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.[1] Goals can also be used to evaluate the success of rehabilitation interventions.[1] 

Setting Goals

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. 

Complete Lesions

For individuals with an ASIA complete lesion with no zones of partial preservation we could expect to see the following typical outcomes.

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
C7 Tetraplegia
C8 Tetraplegia

Thoracic Paraplegia

T1 - T9 Paraplegia
T10 - T12 Paraplegia

Lumbar and Sacral

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.

L1 - L2 Paraplegia
L3 - L4 Paraplegia
L5 Paraplegia
S1 - S3 Paraplegia

Incomplete Lesions

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. 

References

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  1. 1.0 1.1 1.2 Wade P. Goal setting in rehabilitation: an overview of what, why and how. Clin Rehabil. 2009 Apr;23(4):291-5 http://journals.sagepub.com/doi/abs/10.1177/0269215509103551 (accessed 20 July 2018)