re looking at perhaps needing fully catheter or or even moving to a suprapubic catheter in the long run if they’re not able to manage their bladder on their own.
Hydration is key. They’re still looking at a fairly high incidence of UTI’s in this population just due to the frequency of inserting foreign body into the urethra. And then sometimes, you know, with the 6’s and the 7’s, they may be doing intermittent cathing. They may not be able to do appropriate hand hygiene or as good as they want to and so you could get some bacteria, exposing the urethra that way as well.
These injuries so the ABC and D any of these injuries in the cervical region are going to lead to spastic bowel and bladder, which means it’s going to need help kind of opening up the anal sphincter. You’re A’s and B’s are going to have a variety of skills. Your C5’s and your C6’s may need some help.
C6’s may be able to get to a point where they can do their own bowel program, they can answer a suppository. Your C7’s and your C8’s, as long as their body type is right are going to be able to cath themselves and they’re going to be able to do their own bowel program for the most part. They’ll be able to transfer themselves over and insert depository or do a digital simulation as necessary. But due to a lack of fine motor control, the C5s are likely going to need more help.
The C’s and D’s because we’re looking at maybe getting some more motor, some more movement below their level of injury. That may mean maybe they have some voluntary control over their anal sphincter. And perhaps they can get to the point where they can volitionally void or perhaps they’ve regained, even a C5 has regained a little bit of fine motor or bicep strength that would allow them to complete a bowel program entirely on their own too.
So here in this section, I want you to think C5 gonna need the most help C8, the least amount of help AIS A more help than an AIS D. Okay.
And you’re gonna hear me, you’re gonna hear me as we go through all of these. Again, there’s just so much variety in this C5 C6 C7 C8 range that there’s a lot to really cover. So I’m going to try to condense that as best as I can.
Skin Considerations
Again, your A’s and B’s in this group, they’re going to have less sensation. Your A’s that sensation will be absent below their level of injury. So it’s really really important that we look at all the surfaces that they’re on, wheelchair, commode, chair, bed. And we’re considering those surface ties, we’re doing pressure mapping, and making sure that we know what appropriate positioning looks like and we’re educating as necessary.
B’s, you may start to get some amount of sensation below, even to the point where an individual who’s using a manual wheelchair or power wheelchair starts to get some body feedback that tells them, I should probably pressure relieve right now I’m starting to get a little uncomfortable.
Your C’s and D’s, we were going to have some diminished, even some absence sensation below the level of injury but more is going to be there and they can typically rely on their body giving them the feedback that they’re uncomfortable and that they may need to change positions.
What we need to get specific on is the areas that we see from doing AIS testing, where they may be absent in sensation. So if they have a lot of sensation through their trunk and even on their legs, maybe they’re missing some on their heels, maybe a little bit on their bottom yet. And we need to educate them on the fact that hey, you can feel in a lot of places but here are some areas that are still prone to skin breakdown that may be some issues for you moving forward.
So pay specific attention to your heels, make sure you’re using the muscle action that you have to move your body around frequently throughout the day, even if you’re using a wheelchair.
I just think about I think about myself so often, I can’t just sit in one spot. I’m constantly moving my arms here, I’m shifting around in my chair, I’m moving forward and backward, you guys may be doing the same. Perhaps you’ve even left the room as I’m talking because you got bored with what I’m saying? But hopefully not.
So that’s an area that we need to get real specific on in helping people understand and protect their skin over the long run.
Seating and Positioning
A wide variety of seating options for this group. Most of our C5s are probably going to end up in a power wheelchair. If they move into a manual wheelchair, they may not have enough upper extremity strength to propel a manual wheelchair entirely on their own. So we may be looking at power add ons for C5s. And power add ons maybe like your power assist wheels made by emotion or a smart drive.
There are actually a number of products on the market now that you can add on to a manual wheelchair that gives some amount of power assist to the individual, as they are using that manual wheelchair.
So your C5’s, again are going to be the ones that are more likely to end up in a power wheelchair. The C6’s, 7’s, and 8’s are likely going to be in manual wheelchairs.
I say likely because if you get that individual that perhaps is a little older, or they’ve had a high prevalence of shoulder injury in the past, or perhaps their their body type, just maybe they’re big enough that a manual chair doesn’t make sense. Those folks may end up in a power wheelchair, just to give them a little bit more independence.
But with the muscles that you add on with a C6, C7, C8 type of injury, functionally those folks should be able to propel a manual wheelchair on their own. And you may be looking at then power add ons for community distance.
You know, I think a lot of therapists at least are in favor of some of those power add ons, especially for preventing shoulder injury in the long run. Again, those levels of injury are starting to push manual wheelchairs a lot more, they’re using their arms for all of their transfers and we’ve we’ve just got to think about how do we preserve your shoulder health in the long run. So you’re not, you know, ending up with a shoulder injury that’s going to start to limit your independence, 5 to 10 years from now because of overuse, right. So those are things for us to think about.
So that was kind of going through level by level. You look at your A’s, you know, C5, C6, C7 and C8, you’re looking at all of them probably being in a manual wheelchair, or a power wheelchair. The B’s again, manual wheelchair power wheelchair. Your C’s, probably again using using a wheelchair but your D’s you may start to get them out of the chair. They may be walking around full time or they may need like a manual wheelchair for some longer distance mobility.
As a therapist and you’re weighing how far could this person walk? Are they appropriate for community distances? Is it just residential distances? And a lot of that is going to also depend on how much toner spasticity they have, how much freedom of movement they have from the strength available to them.
Transfers and Bed Mobility
Your C5’s again here are going to be more dependent than the 6’s, the 7’s and the 8’s. We have had some C5s that have learned how to slide board transfer themselves but they still have needed a support person available to prevent a fall. Many C6’s can get to the level where they can independently slide board transfer themselves. That includes the placement of the sideboard.
The 7’s and the 8’s, they’re going to be able to use a slide board to transfer themselves in and out of vehicles, in and out of bed, in and out of their shower chairs or shower benches. And they may even be able to get away from using a slide board and do what’s called more of like a squat pivot or a popover type of transfer.
So our C5’s are also going to need a lot of help with rolling still. They may have the ability to kind of hook an arm under a bed rail, and use their biceps to pull themselves onto their side, or at least to help with that. But then you get into your 6, 7, and 8 and many of them as long as they gain the strength.
That may take a little while after the initial injury, but as long as they regain that strength, they get to the point where they can complete their bed mobility on their own.
And then, just looking at this from an AIS score standpoint, our A’s and B’s, likely using more slide boards to transfer based off of the information I just gave you. You get into the C’s and D’s and perhaps we can start using some stand pivot transfers with a walker and that, around the D’s, we may be looking at more stand pivot transfers, either with assistance or completely on their own. So just depending on what their balance ability is, again, level of tone, spasticity, and strengthen their legs. That’s kind of what we’ll be looking at for them.
Walking
Our AIS A’s and B’s, and all of these low cervical injuries are going to require some amount of robotics to walk just because lower extremity use will not be there. But once we get into the C’s and D’s, we may have some ability to start taking some steps, either within the robotic system with an AIS C or within a bodyweight support system with an AIS C level injury.
And with the D out of some of those systems even walking over ground like you see in this picture here. So those again, are the folks that have ever recovered over half of their muscle groups moving against gravity below that level of injury, gives them a good shot of getting on their feet again, and as maybe some of you guys have called, become a walking quad.
So a lot of the time, when we start to see people at our inpatient level, they maybe just started doing some short distance walking, or they just have the ability to stand and do a pivot transfer as an AIS D. And so there’s a lot of recovery, that still needs to happen from a gait training standpoint, even around that three month mark, when we typically get them.
Grooming and Hygiene and Eating
For our 5, 6, and 7 level injuries, we’re probably going to need some kind of grip assistance on the devices that we’re using. So you see some pictures over on the side here, of different assistive devices to help them do that. Your C5’s are going to be able to at least maybe bring hand to mouth. They may be weak still and need to strengthen the biceps, and some shoulder muscles to help get the hand all the way to the mouth. But they definitely will need the grip assist.
The C6’s, they may need the grip on utensils built up a little more. But they can use what we call tenodesis, which is that you know, lifting the hand up and bending the wrist back. As you do that your fingers kind of start to naturally curl, and it helps give them some amount of grip. And so they may be able to do that with a built up handle.
C7 would be the same way. We may be looking to preserve that tenodesis for them. And C8 we said C8 starts to get those finger flexors so they can actually start to grip things a little bit more, but would still be perhaps weak on their fine motor control and need that to be built up.
One difference in this area between the A’s and B’s, and the C and D’s would be, if we have someone that’s an AIS C or D, and they have some amount of movement, and that tenodesis range, maybe we start to break through some of their tenodesis. So we don’t want those tendons to tighten down in the hand because they’re starting to get some of that movement back below the level of injury. We want to try to strengthen the fine motor control that they have to give them grip back.
Versus an A or B type of injury. C5, C6, C7? Well C5 through C7, AIS A or B, those injuries, we’re probably going to help them preserve that tenodesis to allow them the functionality to use these devices and be more independent in the long run.
Assistive Technology
You know this is an area of the market that we all benefit from as well. But because most of these levels of injury are dealing with decreased and fine motor control, they’re not going to be able to type in the same way that we do. They may not quite quite be as fast and so if they’re looking to get back to school or to work, using voice dictation to write papers, to type, those types of things may be easier than just using a stylus on a keyboard.
But the important thing is that we need to kind of explore those paths with each individual because some folks may not like the dictation they may want to go a little slower and use a stylus to type.
A lot of the smart home technology that’s out there right now can also be of great assistance, whether it’s turning off lights or operating devices within the home, accessing your phone without needing to push buttons or things like that. You see some of the phones going to just face recognition instead of needing to push a button to get into the phone in the first place. And so those types of changes are happening for the general public.
This is a bit of an aside here, but we’re just working with a gal for a short period of time recently, who said, I really love some of the changes that have come from the pandemic, because I feel like I’m on an equal playing field. I don’t have to be that person that, you know, because my walking isn’t that great, everyone thinks is going to fall down when I go into the store to pick up my groceries.I can pre order and just go pick them up in a line or have them delivered to me and everyone’s doing that right now.
I feel like phones and smart home technology, it’s moving in that same direction too and has been moving in the same direction, where it’s kind of like an even playing field. It’s just kind of considered normal. And so there’s a lot of functionality from our devices these days that allow folks to access it as they would prior to a spinal cord injury as well.
Environmental Modifications
I talked earlier about you know, environmental modifications, essentially decreasing as you move from AIS A to AIS D, you gain more movement. But also, as you move from a C5 down to a C8, so lower that level of injury, you require less modifications within the home.
So your A’s and B’s may needs some more of that smart home technology ramps present, open designs within the home. You may need more renovations done to be able to access the home environment. Harder floors for pushing around a manual wheelchair on. Those types of things.
Your C7s and 8’s, it’s going to be easier for them to get around as an AIS A or B within those settings than it would a C5 or a C6. And then likewise, your your AIS C’s and D’s for these injuries, it’s going to be a little bit easier for them to get around as well. Your D’s especially may not need as many modifications done to their homes because they may be on their feet, they may be able to walk around and not utilize a wheelchair within that home setting.
Tim Benak – 49:54
All right, Brad, got another question here for you. This is more for the audience, for some engagement. We were just curious. How many of you think that ADA laws allow individuals to freely access built environment, which is a new term that I’ve learned yesterday from Brad.
And then also what issues do you see individuals commonly encountering in their home or community environments? So give you a couple seconds here, if you can put your answers in the chat. And then we’ll have a quick little discussion about it.
So the question was, if you have experience with these injuries or managing these injuries, what are some issues talking about ADA laws that you may see individuals encountering in their communities or their home environments.
Size of doorways, bathrooms not everywhere being wheelchair accessible, mainly stores, individual having to go to stores to get things. I’ve seen that as well, where you kind of look around, I think in our world, you notice those things on your own a little more, and you just kind of have a little bit more empathy for realizing that individuals might not be able to access things they want to because of those types of limitations. So, one other one, older homes, we run into that often as well.
Brad Dexter – 51:40
So ADA laws have been in there, they’re more recent within the last 30 years here. And so there have been certainly really good changes that have happened because of that, that have helped a lot of public spaces to retrofit their storefronts or the design within their stores to allow for better accessibility from individuals that may be utilizing a wheelchair as their primary mode of mobility.
It carries over into all of those public domains. But houses and apartment buildings don’t have to be built necessarily to allow for complete access of an individual that is using a wheelchair. And so you may, especially with apartments, a lot of the time we run into this a lot when we’re looking for placement for folks. Maybe the home isn’t the best place because it’s older and it would take a lot of money to renovate that. But could you go to an apartment for some amount of time and those apartment buildings, it’s always the minimal, necessary things that need to be done.
Tim Benak – 52:45
I was just going to touch on that. Someone made a comment about when you’re looking at rental apartments, handicap accessible is typically more for walkers, not wheelchairs.
Brad Dexter – 52:52
Absolutely. So you may have a grab bar, but it’s still not really accessible for wheelchairs, nothing is really that wide and everything still kind of a pie.
And so when I, when I said built environment to Tim, he was like, what does that mean? And there’s more of a push for what’s called Universal Design, which is more open spaces and allows for more freedom of movement, not only in houses, but apartment buildings, public spaces, public domains to allow more people, regardless of how they move to be able to access those places more freely.
I think there’s still a long way to go with what ADA was originally intended to do.
Tim Benak – 53:41
Absolutely. Then just one other kind of just the approach to getting back to work after these injuries, a lot of times employers may not be willing to make those changes.
Brad Dexter – 53:51
So that’s just an area from an advocacy standpoint, that spinal cord injury organizations and individuals, I try to encourage individuals to keep fighting for some of those changes on local levels.
It’s cool, you know, sometimes in smaller communities, people just rally around that and they make things happen for individuals, but it’s harder to make that change at a larger scale. Newer builds, newer areas of cities tend to tend to look that way, a little bit more universal design. But it’s hard to retrofit older parts of cities at this point too.
Driving and Transportation
Driving and transportation is going to fluctuate quite a bit again. So our C5 level injuries, most of the time, they may be driving from a power wheelchair or a manual wheelchair with like a tie down type of system within the vehicle. They may need a ramp to drive that chair up into it, which means you’re looking at a van or an SUV type of vehicle that they would need to utilize.
You get into your C6, C7, C8 and because those folks can transfer a little bit easier, perhaps break their wheelchairs down if they’re in a manual wheelchair, you’re looking at them being able to potentially drive a sedan just by transferring in and then getting the appropriate hand controls put in place so that they can drive their vehicle appropriately.
A lot of variability with this one, so those those C6, C7, C8 injuries, maybe they want to offer something a little bigger. There are seats that kind of pull out of vehicles if they’re higher up. So if they’re looking at purchasing a truck or purchasing an SUV, and they want to drive a manual wheelchair, you can get a seat that will drop down from the driver side down to like a transfer level. So they can transfer over from their wheelchair. And then you can get like a boom arm in the back of the truck that would pick up the wheelchair and then store it in the back of the truck for them to be able to utilize it that way.
So, again, I just think if I were in this position, I still want to be a consumer. I want to look at well what would I like to be able to utilize? I have young kids, maybe I’d still be driving a van. But perhaps I want to look at something else. Maybe I had a truck before I always drove a truck and I’d like to get back to that. There may be a price point on that, but it may be appropriate for me to do that. And the nice thing is the technologies come along to allow for that to happen.
Your C5 level injuries may need reduced effort steering, you get into the C7’s and the C8’s and perhaps they just need like a tri pin to help with grasping on the steering wheel to get the wheel around instead of the reduced effort steering.
Your AIS C’s and D’s, if they have some amount of lower extremity movement, perhaps it could even become a driver with their feet. We’ve had individuals that have progressed, they’ve done a driver’s evaluation and used the hand controls and then they’ve progressed and started to get lower extremity movement back and they’ve been able to drive with their feet, either with a left sided gas, by putting that into the vehicle or just a normal setup in the vehicle as well.
So what I want you to hear here is there’s a lot of different options based off that level of injury and their AIS score as well.
Tim Benak – 57:31
I put this photo on, not only because it’s a fantastic photo, but also so I can make the comment that you’re really hard at work in this photo.
Brad Dexter – 57:32
I’m coaching and I think this is actually a unique photo. You see a young gal, she was a C6 level injury, was working on pushing a manual wheelchair, but she was still utilizing a power wheelchair that had seat elevation. And her family, she didn’t have a vehicle at the time, but her family only had trucks and so she had to learn how to transfer over into a truck.
And so in this situation, we had to use that seat elevation on her power wheelchair to help her learn how to, and then to teach family, how to transfer over into a truck without just doing a lift transfer.
Caregiver Needs
A lot of variance here. So the A’s and B’s you’re looking at anywhere from modified independent to 23 hours of care. Modified independent could be your C8 AIS A or your C7 AIS A and a C5 AIS A you may be looking at quite a bit of care for them throughout the day.
Tim Benak – 58:31
Keep going, I’m just gonna launch the poll real quick. We got a few people that may have to peel off right away. So there will be a poll question on the screen.
Again, if you’re looking to receive your your CEU, please answer that. That’s how we know who we send that email to. So that’s going to be launched right now and Brad’s going to keep going with his presentation.
Brad Dexter – 58:42
You contrast that with the C’s and D’s and again, just because of their functional ability, and the strength that perhaps they’ve gained, the level of or the amount of care that they’re going to need throughout the day is significantly different than those A’s and B’s.
Durable Medical Equipment
Again, big change between C5 and C8. So your C5’s are going to require quite a bit more, they may need the hoyers, they may need shower, custom shower wheelchairs, power wheelchairs, so the costs are going to be a little bit higher. You can almost even group them into the some of the costs of the high quads, the high cervical spinal cord injuries, but your 6’s, 7’s, and 8’s, you’re going to see a decrease in the amount of durable medical equipment needed, the modifications needed to the home.
C’s and D’s again, you should see a decrease in equipment needed. I would just point out sometimes with AIS D’s, they can walk but because of toner spasticity, they may still require using a power wheelchair to get around. They can walk but just short distances and they may need help.
So again, I know I keep saying a lot of variety here. But someone said earlier, you know there’s not not a single spinal cord injury that is the same. Spinal cord injury doesn’t necessarily mean wheelchair. And AIS D doesn’t necessarily mean walking full time all the time either.
So a lot of variability within this group of folks. Alright, so I flew through the last couple slides there but appreciate your guys’s engagement today. And thanks for participating in this, and I hope to keep bringing some great information your way and hope that this is valuable to you all.
Conclusion
Tim Benak – 1:00
Yeah, thank you, Brad, we appreciate it. We’re still gonna be here for a couple minutes. So if you have any questions, type them. If we don’t answer them live, I will make sure to get them sent over to Brad.
As always, please check us out on our social media platforms. We’re always sharing amazing stories. Brad shared some today but check out some more blog posts if you find what we do interesting.
Also expect communication from us in the next 24 hours. Taylor in the background, she’s here. She’s amazing at getting all your guys’s emails, your follow up email sent to you. So I would expect those to be sent to you by the end of the day.
We hope you join us next month. We’re going to be doing more of a podcast style with our CEO Patricia Kearns and Jeff Snell, talking about conflict. So it’ll be similar to what we’ve done in the past, more focused on just a podcast presentation discussion. So be on the lookout for that invite as well.
I think that’s about it. Let’s see, we got a few questions. We have few folks a comment about their poll question, submitting and then saying failed or had an issue there. I’ve got that noted. So I will make sure to get you added to the list. And then, as always, we appreciate you joining.
Oh, here we go. Brad, what are some key documentation points that are required to have a patient qualify for a power chair versus a manual chair?
Brad Dexter – 1:02:04
Key documentation points. So I mean, they should trial both of those. Obviously. If you have an individual that just is having a hard time pushing around that manual wheelchair, perhaps they can do it in a residential setting, but you get them out in community settings where you start to get inclines, declines, uneven surfaces, and they struggle with that, that may start to justify more of the power wheelchair option.
You know, we may have those AIS D’s, where they can do some really short distance walking. But toner spasticity may limit what they’re able to do. And they can be more independent around the home using a power wheelchair, they can be independent with pressure reliefs.
That would warrant using the power wheelchair versus a manual wheelchair in that case too. Looking at home settings, the type of vehicle that they have or going to have, skin integrity, arm strength versus leg strength, tone and spasticity. Those are a lot of the areas that we’re typically looking at and considering with the individual as we’re trying to figure out appropriate seating and positioning for them.
Tim Benak – 1:03:40
Okay. There are a few other questions that we’ll just get sent over to Brad in the next coming days. It’ll take some time. So expect to either hear from myself Taylor or Brad if you had a question that we didn’t get to live and as always reach out to us qLIWebinars@omaha.com. If you have any questions. Brad, do you have your contact information on the next slide? Switch to that. There’s Brad’s direct contact if you have any questions for him.
We appreciate you joining and we hope you have a great rest of the day. Take care.
Categories: Spinal Cord Injury