Prognosis and goal setting for individuals with SCI

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Introduction

Goal setting is “the formal process whereby a rehabilitation professional or a multidisciplinary team, together with the patient and/or their family, negotiate goals.” [1]  Goals are important for several reasons. They ensure that the expectations of individuals with a spinal cord injury and those working with them are similar and realistic, and provide clear indications of what every-one is expected to achieve. If compiled in an appropriate way, they actively engage individuals in their own rehabilitation plan, empowering them and ensuring that their wishes and expectations are met. Goal setting is used to direct rehabilitation interventions towards a specific outcome or outcomes.  Therapists should always involve patients in setting goals for their therapy. Goals that are of value to patients will optimize their motivation for and participation in the therapy and enable them to achieve the highest possible level of independence, autonomy, and control. The process of setting goals can begin with the therapist giving the patient the results of the initial evaluation, including an approximation of the patient's potential for functional recovery. Goal setting is used to direct rehabilitation interventions towards a specific outcome or outcomes. Shared goal setting can also co-ordinate members of the multidisciplinary team and ensure they are working together towards a common goal and that nothing important is missed. Goals can also be used to evaluate the success of rehabilitation interventions. [1][2] 

Prognosis

Outlook is linked directly to both the severity of the neurologic injury, and any associated impairment. With established lesions of the spinal cord, full recovery of neurological function is unlikely, and outcome depends on the ability of rehabilitation to maximize residual function. While surgical intervention may be able to limit further damage where there is a progressive lesion of the spinal cord, which can also lead to some improvement in the overall neurological status. [2][3][4][5]

Functional expectations and prognosis following a spinal cord injury is dependent upon many individualised factors:

  • Neurological Level of Spinal Cord Injury
  • Severity of Spinal Cord Injury (Complete v Incomplete, ASIA Impairment Scale)
  • Patient-Specific Factors
    • Age, Health and Pre-morbid Fitness / Function
    • Past Medical History / Co-morbidities
    • Associated Injuries
    • Secondary Complications
    • Motivation and Psychosocial Well-being

Accurate prediction of clinical outcomes following a spinal cord injury based on early examination are limited. Retention of sacral sensation at the S4 - S5 dermatome, especially pinprick, is considered the most important predictor of improved outcome and useful recovery at 72 hours to 1 week post injury, with 75% of individuals with sacral sparing regaining the ability to walk. It is more difficult to predict ability to walk at the time of injury but estimates indicate that very few patients with ASIA A lesions at the time of injury ultimately ambulate with or without assistance, 30 - 45% of patients with ASIA B lesion ambulate for at least short distances and most patients with ASIA C and D lesions become community ambulators, with those with Brown-Sequard or Cervical Central Cord Syndrome the best prognosis for walking if young when injured. [2][4][5]

Most individuals regain one level of motor function from their initial spinal injury classification completed within 72 hours of injury, with the majority of recovery of function occurring in the first 6 months. For example, an individual presenting with C6 tetraplegia at the time of injury may present with C7 tetraplegia 3 - 6 months later. It is also widely accepted that individuals with an incomplete spinal cord injury can make useful recovery upto 2 years post injury, and in some cases may occur more slowly over a longer period of time, in particular with incomplete tetraplegics. Approximately 50% of patients initially diagnosed with ASIA B or C Lesions improve over the first few months by one ASIA level (i.e. from ASIA B to ASIA C, or from ASIA C to ASIA D). Ninety per cent of individuals with an incomplete spinal cord injury have some recovery of a motor level in their upper-limbs, compared to only 70 - 85% of complete injuries. [4][5][6]

Spinal cord injuries are a serious, widespread health issue that can result in widespeard impairment andis associated with significant challenges to overall wellbeing, including a high risk of secondary complications, mental health problems, financial insecurity, and social isolation. Older age when injured, medical complications, cognitive deficits, poor perceptions of control or self-efficacy, and
poor social support predicted poor social participarion with increased difficulties in reintegration into their community post discharge. While Individuals who were injured at a younger age, and those less severe injuries, had higher level of functional independence and improved employment outcomes, although employment rates are low overall post spinal cord injury. [2][7]

Setting Goals

Goal setting is the process of discussing, planning and documenting outcomes for a patient or client. It can be as simple as a conversation between a physiotherapist and a patient during a treatment session. Or can be more complex and structured in a meeting between a Multidisciplinary Team and a patient. The patient’s social supports, e.g family members or friends, may also be invited to join in with goal setting if they have a role to play in helping the patient achieve a particular goal. One common method of goal setting has been derived from SMART Goals, which originated in the field of project management. [2][8]  

S   Specific 

M  Measurable 

A   Attainable or Assignable 

R   Realistic 

T   Time-related 

While an individual with a spinal cord injury has the potential to achieve the same functional goals as another individual with the same level of injury, factors such as age, body type and build, medical complications, contractures, muscle strength, cognitive dysfunction, motivation etc. all can impact on the actual functional outcome achieved by each individual. Ideally the individual should be involved in both the setting and regular review of their goals. [2] 

Read more about Goal Setting in Rehabilitation in Physiopedia. 

Complete Lesions

For individuals with an ASIA Complete Lesion (AIS A & B) with no zones of partial preservation we could expect to see the following typical outcomes. [2]

Cervical Lesions

Typical Level of Independence in ASIA Complete Spinal Cord Injury
Functional Activities Level of Spinal Cord Lesion
C1 - 3 Tetraplegia C4 Tetraplegia C5 Tetraplegia C6 Tetraplegia C7 Tetraplegia C8 Tetraplegia
Muscles Sternocleidomastoid

Paraspinal Muscles

Accessory Muscles

Upper Trapezius

Diaphragm

Deltoid

Biceps

Brachialis

Brachioradialis

Pectoralis Major

Lattisimus Dorsi

Serratus Anterior

Wrist Extensors

Triceps

Wrist Flexors

Long Finger Extensors

Finger Flexors
Unassisted Ventilation No Yes Yes Yes Yes Yes
Hand to Mouth Activities No No Yes Yes Yes Yes
Self-Feeding No No Limited Yes Yes Yes
Hand Function No No No Yes Limited Yes
Rolling No No Limited Limited Tendonesis Yes Yes
Horizontal Transfers No No Limited Yes Yes Yes
Lying to Sitting No No Limited Yes Yes Yes
Floor to Wheelchair No No Limited Limited Limited Yes
Push Manual Wheelchair No Limited Limited Yes Yes Yes
Stand

Orthosis Parallel Bars

No No No No No No
Walk

Orthosis with Aids

No No No No No No
Drive No No Yes Yes Yes Yes
C1 - C3 Tetraplegia

Individuals with a lesion C1 - C3 only have voluntary function of the facial, pharyngeal, laryngeal, and neck extensor musculature, partial (C2) or full (C3) sternocleidomastoid function, and partial (C3) levator scapulae and trapezius function that results in paralysis of the upper and lower limbs, and trunk but retain movements of the head. Total paralysis of the diaphragm and respiratory muscles occurs in those with a C1-C2 lesion, while those with a C3 lesion may retain some level of diaphragm function, but not enough for spontaneous breathing and consequently are ventilator-dependant for respiratory function. Individuals canachieve a level of independent wheelchair propulsion and pressure relief using a reclining power wheelchair, with chin control and generally are anble to utilise head, mouth or voice activated technology for some daily activities. Individuals require full assistance to perform transfers, motor tasks or personal care activities. 

C4 Tetraplegia

Individuals with a C4 lesion have voluntary function of trapezius, rhomboids and levator scapulae with minimal paralysis of the diaphragm, that results in paralysis of the upper and lower limbs, and trunk, movements of the head, partial function around the shoulder. Individuals can breathe independabtly without a ventilator, and some can use a hand-controlled power wheelchair, and, with adaptive equipment such as a mobile arm support, may achieve self-feeding and facial hygiene. In all other aspects their activity limitations are similar to those with C1-C3 tetraplegia nd require full assistance to perform transfers, motor tasks or other personal care activities. 

C5 Tetraplegia

Individuals with a C5 lesion have paralysis of the lower limbs and trunk with partial paralysis of the upper limb with good function of the deltoid and biceps muscle, but poor strength in other shoulder muscles, triceps, wrist and hand function. Depending on the strength of the deltoids, some individuals may achieve some independent transfers with a sliding board. Hand-cotrolled power wheelchair with joystick is most common for wheelchair propulsion but manual wheelchair propulsion may be possible on even surfaces, especially when assisted with power assist wheels such as the e-motion. all mat and bed skills; and, in certain cases, independent personal care. They can achieve independent self-feeding and facial hygiene, and may achieve upper and possibly lower body dressing.

C6 Tetraplegia

Can achieve independent level transfers (with or without a sliding board) and some uneven transfers; roll over, come to sitting, and gross movement on a mat or bed without adaptive equipment; and all self-care activities, such as dressing, personal hygiene, eating, drinking, and cooking. All can perform manual wheelchair propulsion on level surfaces with handrims. May be able to navigate minor inclines, uneven terrain, and 2- to 4-inch curbs. Can achieve independent living. Have full function of the deltoids, biceps, brachialis, and brachioradialais, as well as significant function in the clavicular portion of the pectoralis major. Have function of the radial wrist extensors and the serratus anterior.

C7 Tetraplegia

Can achieve all independent, uneven transfers over greater distances; all independent mat and bed activities; all self-care activities; and manual wheelchair propulsion on steeper ramps and 4-inch curbs. Have some function of the tripceps and significant function of the anterior deltoids.

C8 Tetraplegia

Can achieve C7 functionality with greater ease with an addition of significant function of the flexor digitorum superficialis and profundus.

Thoracic Lesions

Typical Level of Independence in ASIA Complete Spinal Cord Injury
Functional Activities Level of Spinal Cord Lesion
T1 - 6 Paraplegia T7 - 12 Paraplegia
Muscles Upper Intercostals

Thoracic Extensors

Abdominals

Lumbar Extensors

Lower Intercostals

Unassisted Ventilation Yes Yes
Hand to Mouth Activities Yes Yes
Self-Feeding Yes Yes
Hand Function Yes Yes
Rolling Yes Yes
Horizontal Transfers Yes Yes
Lying to Sitting Yes Yes
Floor to Wheelchair Yes Yes
Push Manual Wheelchair Yes Yes
Stand

Orthosis Parallel Bars

Yes Yes
Walk

Orthosis with Aids

Limited Limited
Drive Yes Yes
T1 - T9 Paraplegia

Can perform all C7-C8 functions with ease. Can also negotiate steep ramps, rough terrain, stairs, and doorways that are narrower than the wheelchair. May negotiate 8-inch curbs or higher. Can achieve ambulation, with difficulty, on even surfaces with KAFOs and crutches or a walker. Full function of the upper extremities and the spine above the level of the lesion, but lack function of the abdominal musculature.

T10 - T12 Paraplegia

Can perform ambulation with KAFOs and crutches on even surfaces, with some difficulty, and negotiate some obstacles. Have varying degrees of function in the abdominal musculature. At T5, patrial function of the rectus abdominis; at T12, full function of the rectus abdominis.

Lumbar and Sacral Lesions

Individuals with a lumbar or sacral spinal cord injury have varying degrees of lower limb paralysis but tend to achieve ambulation without the need for orthoses or aids. Where there is imbalance around the ankle joint or foot an orthotic may be used to prevent the development of contractures.

Typical Level of Independence in ASIA Complete Spinal Cord Injury
Functional Activities Level of Spinal Cord Lesion
Lumbar Paraplegia Sacral Paraplegia
Muscles L1 - 2 Hip Flexors

L3 Knee Extensors

L4 Ankle Dorsiflexors

L5 Long Toe Extensors

S1 - 2 Ankle Plantarflexors
Unassisted Ventilation Yes Yes
Hand to Mouth Activities Yes Yes
Self-Feeding Yes Yes
Hand Function Yes Yes
Rolling Yes Yes
Horizontal Transfers Yes Yes
Lying to Sitting Yes Yes
Floor to Wheelchair Yes Yes
Push Manual Wheelchair Yes Yes
Stand

Orthosis Parallel Bars

Yes Yes
Walk

Orthosis with Aids

Yes Yes
Drive Yes Yes
L1 - L2 Paraplegia

Can achieve ambulation with a four-point gait. Have full function of internal and external obliques and partial function of the iliopsoas and quadratus lumborum.

L3 - L4 Paraplegia

Can achieve ambulation with AFOs. Have significant function of the quadriceps musculature (3/5 or stronger); actual strength will impact ability to ambulate with AFOs. Have partial function of the tibialis anterior and posterior, extensor digitorum longus and brevis, extensor hallucis longus and brevis at L4. With good function of both the gastrocnemius and soleus muscle from S1.

Incomplete Lesions

An incomplete spinal cord injury is an injury involving some preservation of motor and/or sensory function in the lowest sacral segment of the spinal cord, indicating that there is some preservation of motor and/or sensory function below the level of the lesion. Expectations in relation to the functional outcomes of individuals with an incomplete lesion with zones of partial preservation, in particular ASIA C or D are much less predictable as a result of a more diverse range of neurological loss. Overall, it is far more complex to determine the expected functional outcome of an individual with an acute incomplete spinal cord injury. 

References

  1. 1.0 1.1 Wade P. Goal Setting in Rehabilitation: An Overview of What, Why and How. Clin Rehabil. 2009 Apr;23(4):291-5http://journals.sagepub.com/doi/abs/10.1177/0269215509103551 (accessed 20 July 2018)
  2. 2.0 2.1 2.2 2.3 2.4 2.5 2.6 Harvey L. Management of Spinal Cord Injuries: A Guide for Physiotherapists. Elsevier Health Sciences; 2008 Jan 10.
  3. McDonald JW, Sadowsky C. Spinal Cord Injury. The Lancet. 2002 Feb 2;359(9304):417-25.
  4. 4.0 4.1 4.2 Waters RL, Adkins RH, Yakura JS et al: Motor and Sensory Recovery following Incomplete Tetraplegia. Arch Phys Med Rehabil 1994; 75:306–311.
  5. 5.0 5.1 5.2 Waters RL, Adkins RH, Yakura JS et al: Motor and Sensory Recovery following Incomplete Paraplegia. Arch Phys Med Rehabil 1994; 75:67–72.
  6. Waters RL, Adkins R, Yakura J et al: Prediction of Ambulatory Performance based on Motor Scores Derived from Standards of the American Spinal Injury Association. Arch Phys Med Rehabil 1994; 75:756–760.
  7. Wolfe DL, Hsieh JTC: Rehabilitation Practice and Associated Outcomes following Spinal Cord Injuries. In Eng JJ, Teasell RW, Miller WC et al (eds): Spinal Cord Injury Rehabilitation Evidence.Vancouver, 2006:3.1–3.44.
  8. Doran GT. There’s a S.M.A.R.T. Way to Write Management’s Goals and Objectives. Management Review. 1981; 70: 35-36.https://community.mis.temple.edu/mis0855002fall2015/files/2015/10/S.M.A.R.T-Way-Management-Review.pdf (accessed 25 July 2018).