Prognosticating Functional Status Post Injury

Dr Peter Lim Senior Consultant, Department of Rehabilitation Medicine Singapore General Hospital, Singapore Clinical Professor, Department of Physical Medicine & Rehabilitation Baylor College of Medicine, Houston, Texas, USA

Epidemiology • Traumatic SCI in US (pop. 300m) : – Incidence: 12,000 (40 per million) – Prevalence: 265,000 (800 per million) • Other countries: Incidence: <20 per million • Singapore (extrapolated): » Incidence: 100/year ? » Prevalence: 2,000?

• Non-traumatic SCI: – Spondylosis (esp. cervical),Intervertebral disc disorder, Spinal stenosis, Acute infective, Intraspinal abscess, Tuberculosis, , Benign neoplasm, Malignant neoplasm, Congenital, Idiopathic

Regional Model Systems, USA • National Institute on Disability and Rehabilitation Research, US Department of Education • 5-year cycle grant funding • Institutions that are national leaders in SCI care, research, provide highest levels of comprehensive specialty services • National Spinal Cord Injury Statistical Center University of Alabama/Birmingham https://www.nscisc.uab.edu/ SCI Model System Centers Assessment (Motor)

• Most distal segment with normal motor function • Considered normal if at least grade 3, assuming next most proximal muscle tests as 5 Assessment Assessment (Skeletal Level)

• X-rays • CT spine • MRI spine Clinical SCI Syndromes

• • Brown-Sequard Syndrome • Anterior Cord Syndrome • Posterior Cord Syndrome • Conus Medullaris Syndrome •

American Spinal Injuries Association (ASIA) Impairment Scale (International Standards for Neurological and Functional Classification of Spinal Cord Injury) • A: Complete - no sensory or motor function preserved in sacral segments S4-5 • B: Incomplete - sensory but not motor preservation below neurological level and includes S4-5 • C: Incomplete - motor preservation below neurological level; more than half of key-muscles grade < 3 • D: Incomplete - motor preservation below neurological level; at least half of key-muscles grade >= 3 • E: Sensory and motor function normal

Functional status by level : C1-C4

• C1-3 likely long term mechanical ventilation • C4 should not need long term • ADLs: dependent, max assist • Mobility: power wheelchair with chin or sip-n-puff control • Assistive technology, e.g. phone, lights, TV, bed controls • Brain Control Interface Functional status by level : C5

• Have use of elbow flexors (Biceps) • ADLs: – independent feeding and grooming with wrist-hand orthoses – can participate with upper body dressing and bed mobility – assisted for transfers, bowel/bladder • Mobility: – power wheelchair with hand controls – manual wheelchair short distances with rim projections – driving specially modified van possible.

Functional status by level : C6

• Added wrist extensors permit tenodesis • ADLs: – although uncommon, independent without attendant possible – most require assist with lower body dressing, transfers, bowel/bladder • Mobility: – independent manual wheelchair with rim projections – driving with custom lift and hand control an option Functional status by level : C7

• Able to extend elbow (Triceps) • ADLs: – may achieve independence with or without assistive devices – may need assist with transfers over uneven surfaces • Mobility: – manual wheelchair in community (except with curbs, over steps) – may be independent with driving adapted van or car

Functional status by level : C8

• Have functional finger flexion (improved grasp and release) • ADLs: – independent feeding, grooming, dressing, bathing, transfers, bowel/bladder care • Mobility: – independent manual wheelchair propulsion Functional status by level : Thoracic

• Have upper limb muscle function • ADLs: – independent • Mobility: – Advanced wheelchair skills: including rough terrain, wheelies for curbs/steps, transfer from floor to wheelchair – Can drive independently with hand controls – T2-9: may stand with bilateral KAFO – T10-12: may walk independently within home with KAFO and walking devices Functional status by level : Lumbar

• Good trunk control • ADLs: – independent • Mobility: – advanced wheelchair skills – drive independently with hand controls – can be functionally independent with home and community ambulation, usually with devices – full or part-time manual wheelchair often necessary Prognosis for Ambulation after Traumatic Spinal Cord Injury

100 • Initial ASIA Impairment Scale 90 (at 72 hours-1 week): 80 – A: 3% 70 60 – B: 50% 50 – C: 75% 40 – D: 95% 30 20 Consortium for Spinal Cord 10 Medicine: Clinical Practice 0 Guidelines, 1999, PVA ASIA A ASIA B ASIA C ASIA D Return to Work (RTW) • Systematic review of 123 references • Working at time of SCI injury: – 21-67% returned to work • RTW higher when: – injured at younger age – less severe injuries – higher functional independence • Also: – RTW improved with time after injury – overall, employed: 11.5-74% – SCI at childhood/adolescence -> higher adult employment rates – Barriers: transportation, health/physical limitations, lack of work experience/education/training, physical/architectural barriers, discrimination, loss of benefits

Lidal IB et al: Disabil Rehabil 2007, 29(17): 1341-75 Spinal cord injury: Costs (US) Survival • 9,135 subjects from 1973-84 • Cumulative 12-year survival 85.1% (88.2% of normal) • Mortality rates ranged from 1.68 to 15.98 times higher than normal – Range: • 95% (>96% of normal) for those younger than 25 years at injury and neurologically incomplete • 18.1% (26.9% of normal) for 50 years and older with complete

DeVivo MJ et al: Prognostic factors for 12-year survival after spinal cord injury. Arch Phys Med Rehabil 1992; 73(2): 156-62

Survival

Spinal Cord Injury Facts and Figures at a Glance, Feb 2011, (28,000 subjects) National Spinal Cord Injury Statistical Center, Birmingham, Alabama Summary of Factors for Prognosticating Functional Status in SCI

• Severity of cord damage • Completeness of injury • Level/location of cord injury • Early recovery • Surgery: no difference • REHABILITATION Thank You