St.

Paul University Iloilo

College of Physical Therapy

Spinal Cord Injury

In partial fulfillment of the requirements in Seminar 2

Submitted by:

BUENAFLOR, CHRISTIA MAE

CASALMIR, KARLYN DENISE
DELOS REYES, MARY JANESA
DORMITORIO, JENNY LOU
FERMANO, REEZA
LUNASPE, ROMEO GINO
MILLIAN, AIRA MONICA
TARUCAN, KIMBERLY

BSPT-4B

February 23, 2015

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 TABLE OF CONTENTS

I. Definition of terms………………………………………………………………………. 3

II. Anatomy and Physiology of the Spinal Cord……………………………………………. 3

III. Incidence………………………………………………………………………..….. ……9

IV. Etiology…………………………………………………………………………………. 10

V. Pathomechanism…………………………………………………………………………11

VI. Classification……………………………………………………………………………..13

VII. Signs and Symptoms…………………………………………………………………….15

VIII. Differential Diagnosis…………………………………………………………………... 16

IX. Ancillary Procedures…………………………………………………………………….16

X. PT Evaluation…………………………………………………………………………… 17

XI. PT Management………………………………………………………………………… 22

XII. Medical Management…………………………………………………………………… 23

XIII. References………………………………………………………………………………. 38

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 I. Definition of Terms

 Spinal Tracts-composed of bundle of axons, that carry signals from one part of the CNS to
another.
 Paraplegia- Paralysis of the lower half of the body
 Dysrhythmia- an abnormal rhythm
 Septicemia- Invasion of the bloodstream by virulent microorganisms from a focus of
infection
 Ischemia- Local anemia in a given body part sometimes resulting from vasoconstriction,
thrombosis or embolism
 Thrombosis- The formation or presence of a thrombus (a clot of coagulated blood
attached at the site of its formation) in a blood vessel
 Embolus- An abnormal particle (e.g. an air bubble or part of a clot) circulating in the
blood
 Hemorrhage- The flow of blood from a ruptured blood vessel
 Subluxations- Partial displacement of a joint or organ
 Neoplasm- An abnormal new mass of tissue that serves no purpose
 Syringomyelia- A chronic progressive disease of the spinal cord associated with sensory
disturbances, muscle atrophy, and spasticity
 Abcesses- Symptom consisting of a localized collection of pus surrounded by inflamed
tissue
 Autonomic Dysreflexia- clinical syndrome produces an acute onset of autonomic activity from
noxious stimuli below the level of lesion; hypertension persists if not treated promptly, death may
result.
 Clonus – a rapid succession of alternating contractions and partial relaxations of a muscle
occurring in some nervous diseases.
 Graphesthesia – ability to recognize writing on the skin purely by the sensation of touch.
 Stereognosis – known as haptic perception, it is the ability to perceive and recognize the form of
an object in the absence of visual and auditory information to provide cues from texture, size,
spatial properties and temperature.

II. Anatomy and Physiology of Spinal Cord

SPINAL CORD

 “information highway” between your brain and your trunk and limbs.
 Roughly oval in shape, being flattened slightly anteriorly and posteriorly.
 Adults: Medulla Oblongata (inferior part of the brain) → L1-L2
Newborn Infants: L2-L3
 Adult length of the SC ranges: 42-45 cm (16-18 in)
Diameter: 2cm (0.75in)
 Divided into cervical, thoracic, lumbar, and sacral regions.

When the SC is viewed externally, 2 conspicuous enlargements can be seen:

 Cervical enlargement – superior enlargement, extends from the C4 to T1

-gives rise to nerves of the upper limbs.
 Lumbar enlargement- inferior enlargement, extends from T9 to T12
-gives rise to nerves of the pelvic region and lower limbs

Conus medullaris- conical structure, inferior to lumbar enlargement; ends at the level of intervertebral
disc between L1-L2 in adults.

Filum terminale- arising from the conus medullaris; an extension of the pia mater that extends inferiorly
and fuses with the arachnoid and dura mater and anchors the spinal cord to the coccyx.

Cauda equina- bundle of nerve roots that occupy the canal of vertebra L2-S5; resemblance to a horse’s
tail.

Meninges- are three protective, connective tissue coverings that encircle the spinal cord and brain.

- from superficial to deep: (1) dura mater, (2) arachnoid mater, and (3) pia mater.

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Spinal meninges

- surround the spinal cord and are continuous with the cranial meninges, which encircle the brain.

- all three spinal meninges cover the spinal nerves up to the point where they exit the spinal column
through the intervertebral foramina.

1. Dura Mater- most superficial of the three spinal meninges is a thick strong layer composed of
dense, irregular connective tissue .
- forms a loose-fitting sleeve called the dural sheath around the spinal cord.
- space between the sheath and the vertebral bone, called the epidural space, is
occupied by blood vessels, adipose tissue, and loose connective tissue.
2. Arachnoid Mater- the middle of the meningeal membranes, is a thin, avascular covering
comprised of cells and thin, loosely arranged collagen and elastic fibers; adheres to the dural
sheath.
- between the dura mater and the arachnoid mater is a thin subdural space,
which contains the interstitial fluid.
3. Pia Mater- innermost meninx is a thin transparent connective tissue layer that adheres to the
surface of the spinal cord and brain.
- within are many blood vessels that supply oxygen and nutrients to the spinal cord.
- denticulate ligaments: are thickenings of the pia mater; protect the spinal cord against
sudden displacement that could result in shock.
- between the arachnoid mater and pia mater is a space, the subarachnoid space, which
contains shock-absorbing cerebrospinal fluid (CSF).

Internal Anatomy of the Spinal Cord

Two Kinds of Nervous Tissue in the SC

1. Gray Matter- relatively dull color because it contains little myelin.
- contains the somas, dendrites, and proximal parts of the axons of neurons.
- site of synaptic contact between neurons, and therefore the site of all synaptic
integration (information processing) in the central nervous system (CNS).
2. White Mater- contains an abundance of myelinated axons, which give it a white
appearance.
- composed of bundles of axons, called tracts, that carry signals from one part
of the CNS to another.

Gray Matter

- spinal cord has a central core of gray matter that looks like a butterfly, or H-shaped in cross sections.

- core consists mainly of: (Columns)

A. Anterior Gray Horns/Columns

- composed of 2 multipolar nerve cells whose axons exit via the Anterior nerve roots as Spinal nerves:

 Alpha Efferent Nerves- large diameter fibers that innervate skeletal muscles.
 Gamma Efferent Nerves- smaller diameter fibers that innervate intrafusal muscle fibers of
neuromuscular spindles.

Subdivided into 3 nerve groups or columns:

a. Medial Column/Group- innervates the skeletal muscles of the neck and trunk.
b. Central Column/Group- smallest group confined in the cervical and lumbar segments.
-form accessory (SCM, Trapezius) and phrenic nuclei - diaphragm
(C3,4,5) and lumbosacral nuclei.
c. Lateral Column/Group- present in the cervical and lumbar segments.
-innervate the skeletal muscles of the limbs.

B. Posterior Gray Horns/Columns

Subdivided into 4 nerve groups/columns:

a. Substantia Gelatinosa Column/Group- composed of Golgi Type II Neurons.

-receive afferent fibers concerned with Pain, Temperature, and Touch.

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 b. Nucleus Proprius Column/Group- receive fibers from posterior white column, concerning
Proprioception, 2-Point Discrimination and Vibration.
c. Nucleus Dorsalis or Clarke’s Column- receive Proprioceptive Information from
neuromuscular and tendon spindles.
d. Visceral Afferent Nucleus- receives Visceral Afferent information

C. Lateral Gray Column

*between the posterior and anterior gray horns are the Lateral Gray Horn/Columns, which are
present only in thoracic and upper lumbar segments of the spinal cord.
*Lateral Gray Horns- give rise to pre-ganglionic Sympathetic nerve fibers.

D. Gray Commissure and Central Canal

- divides into an Anterior and Posterior Gray Commissure by the Central Canal.

-inferiorly the Central Canal expands into Terminal ventricle at level of Conus medullaris.

White Matter

-surrounds the gray matter and consist of myelinated nerve fibers, neuroglia, and blood vessels.

-these are arranged in 3 pairs called columns/funiculi: (Anterior, Lateral, and Posterior)

-each column/funiculi is consists of subdivisions called tracts or fasciculi.

Divisions:

a. Anterior Columns/Funiculi- between midline and point of emergence of anterior nerve root.
b. Lateral Columns/Funiculi- between the anterior and posterior nerve roots.
c. Posterior Columns/Funiculi- between the posterior nerve root and midline.

Blood Supply of the Spinal Cord

•Anterior Spinal Artery– arises from the vertebral arteries; supply blood flow to the anterior two-thirds
of the spinal cord

•Posterior Spinal Artery– arise directly and indirectly from the vertebral arteries run inferiorly along the
sides of the spinal cord, and provide blood flow to the posterior one-third of the spinal cord

•Radicular Arteries– reinforce the posterior and anterior spinal arteries; branches of local arteries (deep
cervical, intercostal and lumbar arteries)

 Artery of Adamkiewicz– or the arterioradicularis magna is the name given to the lumbar
radicular artery; largest radicular vessel that supplies the spinalcord.

•Internal Venous plexus – venous drainage of the spinal cord

Spinal Tracts

A. Ascending (sensory) Tracts- carry sensory information up the spinal cord.

-sensory signals typically travel across 3 neurons from their origin in the receptors to their
destination in the sensory areas of the brain:
 First-Order Neuron – detects a stimulus and transmits a signal to the spinal cord or
brainstem.
 Second-Order Neuron – continues as far as a “gateway” called the thalamus at the upper
end of the brainstem.
 Third-Order Neuron – carries the signal the rest of the way to the sensory region of the
cerebral cortex.

Major Ascending Tracts:

 Fasciculus Gracilis – carries signals from the midthoracic and lower parts of the body.
- contains fibers from sacral, lumbar, and lower 6 thoracic nerve.
- these fibers carry signals for vibration, visceral pain, deep and
discriminative touch (touch whose location one can precisely identify), and especially
proprioception from lower limbs and lower trunk.

 Fasciculus Cuneatus – joins the fasciculus gracilis at the T6 level.

- occupies the lateral portion of the dorsal column.

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 - carries the same type of sensory signals, originating from level T6 and up
(from the upper limb and chest).

*Both paths terminate in the Nucleus Gracilis and Nucleus Cuneatus at the medulla oblongata.

 Spinothalamic Tract – and some smaller tracts form the anterolateral system, which passes up
the anterior and lateral columns of the spinal cord.
- carries signals for pain, temperature, pressure, tickle, itch, and light or
crude touch.

 Dorsal and Ventral Spinocerebellar Tracts – travel through the lateral column and carry
proprioceptive signals from the limbs and trunk to the cerebellum.
- both tracts provide the cerebellum with feedback needed to coordinate
muscle action.

B. Descending (motor) Tracts- carry motor signals down the brainstem and spinal cord.
- a descending motor pathway typically involves two neurons called the upper and lower motor
neuron.
 Upper Motor Neuron begins with a soma in the cerebral cortex or brainstem and has an
axon that terminates on a Lower Motor Neuron in the brainstem or spinal cord.
 Lower Motor Neuron – then leads the rest of the way to the muscle or other target organs.

*Names of most descending tracts consist of a word root denoting the point of origin in
the brain, followed by the suffix –spinal.

Major Descending Tracts:

 Corticospinal Tracts – carry motor signals from the cerebral cortex for precise, finely
coordinated limb movements.
- fibers of this system form ridges called pyramids on the ventral surface of
the medulla oblongata, so these tracts were once called pyramidal tracts.
-Decussating fibers: Lateral Corticospinal Tract
-Non decussating fibers: Anterior Corticospinal Tract

 Tectospinal Tract – fibers arise from the superior colliculi of the midbrain.
- reflex movements of the head, especially in response to visual and auditory
stimuli.

 Lateral and Medial Reticulospinal Tracts – originate in the reticular formation of the
brainstem.
- control muscles of the upper and lower limbs, especially to maintain
posture and balance; also contain descending analgesic pathways that reduce the transmission of
pain signals to the brain.

 Vestibulospinal Tract – begins in a brainstem vestibular nucleus that receives impulses for
balance from the inner ear.
- passes down the ventral column of the spinal cord and facilitate the activity
of extensor muscles while inhibiting flexor muscles in association for maintaining balance.

MAJOR SPINAL TRACTS

TRACTS COLUMN DECUSSATI FUNCTIONS
ON
ASCENDING (SENSORY)
-Fasciculus Gracilis Dorsal In Medulla -Limb and trunk position and
movement, deep touch, visceral
pain, vibration, below T6
-Fasciculus Cuneatus Dorsal In Medulla - Same as fasciculus gracilis, from
T6 up
-Spinothalamic Lateral and Ventral In spinal cord -light touch, tickle, itch, temp.,
pain, et pressure
-Dorsal Spinocerebellar Lateral None -feedback from muscles
(proprioception)
-Ventral Spinocerebellar Lateral In spinal cord -same as dorsal spinocerebellar
DESCENDING (MOTOR)
-Lateral Corticospinal Lateral In medulla -fine control of limbs
-Anterior Corticospinal Ventral None -fine control of limbs
-Tectospinal Lateral and Ventral In midbrain -reflexive head-turning in

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 response to visual and auditory
stimuli.
-Lateral Reticulospinal Lateral None -balance and posture; regulation
of awareness of pain
-Medial Reticulospinal Ventral None -same as lat. Reticulospinal
-Vestibulospinal Ventral None - facilitate the activity of extensor
muscles while inhibiting flexor
muscles in maintaining balance.

Difference between UMN and LMN injuries

UMN (Pyramidal Tract) LMN (Extrapyramidal Tract)

Deep Tendon Reflexes Increased Decreased
Muscle Tone Spastic Flaccid
Babinski Reflex Present Absent
Bowel/Bladder Spastic Flaccid

Others:

 UMNL

o Lesions of the Corticospinal Tracts (Pyramidal Tracts) – Superficial Abdominal Reflexes

(absent); Cremasteric reflex (absent); loss of performance of fined-skilled movements (distal
end limbs)

o Lesions of the Descending Tracts Other than the Corticospinal Tracts (Extrapyramidal
Tracts)– Severe paralysis with little or no muscle atrophy (except secondary to disuse);
spasticity or hypertonicity (LE: maintained in extension; UE: flexion); Exaggerated deep
muscle reflexes and Clonus (flexor fingers, quadriceps femoris, and calf muscles); Clasp-
knife reaction

 LMNL

o Flaccid paralysis; Atrophy; Loss of Reflexes; Muscular Fasciculation; Muscular Contracture;

Reaction of Degeneration

DERMATOMES AND MYOTOMES

Each of the spinal nerves exits the spinal canal between two of the vertebra.  Each then goes to a
particular area of the body.  The area of skin served by each of these nerves is called its dermatome.

 Dermatome is an area of skin in which sensory nerves derive from a single spinal nerve root . It is
also useful to help localize neurologic levels, particularly in radiculopathy.

Dermatomes

C1 Verdex of the Skull

C2 Occipital Protuberance

C3 Supraclavicular Area , Mandible

C4 Acromioclavicular Area

C5 Lateral Epicondyle of Humerus , Deltoid

C6 Thumb

C7 Middle Finger ,Index Finger, Ring Finger

C8 Little Finger

T1 Med. Epicondyle of Humerus

T2 Apex of Axilla

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T4 Nipple Line

T6 Xiphisternum

T10 Umbilicus

T12 Inguinal Line

L2 Mid. Anterior Thigh

L3 Med. Femoral Condyle

L4 Medial Malleolus

L5 Dorsum of the Foot

S1 Lateral Heel

S2 Popliteal Fossa

S3 Ischial Tuberosity

S4,S5 Perineal Area

Myotomes

 Myotome is the group of muscles that a single spinal nerve root innervates. Similarly a
dermatome is an area of skin that a single nerve innervates. In vertebrate embryonic development,
a myotome is the part of a somite that develops into the muscles.

Nerve Root Action Muscle Weakness

C1 Neck flexion None

C2 Neck extension Longus Colli, SCM ,

Rectus Capitis
C3 Lateral neck flexion Trapezius, Splenius Capitis

C4 Shoulder elevation Trapezius , Levator

Scapulae
C5 Elbow flexion Suprapinatus, Infrapsinatus,
Deltoid, Biceps
C6 Wrist extension Biceps, Supinator , Wrist
extensors
C7 Wrist flexion , Elbow extension Triceps, wrist flexors

C8 Flex IP , Adduction of thumb Ulnar deviators, thumb

extensors and adductors
T1 Fingers abduction , thumb T1-T2 – Disc lesions at
extension upper 2 thoracic levels do
not appear to give rise to
root weakness. Weakness
of intrinsic muscles of the
hand is caused my other
pathologies such as
Thoracic Outlet pressure
T3-T12 – Articular and
dural signs and root pain
are common. Cutaneous
Analgesia or root signs are
rare that gave definite
localizing value. Weakness
is not detectable.

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 L1 Hip hike None

L2 Hip flexion Psoas, hip adductors

L3 Knee extension Psoas, Quadriceps, Thigh

atrophy
L4 DF Tibialis anterior, extensor
hallucis
L5 Toe extension Extensor halluces, Gluteus
medius ,
Dorsiflexors,hamstring and
calf atrophy
S1-S5 Hip ext, ER, Knee ext, PF , S1- Calf and hamstring,
inversion, toe flexion gluteals, peroneals,
plantarflexors
S2- Same as S1 except
peroneals
S3- None
S4 – Bladder and rectum

III. Incidence

Incidence and Prevalence

 Annual incidence of traumatic SCI requiring hospitalization in the United States is ~40
new cases per million population (or ~12,000 cases per year).
 In other developed countries, has been shown to be somewhat lower than that in the
United States; often <20 new cases per million per year; perhaps partly because of the
higher U.S. incidence of violence-related SCI.

Age at Time of Injury, Gender, and Ethnicity

 Lowest: <15 y/o
 Highest: 16-30 y/o
 >30 y/o, consistent decline in incidence
 Current average age at onset: 40.2 years
 >60 y/o constituted 4.5% of all new patients with SCI in the mid 1970s, 11.5% in the mid
1990s
 Males (>80% of all SCI)
 Caucasians (~2/3 of all persons enrolled in the NSCID)

Causes of Spinal Cord Injury

 Most common causes of Traumatic SCI in descending order of incidence:
o Vehicular crashes (42.1%)
o Falls (26.7%)- most common cause of SCI among elderly
o Violence (15.1%)- most common cause of SCI among African Americans
o Sports (7.6%)
 Women (rarely sustain SCI)
 Relatively more injuries occur on weekends and during summertime.

Neurologic Level and Extent of Neurologic Deficit

 Tetraplegia> Paraplegia (50.5% vs. 44.1%) according to NSCID
 Neurologic Categories:
o Incomplete tetraplegia (30.1%)
o Complete tetraplegia (20.4%)
o Complete paraplegia (25.6%)
o Incomplete paraplegia (18.5%)

Life Expectancy and Causes of Death

 Mortality rate is highest during the first postinjury year (6.3%) but declines significantly
thereafter.

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  Significant predictors of mortality:
o Older
o Male
o Injured by acts of violence
o Neurologically complete
o Ventilator dependent
o High neurologic level
 Additional factors that affect longevity after the first postinjury year:
o Low life satisfaction
o Poor health
o Emotional distress
o Functional dependency
o Poor adjustment to disability
 Diseases of respiratory system, especially pneumonia, are the leading cause of death both
during the first postinjury year and during subsequent years.
 “Other heart disease”- 2nd; reflect deaths that are apparently caused by heart attacks in
younger persons without apparent underlying heart or vascular disease and cardiac
dysrhythmia
 Renal Failure- was by far the leading cause of death after SCI in the past

Primary Causes of Death Percentage

Diseases of the respiratory system (70% pneumonia) 22

Other heart disease (likely over reported representing poor quality of 12

cause-of-death data after SCI)

Infective and parasitic diseases (94% septicemia usually associated 10

with pressure ulcers or urinary tract or respiratory tract infections)

Hypertensive and ischemic heart disease 8

Neoplasms 7

Diseases of pulmonary circulation (96% pulmonary emboli) 5

Diseases of the genitourinary system 4

Suicides 4

Other causes 28

IV. Etiology

Two broad etiological categories of SCI:

 Traumatic injuries
o Most frequent cause of injury in adult rehabilitation populations
o Result from damage caused by a traumatic event eg. MVA, falls, or gunshot
wounds

 Nontraumatic damage
o Generally results from disease or pathological influence
o Examples of nontraumatic conditions that may damage the spinal cord:
 Vascular malfunctions (AVM, thrombosis, embolus, hemorrhage)
 Vertebral subluxations (secondary to RA or DJD)
 Infections (syphilis or transverse myelitis)
 Spinal neoplasms
 Syringomyelia
 Abcesses of the spinal cord

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  Neurological diseases (MS and ALS)

MECHANISMS OF INJURY

Areas of the spine that demonstrate the highest frequency of injury:

 Between C5 and C7 (cervical region)
 Between T12 and L2 (thoracolumbar region)

Major Mechanisms of Injury:

 Flexion
 Compression
 Hyperextension
 Flexion-rotation

Two additional contributing mechanisms:

 Shearing
 Distraction

V. Classification

Based on ASIA (American Spinal Injury Association):

 Neurological level of injury – the most caudal level at which both motor and sensory
modalities are intact
 Motor level – is referred to as the most caudal segment of the spinal cord with normal
motor function bilaterally.
 Sensory level – is defined in the same way except in terms of sensory function.
 Zone of partial preservation – used only with complete injuries, refers to the dermatomes
and myotomes caudal to the neurological level that remain partially innervated. The most
caudal segment with some sensory and/or motor function defines the extent of the ZPP.

Classification Definition

A = Complete No motor or sensory function is preserved

in the sacral segments S4 to S5.

B = Sensory Incomplete Sensory but not motor function is

preserved below the neurological level and
includes the sacral segments S4 to S5.

C = Motor Incomplete Motor function is preserved below the

neurological level, and more than half of
key muscles below the neurological level
have a muscle grade less than 3.

D = Motor Incomplete Motor function is preserved below the

neurological level, and at least half of key
muscles below the neurological level have
a muscle grade of 3 or more.

E = Normal Motor and sensory function is normal.

Clinical Syndromes
A. Brown-Sequard Syndrome

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  Occurs from hemisection of the spinal cord and is typically caused by penetration
wounds (i.e. gunshot or stab).
 Partial lesions occur more frequently.
 True hemisections are rare.
 Asymmetrical
 Ipsilateral side:
(1) Loss of sensation in the dermatome segment corresponding to the level of the
lesion.
(2) Faccid paraysis at the level of the lesion
(3) Motor loss below the level of the lesion
(4) Lateral Column damaged:
- decreased reflexes
- lack of superficial reflexes
- clonus
- (+) Babinski sign.
(5) Dorsal Column damage:
- loss of proprioception
- loss of kinesthesia
- loss of vibratory sense
 On the side contralateral to the lesion:
(1) Spinothalamic tract damage:
- loss of sense of pain and temperature which begins several
dermatome segments below the level of injury (discrepancy in levels
occurs because the Lateral Spinothalamic tracts ascend 2 to 4
segments on the same side before crossing.)

B. Anterior Cord Syndrome

 Flexion injuries of the cervical region
 Compression of the anterior cord from fracture, dislocation, or cervical disk
protrusion.
 Below the level of lesion:
(1) Loss of motor function (Corticospinal tract damage)
(2) Loss of pain and temperature (Spinothalamic tract damage)
 Proprioception, kinesthesia, and vibratory sense are generally preserved.

C. Central Cord Syndrome

 Hyperextension injuries to the cervical region
 It is associated with congenital and degenerative narrowing of the spinal canal.
 The resultant compressive forces give rise to hemorrhage and edema.
 UE > LE
 Sensory > motor
 Complete preservation of sacral tracts: normal sexual, bowel and bladder function
is retained.

D. Posterior Cord Syndrome

 Extremely rare
 Neck hyperextension injuries, PSA occlusion, tumors, disk compression, and
vitamin B deficiency
 Preservation of motor function, sense of pain, temperature and light touch
 Loss of proprioception, vibration and epicritic sensations (e.g., two-point
discrimination, graphesthesia, stereognosis) below the level o lesion
 Gait: wide-based steppage gait pattern
 This syndrome was seen with tabes dorsalis (a condition found with late-stage
syphilis).

E. Cauda Equina Injuries

 Peripheral nerve (LMN) injuries – the same potential to regenerate as
peripheral nerves elsewhere in the body
 Full return of innervation is not common because:
(1) There is a large distance between the lesion and the point of innervation.

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 (2) Axonal regeneration may not occur along the original distribution of the
nerve.
(3) Axonal regeneration may be blocked by glial collagen scarring.
(4) The end organ may no longer be functioning once reinnervation occurs.
(5) The rate of regeneration slows and finally stops about 1 year.

VI. Pathomechanism

POTENTIAL
ASSOCIATED
FORCE ETIOLOGY ASSOCIATED
FRACTURES
INJURIES
Flexion  Head-on collision in  Wedge fracture of  Tearing of posterior
which head strikes anterior or vertebral ligaments.
steering wheel or body (vertebral body  Fractures of posterior
windshield. compressed). elements: spinous
 Blow to back of head  High percentage of processes, laminae, or
or trunk injuries occur from C4 pedicles.
 Most common to C7 and from T12 to  Disruption of disk.
mechanism of SCI L2  Anterior dislocation of
vertebral body.
Compression  Vertical or axial blow  Concave fractures of  Bone fragments may
to head (diving, surfinf, endplate lodge in cord.
or falling objects).  Explosion or burst  Rupture of disk.
 Closely associated with fracture (comminuted)
flexion injuries.  Teardrop fracture.

Hyperextension  Strong posterior force  Fractures of posterior  Rupture of anterior

such as rear-end elements: spinous longitudinal ligament.
collision. process, laminae, and  Rupture of disk.
 Falls wit chin hitting a facets.  Associated with
stationary object (more  Avulsion fracture of cervical lesions; only
commonly seen in anterior aspect of of minor influence in
elderly populations). vertebrae. thoracolumbar injuries.
Flexion-  Posterior to anterior  Fracture of posterior  Rupture of posterior
rotation force directed at rotated pedicles, articular facets, interspinous ligaments.
vertebral column (e.g., and laminae (fracture is  Subluxation or
rear-end collision with very unstable if posterior dislocation of facets
passenger rotated ligaments rupture). joints.
toward driver)  In thoracic and lumbar
regions, facets may
“lock”.

SCI pathology results from several mechanisms occurring both concurrently and in sequence.

 Primary mechanical insult results in initial loss of axons and demyelination.

 Subsequent secondary injury is characterized by further neuronal/axonal cell death and
myelin degradation, usually due to secondary inflammation from infiltrating lymphocytes
and monocytes and also reactive oxygen species secreted by activated astrocytes
composing the glial scar.
 Both the glial scar and post-traumatic cyst or syrinx formation provide physical
impediments to regeneration, and cyst formation can further damage neurons by exerting
physical pressure on their damaged axons.

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 A.

PRIMARY INJURY

TRAUMATIC NON- TRAUMATIC

 Fracture, dislocate, crushes or Prolonged bleeding, inflammation, fluid

compresses the vertebrae or wounds accumulation, infections, or disk
that penetrate or cut the SC degeneration

Damage to the vertebrae, ligaments or disks of

the spinal column or to the spinal cord

 Axons are cut off or damaged beyond repair, and neural cell membranes are
broken. Blood vessels may rupture and cause heavy bleeding in the
central grey matter, which can spread to other areas of the spinal cord

Spinal cord swells to fill the entire cavity

of the spinal canal at the injury level

Swelling cuts off blood flow, which also cuts

off oxygen to spinal cord tissue

Loss of neurons/axons Demyelination

B. SECONDARY DAMAGE (ONGOING DAMAGE)

14
 SPINAL CORD INJURY

Hemorrhages, thrombosis
and vasospasms of injured
area

Hypoperfusion, hypoxia and ischemia

of neurons and non-neuronal cells

Reperfusion of ischemic area Invasion of neutrophils,

leads to free radicals macrophages and monocytes

Excessive release of neurotransmitters

can cause additional damage by Production of Microglial
overexciting nerve cells cytokines cells
activation

Disruption of Further
mitochondrial production of
Further
function free radicals
inflammatory
Excitotoxicity and damage
neuronal
malfunction
NoGo-A, MAG, OMG
prevents axonal growth
and regenerationn
NEURONAL DEATH

GLIAL SCAR

VII. Signs and Symptoms

1. Spinal shock
-absence of all reflex activity;
(-) DTR, bulbocavernosus reflex, cremasteric reflex and delayed plantar response.
-loss of sensation and motor function below the level of lesion.
-flaccidity
-One of the 1st indicators that spinal shock is resolving is (+) bulbocavernosus reflex.

2. Motor and Sensory Impairment

-either complete or partial loss of muscle function below the level of lesion.

15
 -disruption of of the ascending sensory fibers following SCI results in impaired or
absent sensation below the level of lesion.

3. Autonomic dysreflexia – is a pathological autonomic reflex that typically occurs in

lesions above T6 (above sympathetic splanchnic outflow).
Symptoms:
-Hypertension
-Bradycardia
-Headache
-Profuse swelling
-Increased spasticity
-Restless
-Vasoconstriction( below the lesion)
-Vasodilation(above the lesion)
-Constricted pupils
-Nasal congestion
-Piloerection
-Blurred vision

4. Postural Hypotension (Orthostatic Hypotension) - is a decreased in blood pressure that

occurs when assuming an erect or vertical position (e.g., lying-to-sitting or sitting-to-standing) .
5. Impaired Temperature Control
6. Respiratory Impairment
7. Spasticity
8. Bladder and Bowel Dysfunction
9. Sexual Dysfunction
10. Indirect Impairments and Complications
-respiratory complications
-pressure sores
-deep vein thrombosis
-contractures
-heterotopic(ectopic) ossification
-pain
*Traumatic pain
*Nerve root pain
*Spinal cord dysesthesias
*Musculoskeletal pain
*Osteoporosis and renal calculi

VIII. Differential Diagnoses

Condition Differentiating Signs and Differentiating Tests

Symptoms
Non-compressive myelopathy Similar neurologic picture. MRI confirms the lack of Spinal
No history of trauma or Cord compression or trauma

16
 other chronic event
Transverse myelitis Signs of unilateral Lumbar puncture demonstrates
involvement, incomplete increased WBC count and absence
lesion or a Brown- of infection. Spinal cord MRI
Sequard’s type of lesion. reveals a cord lesion that enhances
gandolinium administration.

IX. Ancillary Procedures

 Computerized Tomography Scan (CT scan) –a CT scan may provide a better look at
abnormalities seen on an X-ray. This scan uses computers to form a series of cross-sectional
images that can define bone, disk and other problems.

 X-rays -medical personnel typically order these tests on people who are suspected of
having a spinal cord injury after trauma. X-rays can reveal vertebral (spinal column)
problems, tumors, fractures or degenerative changes in the spine.

 Magnetic resonance imaging (MRI) -uses a strong magnetic field and radio waves to
produce computer-generated images. This test is very helpful for looking at the spinal cord
and identifying herniated disks, blood clots or other masses that may be compressing the
spinal cord.

X. PT Evaluation

I. Acute Medical Management Phase

Goals:
1. Assist the therapist in determining the lesion level
2. Identify general functional expectations
3. Formulate appropriate treatment goals
A. Respiratory Examination
 Function of Respiratory Muscles
 Respiratory rate should be noted
 Muscle strength and tone of the diaphragm, abdominals, and intercostals should
be examined.
 Chest Expansion
 Circumferential measurements should be taken at the level of the axilla and
xiphoid process using a cloth tape measure.
 Normal Chest expansion is approximately 2.5 to 3 in. ( 6.4 to 7.6 cm) at the
xiphoid process.
 Breathing Pattern
 This is being done by manual palpation over the chest and abdominal region and
by observation.
 Particular observation should be directed toward use of accessory neck muscles
and alteration in breathing pattern when patient is talking or moving.

17
 - Tactile (vocal) Fremitus- vibration felt while palpating over the chest wall as
a patient speaks.
- Procedure: PT places the palms of his/her hands lightly on the chest wall
and patient is asked to speak a few words and repeat “99” several time
 Vital Capacity
 Initial measures may be taken with a hand-held spirometer
 It can also be used as a baseline for defining respiratory muscle weakness
 Cough
 It allows patient to remove secretions
3 cough classifications:
1. Functional- strong enough to remove secretions
2. Weak functional- adequate force to clear upper respiratory tract secretions in small
quantities
3. Nonfunctional- unable to produce any cough force
B. Integument
 Patient education related to skin care is crucial and should be initiated early
 Frequent position changes and skin inspection
 The patient’s entire body should be observed regularly with areas most susceptible to
pressure.
 Palpation is useful for identifying skin temperature changes that may be indicative of
hyperemic reaction.
 If the patient is wearing a halo, vest or other orthotic device, contact points between the
body and the device must also be inspected.
Areas Most Susceptible to Pressure in Recumbent Position

Supine Prone Side lying

Occiput Ears (head rotated) Ears

Scapulae Shoulders (anterior aspect) Shoulders (lateral aspect)

Vertebrae Iliac crest Greater Trochanter

Elbows Male Genital region patella Head of Fibula

Sacrum Dorsum of feet Knees (medial aspect from

contact between knees)

Coccyx Lateral Malleolus and

medial malleolus (contact
between malleoli)

Heels

C. Sensation
 Particular emphasis should be placed on pin prick and light touch responses as well as
proprioceptive responses.

18
D. Tone and Deep Tendon Reflexes
 Muscle tone should be examined with reference to quality, muscle groups involved, and
factors that appear to increase or to decrease tone.
 Deep tendon reflexes most commonly examined and their levels of innervation:
- Biceps (C5)
- Extensor Carpi Radialis Longus (C6)
- Triceps (C7)
- Quadriceps (L3)
- Gastrocnemius (S1)
E. Manual Muscle Test and Range of Motion
 In addition to testing key muscles identified in the ISNCSCI, other muscle groups should
be tested throughout the myotomes that have intact innervation.
 Deviations from standard positioning may be necessary and should be carefully
documented due to limited mobility and surgical precautions during acute phase.
 In cases of spinal instability, extreme caution should be used when performing gross
muscle and ROM tests.
F. Functional Status
 A detailed, accurate and specific determination of functional skills is usually delayed
until active rehabilitation stage when patient is medically stable and cleared for activity.
 An initial screening of functional ability may be done during the early acute stage but the
therapist must be aware of the contraindications or precautions to the movements
necessitated by healing and potentially unstable fracture sites.
II. Active Rehabilitation Phase
- All the examination procedures completed during the acute phase will be continued at
regular intervals during Active Rehabilitation Phase
- During MMT, the therapist must be alert to the distinction between true voluntary
contraction and movement associated with spasticity or substitution.
1. Functional Independence Measure (FIM)
- An 18 item measure of physical, psychological, and social function that is part
Uniform Data System for Medical Rehabilitation.
- Used to measure functional ability in variety of activities of daily living (ADL) such
as dressing, grooming, transfers, locomotion and toileting.
 FIM LEVELS
No Helper
- 7 Complete independence (timely, safety)
- 6 Modified Independence (device)
Helper- Modified Dependence
- 5 Supervision (Subject=100%)
- 4 Minimal Assistance (Subject=75%)
- 3 Moderate Assistance (Subject= 50%)

19
 Helper- Complete Dependence
- 2 Maximal Assistance (Subject= 25% or more)
- 1 Total Assistance or not testable (Subject less than 25%)
 Most individuals with SCI will rely on wheelchair as their primary means of locomotion
in their home and community. As such, it is important to examine the patient’s ability to
perform wheelchair skills.
 This includes the following skills:
 Setting and releasing the wheel locks
 Removing footrests and armrests
 Propelling the wheelchair on the level surfaces
 Performing wheelies
 Ascending and descending curbs
2. Wheelchair Skills Test
 It is used as diagnostic measure to determine which wheelchair skills need to be
addressed in therapy and document improvement during rehabilitation.
 Different skills are categorized according to 3 levels:
- Indoor
- Community
- Advanced
 Seating and Wheelchair Examination should be performed as well to determine the most
appropriate seating system and wheelchair for the patient.

 Regaining the ability to walk is a common goal for most individuals with SCI
 Two commonly used outcome measures designed to examine walking ability after SCI:
1. Walking Index for Spinal Cord Injury (WISCI)
- Assessed the amount of physical assistance needed and devices required for
walking following paralysis that result from Spinal Cord Injury (SCI)
Revised Scale of WISCI
Leve Description
l
0 Client is unable to stand and/or participate in assisted walking.
1 Ambulates in parallel bars, with braces and physical assistance of two persons, less
than 10 meters.
2 Ambulates in parallel bars, with braces and physical assistance of two persons, 10
meters.
3 Ambulates in parallel bars, with braces and physical assistance of one person, 10
meters.
4 Ambulates in parallel bars, no braces and physical assistance of one person, 10 meters.
5 Ambulates in parallel bars, with braces and no physical assistance, 10 meters.
6 Ambulates with walker, with braces and physical assistance of one person, 10 meters.
7 Ambulates with two crutches, with braces and physical assistance of one person, 10
meters.
8 Ambulates with walker, no braces and physical assistance of one person, 10 meters.

20
9 Ambulates with walker, with braces and no physical assistance, 10 meters.
10 Ambulates with one cane/crutch, with braces and physical assistance of one person, 10
meters.
11 Ambulates with two crutches, no braces and physical assistance of one person, 10
meters.
12 Ambulates with two crutches, with braces and no physical assistance, 10 meters.
13 Ambulates with walker, no braces and no physical assistance, 10 meters.
14 Ambulates with one cane/crutch, no braces and physical assistance of one person, 10
meters.
15 Ambulates with one cane/crutch, with braces and no physical assistance, 10 meters.
16 Ambulates with two crutches, no braces and no physical assistance, 10 meters.
17 Ambulates with no devices, no braces and physical assistance of one person, 10
meters.
18 Ambulates with no devices, with braces and no physical assistance, 10 meters.
19 Ambulates with one cane/crutch, no braces and no physical assistance, 10 meters.
20 Ambulates with no devices, no braces and no physical assistance, 10 meters.

2. Spinal Cord Injury Functional Ambulation Inventory (SCI-FAI)

 The SCI-FAI is composed of three sub-scales, these include:
 Gait Parameters: max score = 20 pts. (each limb scored individually and
assessed by evaluating the following):
- Weight shift
- Step width
- Step rhythm
- Step height
- Foot contact
- Step length
 Assistive Device: max score = 14 pts. (each limb scored individually)
- Ranks assistive devices by the degree of assistance they provide
- includes use of UE weight bearing devices and LE orthotics
 Temporal Distance: max score = 5 pts.
- Assesses walking mobility described as the capability and frequency a
patient walks during a normal day
- Includes a 2 minute walk test
ASIA Impairment Scale

21
 XI. Medical Treatment

ACUTE MANAGEMENT PHASE

EMERGENCY CARE
 Management of SCI begins at the location of the accident.
 Rescue personnel must be adept at questioning and examining for signs of SCI before
moving the individual.
 When SCI is suspected, efforts should be made to avoid both active and passive movement

22
 of the spine.
 Movement of the spine can be averted by strapping the patient to a spinal backboard or a
full-body adjustable backboard, use of supporting cervical collar, and assistance from
multiple personnel in moving the patient to safety.
 Administration of high doses of methylprednisolone within 3 to 8 hours of injury for 24-48
hours can modestly improve motor and functional recovery.
 A complete neurological examination is performed.
 Radiographic and imaging studies, assist in determining the extent of damage and plan for
management.
 Attention is directed toward preventing progression or neurological impairment by
restoration of vertebral alignment and early immobilization of the fracture site.
 Urinary catheter typically is inserted, and secondary injuries are addressed.
 Unstable spinal fractures require early reduction and fixation.
 Symptoms of instability may include:
Pain
Tenderness at the fracture site
Radiating pain
Increasing neurological signs
Decrease motor function

FRACTURE STABILIZATION
Conservative or Operative Methods
 Closed reduction - traction devices (can be applied by the use of tongs attached to the outer
skull or by a halo device).
- Prolonged bed rest in traction is only recommended when other treatment
options are not available.
 Surgical Decompression and Stabilization Indications:
- deteriorating neurological status
-instability following closed reduction
-unstable fracture site
-bilateral facet dislocation.
Operative Treatment consists:
-anterior or posterior arthrodesis with plate or rod fixation.
-Surgical intervention may occur as early as within the first 24 hours postinjury.

IMMOBILIZATION
 tongs, halo devices, turning frames, beds, and orthoses to allow for healing.

A. TONGS

 Crutchfield, Barton, Vinke, Gardner-Wells

 Inserted on the laterally on the outer table of the skull
 Traction is accomplished by attachment of a traction rope to the skull fixation.
Patient is a supine position, this rope is threaded through a pulley or traction collar with
weights attached distally. The weights hang freely without touching the floor.
 The tongs are used primarily as a temporary mode of skeletal traction with replacement
using halo device.

B. HALO DEVICES
 Used commonly to immobilize cervical fractures.
 Consist of a halo ring with four steel screws that attach directly to the outer skull. The halo is
attached to a body jacket or vest by four vertical steel posts.
 Contraindicated with severe respiratory involvement.
 Advantages:
1. Assist in reducing the secondary complications of prolonged bed rest.
2. Permit earlier progression to upright activities
3. Allow earlier involvement in a rehabilitation program
4. Reduce the length and cost of hospital stay

 For pts. Without neurological involvement, discharge from the hospital may occur days after
the application of the halo device.

23
 Skeletal traction devices are left in place until radiographic findings indicate stability has
been achieved (approximately 12 weeks)
 Following removal, a cervical orthosis is applied during a transitional period (approximately
4 to 6 weeks) until unrestricted movement is allowed.
 Sterno-occipital-mandibular immobilizer (SOMI) cervical orthosis, hard collar or custom-
made plastic collars are frequently used during the transition period, with progression to a
soft foam collar prior to resuming unsupported movement.

C. TURNING FRAMES AND BEDS

 Most commonly used turning frame is the stryker frame.
 It is consist of the anterior and posterior frame attached to a turning base.
 In turning from a supine position, the anterior frame is placed on top of the pt.
 A circular ring clamps in place to secure the two frames during turning
 Safety straps provide additional security
 Rotation to the prone position is accomplished by manually turning the two frames as a unit
 The uppermost frame is then removed. Return to the supine position is accomplished in the
same manner.
 Primary benefit of these devices is that they allow positional changes while maintaining
anatomical alignment of the spine.
 Turning can be accomplished without interruption of the cervical traction.
 Disadvantage: Positioning is limited to prone and supine. This is particularly problematic for
pts. With a low tolerance for the prone position
 These frames cannot cannot accommodate obese pts. And are suitable for unconscious pts.
 Frames are now used primarily as a temporary method of immobilization.
 In some facilities standard hospital beds are used. Any of a variety of special pressure
relieving mattresses (gel, sand, water, or foam) are used for pressure relief. Positional
changes are accomplished by log rolling.

D. THORACOLUMBOSACRAL ORTHOSES
 Commonly used to immobilize the spine in pts. With thoracic or lumbar injuries.
 Plastic body jackets functions to immobilize the spine and allow earlier involvement in
rehabilitation program.
 Body jackets are typically bivalved to allow for removal during bathing and skin inspection.

XII. PT Treatment

During the acute phase, emphasis is placed on respiratory management, prevention of indirect
impairments and complications, maintaining ROM, and facilitating active movement in
available musculature.
A. RESPIRATORY MANAGEMENT
Primary goals of management: Improved ventilation, Increased effectiveness of cough, Prevention of
chest tightness and ineffective substitute breathing patterns

DEEP BREATHING EXERCISES

 Diaphragmatic breathing should be encouraged.

 The therapist can apply light pressure during both inspiration and expiration. Inspiration- manual
contacts can be made just below the sternum. This will assist the pt. to concentrate on deep breathing
patterns even in the absence of thoracic and abdominal sensation.
Expiration- manual contacts are made over the thorax with the hands spread wide. Creates a
compressive force on the thorax, resulting in a more forceful expiration followed by a more efficient
inspiration.

 Pts. are immobilized in traction devices or limited to recumbent positions may benefit from use of a
mirror to provide visual feedback during these activities.

GLOSSOPHARYNGEAL BREATHING

 Appropriate for pts. With high-level cervical lesions.

 Utilizes accessory muscles of respiration to improve vital capacity

24
 Pt. is instructed to inspire small amounts of air repeatedly, using a “sipping” or “gulping” pattern,
thus utilizing available facial and neck muscles.

 Enough air is gradually inspired to improve chest expansion despite paralysis of the primary muscles
of respiration

AIRSHIFT MANEUVER

 Provides the pts. With an independent methods of chest expansion.

 Closing the glottis after a maximum inhalation, relaxing the diaphragm, and allowing air shift from
the lower to upper thorax.

 Airshifts can increase chest expansion

STRENGTHENING EXERCISES

 Progressive resistive exercises can be used to stregthen the diaphragm.

 Accomplished by manual contacts over the epigastric area below the xiphoid process by use of
weights.

 Strengthening exercises for innervated abdominal and accessory musculature are also indicated.

ASSISTED COUGHING

 Manual contacts are placed over the epigastric area. The therapist pushes quickly in

 an inward and upward direction as the pt. Attempts to cough.

ABDOMINAL SUPPORT

 Abdominal corset or binder is indicated for pts. Whose abdomen protrudes, allowing the diaphragm
to “sag” into poor position for function.

 The corset will support the abdominal contents and improve the resting position of the diaphragm

 Abdominal supports provide the secondary benefits of maintaining intrathoracic pressure and
decreasing postural hypotension.

STRETCHING

 Mobility and compliance of the thoracic wall can be facilitated by manual stretching of pectoral and
other chest wall muscles.

B. RANGE OF MOTION AND POSITIONING

 Full ROM exercises should be completed daily except in those areas that are contraindicated or
require selective stretching

 With paraplegia, motion of the trunk and some motions of hip are contraindicated

 Straight leg raising more than 60° and hip flexion beyond 90° (during combined hip and knee
flexion) should be avoided

 If possible, ROM exercises should be completed in both the prone and supine positions

 In the prone position, attention should be directed toward shoulder and hip extension and knee
flexion

 With tetraplegia, motion of the head and neck is contraindicated pending orthopedic.

 Stretching the shoulders should be avoided during the acute period

 Pt. Should be positioned out of the usual position of comfort, in which there is internal rotation,
adduction and extension of the shoulders, elbow flexion, forearm pronation, and wrist flexion.

25
 Pts. With SCIs do not require full ROM in all joints

 After the acute phase, the hamstrings will require stretching to achieve a straight leg raise of
approximately 100°

 Care should be taken not to overstretch the hamstrings muscles as some tightness in this muscle
group provides passive pelvic stabilization in sitting.

 Process of understretching some muscles and full stretching of others to improve function is referred
to as selective stretching

 Alignment for the fingers, thumb, and wrist must be maintained for functional activities or future
dynamic splinting

 For high-level lesions, the wrist positioned in neutral, the web space is maintained, and the fingers
are flexed.

 If the wrist extensors are functional (fair muscle grade), a C-bar or short-opponens splint is usually
sufficient.

 Ankle boots or splints are indicated to maintain alignment and to prevent heel cord tightness and
pressure sores. Ankle boots designed to suspend the heel in space and distribute pressure evenly
along the lower leg available commercially.

 Sandbags or towel rolls also may be required to maintain a position of neutral hip rotation.

 For pts. Wearing a halo device, one or two pillows under the chest will allow assumption of the
prone position

C. SELECTIVE STRENGTHENING

 All remaining musculature will be strengthened maximally

 During the first few weeks following injury, application of resistance may be contraindicated to
(1)musculature of the scapula, and shoulders in tetraplegia and (2)musculature of the pelvis and trunk
in tetraplegia.

 Several forms of strengthening exercises are appropriate during this early phase: bilateral manually
resisted motions in a straight planes, bilateral UE proprioceptive neuromuscular facilitation (PNF)
patterns, progressive resistive exercises using cuff weights or dumbbells

 Biofeedback training also may be a useful adjunct during early exercise programs

 With tetraplegia, emphasis should be placed on strengthening the ant. Deltoids, shoulder extensors,
biceps and lower trapezius.

 With paraplegia, all UE musculature should ne strengthened, with emphasis on shoulder depressors,
triceps, and latissimus dorsi, which required for transfers and ambulation

D. ORIENTATION TO THE VERTICAL POSITION

 The pt. Typically will experience symptoms of postural hypotension if approach to management is
somewhat required some period of immobility

 Gradual acclimation to upright posture is most effective

 The use of an abdominal binder and elastic stockings will retard venous pooling

 Initially, Upright activities can be initiated by slowly elevating the head of the bed and progressing to
a reclining or tilt-in-space wheelchair with elevating leg rests

 Vital signs should be monitored carefully and documented during this acclimation period

26
 Pts. Who have been immobilized in the halo or undergone surgical spine stabilization will not
confined to recumbent position for prolonged periods

ACTIVE REHABILITATION PHASE

Goals should be established individually for each pt on the basis of examination findings in accordance
with the level and extent of injury.

Emphasis of treatment is on maximizing functional independence.

Most Distal NN root Available movements Functional capabilities Equipment and

segments innervated and Resistance required
key muscles
C1, C2, C3 Talking Bed skills
Mastication ADL Dependent
Sipping *Total dependence in Mechanical ventilator;
Blowing ADL may use phrenic nerve
stimulator during the
*Activation of light day
switches, page turners,
call buttons, electrical Independent with power
appliances and speaker wheelchair, portable
phones ventilator is typically
attached; microswitch or
*Wheelchair skills and sip and puffcontrols
transfers may be used
Dependent
C4 Respiration ADL Dependent
Diaphragm Scapular elevation
Trapz *limited self feeding Mobile arm supports,
powered flexor hinge
*Typing hand splint.
Adapted eating
*page turning equipment (long straws,
built up handles on
*activation of light utensils, plate guards
switches, call buttons, and so forth)
electrical appliances and Plexigals lapboard
speaker phones
Computer keyboard
*Wheelchair skills using head or mouth
stick or sip and puff
*Pressure relief controls: another option
*Transfers is a rubber tipped stick
Skin inspection held in hand by a splint
Cough with
glossopharyngeal Head or mouth stick
breathing Environmental control
*table games such as unit for powered page
cards or checkers turner
*painting and drawing Environmental control
units

Independent with power

wheelchair with head,
mouth, chin, breadth or
sip and puff controls

Power tilt in space

wheelchair

Dependent
Dependent

27
 Dependent
Head or mouth stick
built up playing pieces
Full time attendant
required
C5 Bow flexion and Able to accomplish all Some assistance
Biceps supination activities of C4 required
Brachialis Shoulder ER tetraplegic with less Assistance is required in
Brachioradialis Shoulder abduction to adaptive equipment and setting up patient with
Deltoid 90 degrees more skill necessary equipment;
Infraspinatus Limited shoulder patient can then
Rhomboids flexion Self feeding accomplish activity
supinators independently
Typing
Mobile arm supports,
Page turning deltoid aid
Limited UE dressing Adapted utensils and
Limited self care splinting
Computer keyboard
Transfer Activities Hand splints
Adapted typing sticks
Skin inspection Some patients may
Pressure relief require mobile arm
supports or slings
Cough with manual
pressure to diaphragm Same as above
Assistance required
driving Hand splints
Adapted equipment
Independent with
manual wheel chair with
plastic coated handrim
projections

Power wheelchair with

joystick or adapted UE
controls

Dependent
Assistance required

Van with hand controls

Part time attendant
required
C6 Shoulder flexion, Self feeding Some assistance top
ECR extenson, Internal indep with use of side
Infraspinatus Rotation, adduction Dressing rails on bed or overhead
Latissimus Dorsi Scapular abduction and triangle
Pecs major upward rotation Self care
Pronator teres Fa ponation Unversal cuff
SA Wrist extension Wheelchair skills Intertwine utensils in
Teres minor fingers
Transfers, skin Adapted utensils
inspection and pressure
relief Utelizes momentums,
button hooks, zipper
Bowel and bladder care pulls, or other clothing
adaptations: dependent
Cough with application on momentum to extend
of pressure to abdomen limbs

Driving Cannot tie shoes

Universal cuff
Wheelchair Sports Flexor hinge splint

Meal Preparation Adaptive equipment

Indep with manual
wheelchair with

28
 projection or friction
surface hand rims:
power wheelchair may
be required for long
distances and
community mobility

Independent with
sliding board on level
surfaces
Independent

Can be indep with

equipment depending on
bowel and bladder
routine

Indep

Automobile wit hhand

controls and U shaped
cuff attached to steering
wheel
Sually requires
assistance in getting
wheelchairinto car

Limited participation

Can be indep with

occasional light meals
with adaptive
equipments
C7 Elbow extension Self feeding Indep
EPL, EPB Wrist flexion
Extrinsic finger Finger extension Dressing Indep
extensors
FCR Self care Button hook may be
triceps required
Wheelchair skills Shower chair
Hand held shower
Transfers nozzle
Adapter handles n
Bowel and bladder care bathroom

Manual cough Indep with manual

wheelchair with friction
Housekeeping surface hand rims

Driving Indep

Indep with appropriate

equipment

Indep

Light kitchen activities

Requires wheelchair
accessible kitchen and
living environment
Adapted kitchen tools

Automobile with hand

controls

Ab;e to get wheelchair

in and out of car
C8 to T1 Full innervations of UE ADL Indep

29
Extrinsic finger flexors mm including fine Indep in all self care and
FCU coordination and strong Wheelchair skills personal hygiene
FPL FPB grasp Some adaptive
Intrinsic finger flexor Housekeeping equipment may be
required
Transfers
Indep with manual
Driving wheelchair with
standard hand rims
employment
Indep in light
housekeeping and meal
preparation
Some adaptive
equipment may be
required
Requires a wheelchair
accessible living
environment

Indept

Automobile with hand

controls

Able to work in a
building free of
architectural barriers
sT4 to T8 Improved trunk control Bed skills Indep
Top half of intercostals Increased respiratory
Long mm of back reserve ADL Indep in all areas
(sacrospin semispin) Pectoral girdle
stabilized for lifting Wheelchair skills Indep with manual
objects wheelchair
Curb climbing in w/c
Able to negotiate curbs
Wheelchair in sports using a wheelie
technique
Transfers
Full participation
Physiological standing
Indep
housekeeping
Standing table or frame

Bilat knee ankle foot

orthoses- may ambulate
for short distances

Indep with routine

activities
Requires a w/c
accessible living
environment

T9 to T12 Improved trunk control Household ambulation Bilat KAFOs and

Lower abdominalis Increased endurance crutches pr walker
All inter costals Wheelchair Skills
Wheelchair used for
energy conservation
L2, L3, L4 Hip flexion Functional Ambulation Bilat KAFOs and
Gracilis Hip abduction crustches
Iliopsoas Knee extension Wheelchair skills Wheelchair used for
Quadratus Lumborum convenience and energy
Rectus femoris conservation
Sartorius

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L4, L5 Strong hip flexion Functional ambulation Bilat KAFOs and
Extensor Digitorum Strong knee extension crutches or canes
Low back mm Weak knee flexion Wheelchair skills Wheelchair used for
Medial hamstrings Improved trunk control convenience and energy
Post tibialis conservation
Quads
Tibialis ant

A. CONTINUING ACTIVITIES

 Emphasis is also placed on regaining postural control and balance by substituting upper body control
and vision (for lost proprioception).

 This phase of treatment will also focus on improved cardiovascular response to exercise.

B. SKIN INSPECTION

 Pt. Will be instructed gradually to assume responsibility for skin inspection.

 This will involve practice in use of long-handled or adapted mirrors to allow inspection of areas not
easily visible.

 Pts. With high level lesions may be incapable of skin inspection.

C. MAT PROGRAMS

 The sequence of activities typically progresses from achievement of stability within a posture and
advances through controlled mobility to skill in functional use

 Early activities are bilateral to symmetrical

 Gradual emphasis is placed on improved timing and speed.

 Mat activities are often individual components of more complex functional skills

 Sequences from easiest to most difficult

 Progression through the sequence of mat activities develops improved strength and functional ROM,
improves awareness of the new center of gravity, promotes postural stability, facilitates dynamic
balance, and assists with determining the most efficient anf functional methods for accomplishing
specific tasks.

 the therapist and pt. Often must experiment with different methods of performing task or intervention
to come up with a specific method that works well for the pt.

ROLLING

 Is a functional significance for improved bed mobility, preparation for independent changes in bed
(for pressure relief) and LE dressing

 Frequent starting point of mat programs for pts. With SCI

 If asymmetric involvement exists, rolling should be initiated with movement toward weaker side

 To begin training and facilitate rolling, several approaches can be used

- Flexion of the head and neck with rotation may be used to assist movement from supine to prone
positions
- Extensions of the head and neck with rotation may be used to assist movement from prone to supine
positions
- Bilateral, symmetrical UE rocking with outstretched arm,s produces a pendular motion when moving
from supine to prone positions.
-Crossing the ankles will also facilitate rolling
-In moving from supine prone position, pillows may be placed under one side of the pelvis (or scapula, if

31
needed) to create initial rotation in the direction of the roll
-Several PNF patterns are useful during early rolling activities

PRONE-ON-ELBOWS POSITION

 Functional implications os this activity are improved bed mobility and preparation for assuming the
quadruped and sitting positions

 Facilitates head and trunk control as well as proximal stability of the glenohumeral and scapular
musculature via co-contractions.

 Must be used with caution, particularly thoracic and lumbar injuries

-Weightbearing will improve stability at the shoulders through joint approximation

-Rhythmic stabilization may be used to increase stability of the head, neck and scpaula
Manually applied approximation can be used to facilitate stabilization of proximal musculature
-Unilateral weightbearing on one elbow (static dynamic activity) can be achieved
-Movement within this posture can be achieved by an on-elbows forward backward, and side-to-side
progression
-Strengthening of the serratus anterior and other scapular muscle

PRONE-ON-HANDS POSITION (with paraplegia)

 Development of the initial hyperextension of the hips and low back for pts. Who will require this
postural alignment during ambulation, and standing from a wheelchair or rising from the floor with
crutches and bilateral knee-ankle-foot orthoses (KAFOs)

 It should be noted that this position would not be appropriate for every pt. With paraplegia owing to
excessive lordosis required to assume and to maintain the position.

-Lateral weight shifting with weight transfer bet. Hands will require increase joint approximation
-Additional approximation force can be applied through manual contacts to facilitate tonic holding of
proximal musculature further.
-Scapular depression and prone push-ups may be utilized as strengthening exercises

SUPINE-ON-ELBOWS

 Purpose: assist with bed mobility and to prepare the pt. To assume a long sitting

 If control of abdominal muscles is present, the pt. May have sufficient strength to achieve the
position by pushing the elbows into the mat and lifting into the position

 A more common technique is for the pt. To “wedge” the hands under the hips or to hook the thumbs
into pants pockets or belt loops

 Some pts. May find it easiest to assume this position from sidelying

 Also an important strengthening exercise for shoulder extensors and scapular adductors

-Lateral weight shifting can be practiced in this position

-Side-to-side movement in this posture will enhance the pts. Ability to align the trunk with the LEs when
in bed or in preparation for positional changes
-Precautions should be taken with this posture as if may cause increased shoulder pain due to the pressure
exerted on the anterior shoulder joint capsule

PULL-UPS( with tetraplegia)

 Purpose: strengthen the biceps and shoulder flexors in preparation for wheelchair propulsion

 Pt. In supine position

 Therapist assumes the high-kneeling position with one LE on each side of the pt’s hips. The
therapists grasps the pt’s supinated forearms just above the wrists. Pt. Pulls to sitting and then lowers
back to the mat. Alternately, an over-head trapeze bar can be used for training

SITTING

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 Both long and short sitting position are essential for many activities of daily living, such as dressing,
self-ROM, transfers, wheelchair mobility,

 Pts. With tetraplegia require approximately 100 degrees of straight-leg ROM to assume a long-sitting
position (Hamstring tension and pt. Sitting on sacrum )

 Pts. With low thoracic lesions can be expected to sit with a relatively erect trunk

 Pts. With high cervical lesions will demonstrate poor sitting position

 For pts. With triceps and abdominal musculature (paraplegia), the sitting position can generally be
assumed without difficulty.

 Pts. With tetraplegia initially are taught to assume a stable sitting position by placing the shoulders in
hyperextension and external rotation, and the elbows and wrists in extension with the fingers flexed
(fingers is particularly important to avoid overstretching)

-During early sitting, a mirror may provide important visual feedback

-Manual approximation force used at the shoulders to promote co-contraction.
-A variety of PNF techniques may be used. Specifically, alternating isometrics, and rhythmic stabilization
are important in promoting early stability in this posture.
-Balance activities may be practiced in sitting.
-Sitting push-ups are an important preliminary activity for transfers and ambulation
-Movement within this posture can be accomplished by using a sitting push-up in combination with
momentum created by movement of the head and upper body.

QUADRUPED POSITION

 The functional implication of this all-fours position is its importance as a lead-up activity to
ambulation.

 Allows weightbearing through the hips and is useful for facilitating initial control of the available
musculature of the lower trunk and hips.

-Initial activities will involve practice in maintaining the position; rhythmic stabilization, can be used to
facilitate co-contraction
-Manual application of approximation force also can be used to facilitate co-contraction
-Weight shifting can be practiced in a forward, backward, and side-to-side direction
-Rocking through increments of range (forward, backward, side-to-side, and diagonally) will promote
development of balance response
-Alternately freeing one UE from a weightbearing position may be used in the quadruped position
-Creeping can be used to improve strength ( resisted forward progression)

KNEELING POSITION

 Particularly important in establishing functional patterns of trunk and pelvic control and for further
promoting upright balance control

 Important lead-up activity to ambulation using crutches and bilateral KAFO

-Initial activities will concentrate on maintaining the position using available musculature and postural
alignment (hips fully extended with the pelvis slightly anterior to the knees)
-Balancing activities may progress from support with both UEs to support from only one.
-A variety of mat crutch activities can be used in the kneeling position

TRANSFERS

 Pts with SCI most frequently use some variation of lateral scoot transfer (with or without the use of
transfer board)

 Three important components of transfer skills are:

Momentum- can be used to facilitate movement at a joint(s) when the surrounding musculature is weak.

Muscle substitution

33
Head-hips relationship- Can be used as a first class lever. When the pt. Moves the head in one direction
the buttocks will move in the opposite direction as he or she pivots at the shoulders.

D. PRESCRIPTIVE WHEELCHAIR

 Most pts with SCI will use a wheelchair as the primary means of mobility

 Pts with paraplegia use a wheelchair as a primary means of locomotion because it provides a lower
energy expenditure and greater speed and safety

 Individuals with higher cervical injuries generally rely on a power wheelchair for their mobility
needs

 Two basic frames for manual wheelchairs:

Folding frames- typically incorporate a below-seat crossbar and generally provide a smoother ride on
uneven surfaces. Drawbacks include: more moveable parts causing it to be less energy and slightly less
lateral stability

Rigid frames-more energy efficient, usually lighter weight and often has an adjustable seat-to-back angle.
More difficult to store in a car as both wheels must be removed for storage (on some models the entire
seating system also lifts off) for storage. Some models incorporate shock absorber springs to minimize
this effect.

 Push rim activated power assist wheelchairs (PAPAW)- manual wheelchair to which power assist
wheels have been added. Propelling a PAPAW requires less energy, lower stroke frequency, and less
shoulder ROM than a manual wheelchair. Beneficial for individuals with mid to lower level cervical
injuries who may not have the endurance or strength. Indicated for all pts. With C4 lesions and
above.

WHEELCHAIR SKILLS

 Management of the brakes, arms and pedals is crucial for all transfer activities

 Pts with limited hand function are able to propel the wheelchair by using the base of the hand against
the hand rim

 Wheelchair mobility activities should begin on level surfaces (including doorways and elevators) and
progress to outdoor, uneven surfaces

 Pt. Should be instructed in pressure relief techniques from a sitting position

 Ten to 15 seconds of pressure relief (or tissue redistribution) for every 10 minutes of sitting should
become part of the pt’s routine

 Several common approaches: wheelchair push-ups, hooking an elbow or wrist around the push
handle and leaning toward the opposite wheel, hooking one elbow or wrist around the push handle
and leaning forward

E. AMBULATION AFTER SPINAL CORD INJURY

 Goal: Regaining the ability to walk

 Pt must possess adequate muscle strength, postural alignment, ROM, and sufficient cardiovascular
endurance to initiate gait training

 Individuals with complete SCI must rely on orthotic devices, assistive devices, adequate ROM, and
strengthening neurologically intact musculature for standing and walking

 Adequate cardiovascular endurance for functional ambulation

 Other factors that may restrict ambulation include: severe spasticity, loss of proprioception
(particularly at the hips and knees), pain, and the presence of secondary complications such as
decubitus ulcers, heterotopic bone formation at the hips, or deformity

GAIT TRAINING FOR INDIVIDUALS WITH COMPLETE SPINAL CORD INJURY

34
 For pts with complete SCI training emphasis is on strengthening available musculature, using
assistive devices and orthoses to support weak or denervated muscles, and learning new,
compensatory methods of walking

Orthostatic Prescription

 Varies according o lesion level

 Usually ankle and/or knee control bracing is necessary

 Pts with complete thoracic lesion will require KAFOs

 Scott-Craig Orthosis- prescribed for pts with paraplegia. Consist of standard double uprights, an
offset knee joint providing improved biomechanical alignment, bail locks, a posterior thigh band,
anterior tibial band, adjustable ankle joint, and a sole plate that extends beyond the metatarsal heads

 Reciprocating Gait Orthosis (RGO)- composed of two plastic KAFOs that are joined by a molded
pelvic band with thoracic extensions.

 Ankle-foot orthosis- appropriate for pts with lower-level lesions

Gait Training Strategies

 swing through typ of gait pattern (for pt. With KAFO)

 Crutches should be placed equidistant from both toes at toe-off and be equidistant from both heels at
heel strike

-Putting on and removing orthoses

-Sit-to-stand activities
-Trunk balancing
-Push-ups
-Turning around
-Jack-knifing
-Ambulation activities in the parallel bars
-Assistive devices
Standing from the wheelchair with crutches
-Crutch balancing
-Ambulation activities
-Travel activities
-Elevation activities
Falling

LOCOMOTOR TRAINING FOR INDIVIDUALS WITH INCOMPLETE SPINAL CORD INJURY

 Locomotor training is to train like you walk

 Train like you walk:

-LEs are maximally loaded for weightbearing, minimizing or eliminating loading of arms
-posture, trunk, pelvis, and limb kinematics are coordinated and specific to the task of walking
-compensatory strategies for movement are minimized or eliminated

E. FUNCTIONAL ELECTRICAL STIMULATION

 Application of low-level electrical current to improve function in paralyzed and/or weak muscles

 Can be used for a variety of purposes to improve function and quality of life for individuals with SCI

F. PREVENTION, HEALTH PROMOTION, FITNESS AND WELLNESS

35
SHOULDER PAIN

 Relatively common after SCI

 Factors: Duration of injury, weightbearing, wheelchair use, poor seated posture, age, body, mass
index, level of injury, muscle imbalance at the shoulder joint complex, and decreased ROM

 Prevention of shoulder pain is vital

 Proper postural alignment is a key factor as well as strengthening and stretching shoulder
musculature

EXERCISE

 Important for individuals with SCI

 Endurance training and resistance training- improve function, strength, endurance, respiratory
function, perceived health, and quality of life

 Common endurance exercise modalities include: UE ergometer, wheelchair propulsion, swimming,

and circuit resistance training

 Strength training: 8 to 12 reps per exercise for 2 sessions per week using free weights, weight
machines or elastic tubing

Ambulation After Spinal Cord Injury

 Regaining the ability to walk is a common goal for most individual with SCI. A number of
factors influence the success or failure in attaining this goal.

Patients must posses :

 Adequate muscle strength
 Postural alignment
 ROM
 Sufficient Cardiovascular endurance to initiate gait training.

 Gait Training for Individuals with Complete SCI

 For patients with complete SCI training empahasis is on strengthening available musculature,
using assistive devices and orthoses to support weak or denervated muscle, and learning new,
compensatory methods of walking.

Orthotic Prescription
 Varies according to lesion level
 Usually only in the ankle and knee control bracing
 KAFOs is used by patients with complete thoracic lesion
 Conventional KAFOs include:
 Bilateral metal uprights
 Posterior thigh et calf bands
 Anterior knee flexion pad
 Drop ring or bail locks
 Adjustable locked ankle joints
 Heavy duty stirrup
 Cushion heel
 Ankle joints are usually locked in 5 to 10 degrees of dorsiflexion to assist hip extension at heel
strike
 Scott – Craig Orthosis – frequently prescribed for patients with paraplegia , consists of standard
double uprights, an offset knee joint providing improved biomechanical alignment, bail locks,
posterior thigh band , anterior tibial band, adjustable ankle joint and sole plate that extends
beyond MT heads.
 Modification :
 Plastic solid ankle section in place of the metal ankle joint
 Sole plate
- Thus, this change decreases overall weight of the orthosis, improves cosmesis and eliminates
the needs of customade shoes

36
  Reciprocating Gait Orthosis (RGO) – composed of two plastic KAFOs that are joined by a
molded pelvic band with thoracic extensions. It has also dual cable system that runs posteriorly
and atteches at the hip joints, and these cable attachments transmit forces between LE’s and
provide reciprocal movements.
 Pelvic bands and spinal attachments are rarely prescribed for use with conventional KAFOs and
severely restrict dressing activities, movement from sitting to standing and ambulation, by
reducing trunk and pelvic flexibility and by adding extra weight often as 4lbs.
 AFOs – often appropriate for patients with lowe-level lesions, either conventional metal upright
or plastic FO may be indicated.

 Gait Training Strategies

 A swing-through type of gait pattern should be the ultimate goal for functional ambulators with
KAFOs. In teaching this pattern , it is importnant to stress a smooth even a cadence. Crutches
should be placed equidistant from both toes at toe-off and be equidistant from both heels at heel
strike. Thus, it is important to establish an overall rhythm , as improved timing will result in
improved energy and cosmesis.

 Relevant training activities includes:

 Putting on and removing orthoses

 Sit-to-stand activities
 Trunk balancing
 Push-ups
 Turning around
 Jack knifing
 Ambulation activities in the parallel bars
 Assistive device
 Standing from the wheelchair with crutches
 Crutch balancing
 Ambulation activities
 Travel activities
 Elevation activities
 Falling

 Locomotor Training for Individuals with Incomplete Spinal Cord Injury

 Locomotor training is to train like you walk. It requires defining the task of walking, kinematics,
kinetics, spatial-temporal pattern, posture, balance and adaptability. It also requires environment to
experience the specific task of walking and intense practice with progression towards independence
in the task of walking.

Train like you walk translates into the following practical training guidelines:

 The LE’s are maximally loaded for weightbearing , minimizing or eliminating loading of the
arms
 The posture, trunk pelvis and limb kinematics are coordinated and specific to task of walking
 Compensatory strategies for movement

 Terms to describe also are body weight supported treadmill training, partial body weight
supported treadmill training or weight supported treadmill training. Thus, these terms emphasizes
exercise or training equipment that is currently advocated for retraining walking by
manufacturers and by some clinicians and researchers.

 Functional Electrical Stimulation

 It is the application of low level electrical current to improve function in paralyzes and / or weak
muscles. It can also be used for variety of purposes to improve function and quality of life for
individuals with SCI, these includes:
 Cardiovascular training
 Breathing
 Ambulation

37
  UE function
 Transfers and standing
 Bowel and bladder function
 FES can be also applied using surface electrodes , percutaneous electrodes or surgically
implanted electrodes. Thus, the electrical stimulation is interfaced with a computer which
controls the timing and onset of stimulation.

 Prevention , Health Promotion , Fitness and Wellness

 Improvements in medical care , rehabilitation of techniques and technology have increased the
life span of individuals with SCI. It is because of the variety of secondary complications that
these individuals are at risk for developing throughout their life span, it is important to develop
effective prevention and fitness strategies that can be carried out after patients have finish their
rehabilitation.

Complication /s:

 Shoulder Pain – relatively common after SCI

o The cause of this is associated with variety of factors:

 Duration of injury
 Weight-bearing
 Wheelchair use
 Poor seated posture
 Age
 Body mass index
 Level of injury
 Muscle imbalance at the shoulder joint complex
 Decreased ROM

Pain is biomechanical in nature, thus patients with SCI must perform ADLs and mobility such as
transfer with weightbearing on the UEs , reach overhead from seated position in a wheelchair in
an internally rotated shoulder posture to reach objects on counter and propel a wheelchair for
locomotion.

Proper postural alignment is a key factor as well as strengthening and stretching shoulder
musculature.

 Exercise

 Just like individuals without disabilities , exercise is important for individuals with SCI.

 Endurance training and resistance training – improves function, strength, endurance ,

respiratory function , perceived health and quality of life.

- According to American College of Sports Medicine , an individual with SCI should exercise
3 to 5 times a week at 50 to 80 percent of peak HR.

 Common endurance exercise modalities include:

 UE ergometer
 Wheelchair propulsion
 Swimming
 Circuit resistance training

- For strength training recommendations , this include 8 to 12 repetitions per exercise for 2
sessions per week using one of the following exercise modalities:

 Free weights
 Weight machines
 Elastic tubing

 Education

38
 An important aspect of long-range of rehabilitation planning involves educating the patient in a
life long management of the disability. This will focus on community reintegration and methods
of maintaining the optimal state of health and function achieved during rehabilitation.

Consideration must be given to multiple issues such as:

 Housing
 Nutrition
 Transportation
 Finances
 Maintaining functional skills and level of physical fitness
 Employment
 Social and recreational activities involvement

XIII. References

 Physical Medicine and Rehabilitation. Braddom, Randall L. 4TH Edition

 Physical Rehabilitation, Susan B. O’Sullivan, Thomas J. Schmitz. 5th ed.
 http://bestpractice.bmj.com/best-practice/monograph/1176/diagnosis/differential.html
 Mayo Clinic Staff. (1998). Diseases and Conditions: Spinal Cord Injury. Tests and
Diagnosis. Retrieved February 22, 2015, from http://www.mayoclinic.org/diseases-
conditions/spinal-cord-injury/basics/tests-diagnosis/con-20023837
 Anatomy and Physiology, Saladin

 Tortora, G., & Grabowski, S. (2003).Principles of anatomy and physiology (10th ed.).

New York:
Wiley.
 Snell, R. (2010). Clinical Neuroanatomy(7th ed.). Philadelphia: Wolters Kluwer
Health/Lippincott Williams & Wilkins.

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