Spinal cord injury assessment in FCEs

Fiona Breytenbach, MScOT (WITS)

fiona.breytenbach@wits.ac.za

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Acknowledgement for slide content:

Jenna Cohen and Mike Alves

Contents

• Check-in
• NB SCI assessments for function
• Reasonable accommodations
• Factors affecting return-to-work

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How do you feel when you get a SCI case?

SCI Assessments and Outcome measures

Which Ax do you use with SCI clients?

INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY AND HEALTH (ICF)

• Adopted by the World Health Organization in 2001

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• The international standard to describe and measure health and disability

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• A “modern framework for health”

Neurological/Autonomic

• ISNCSCI
• Surface Electromyography

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Strength

• Hand-Held Myometer

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Spasticity

• Modified Ashworth Scale
• Penn Spasm Frequency Scale
• Pendulum Test

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Pain

• Brief Pain Inventory Scale
• Classification System for Chronic Pain in SCI

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Skin Health

• Braden Scale
• SCI Pressure Ulcer Scale

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Mental Health

• CAGE Questionnaire
• Depression Anxiety Stress Scale – 21
• Patient Health Questionnaire

ICF – COMMON OUTCOME MEASURES

Body Structure and Function

Activity Limitations

Participatory Restrictions

Lower Limb and Walking

• 6-Minute Walk Test
• 10-Meter Walk Test
• Berg Balance Scale
• Timed up and Go Test
• Walking Index for SCI
• Standing and Walking Toolkit

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Wheeled Mobility

• Wheelchair Skills Test

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Upper Limb

• Capabilities of Upper Extremity Instrument
• Graded Redefined Assessment of Strength, Sensibility and Prehension
• Jebsen Hand Function Test
• Sollerman Hand Function Test
• Box and Block Test

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Self Care

• Frenchay Activities Index
• Lawton Instrumental Activities of Daily Living Scale
• Spinal Cord Independence Measure (SCIM)

ICF – COMMON OUTCOME MEASURES

Community Reintegration

• Craig Handicap Assessment & Reporting Technique
• Reintegration to Normal Living Index

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Quality of Life

• Short Form-36
• WHO Quality of Life-BREF

International Standards for Neurological Classification of Spinal Cord Injury�(ISNCSCI)��Training on administration of the ASIA: �Annual Gauteng SCI Workgroup courses �(open to public and private OTs): email gp.sciworkgroup@gmail.com

ISNCSCI

• FOCUS ON STANDARDIZED, ACCURATE AND CONSISTENT EXAMINATION OF PWSCI AT CENTERS ACROSS THE WORLD

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• PERFORMED IN SUPINE TO ENSURE SPINAL STABILITY & REPRODUCIBILITY

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• USED TO DETERMINE THE LEVEL AND SEVERITY OF THE INJURY
• PROVIDE PATIENTS / FAMILIES INFORMATION ON AMBULATORY PROGNOSIS
• HELPS ESTABLISH & GUIDE A RATIONALE TREATMENT PLAN
• MAY ALSO BE USED IN RESEARCH

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1. ANORECTAL EXAMINATION

• USED TO DETERMINE:
1. ASIA IMPAIRMENT SCALE (AIS) – SEVERITY (COMPLETENESS) OF INJURY
2. MANAGEMENT STRATEGIES FOR NEUROGENIC BLADDER AND BOWEL
3. PROGNOSIS FOR FURTHER RECOVERY OF NEUROLOGICAL FUNCTION
• EARLY CHANGES ARE SIGNIFICANT FOR PROGNOSIS

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• AN ASSESSMENT OF S4-S5 AND THUS THE LAST NERVES TO LEAVE THE SPINAL CORD
• BY DEFINITION, ANY SENSATION OR MOTOR CONTROL DEFINES AN INCOMPLETE LESION

1. ANORECTAL EXAMINATION

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• EXTERNAL SENSORY EXAM 🡪 LIGHT TOUCH + PIN PRICK AT S4-S5

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• INTERNAL SENSORY EXAM 🡪 DEEP ANAL PRESSURE (DAP)
• A FINGER IS INSERTED 1-2 CM INTO THE ANUS WITH PRESSURE PUT ONTO THE ANORECTAL WALL
• GRADED AS PRESENT (YES) OR ABSENT (NO)

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• INTERNAL MOTOR EXAM 🡪 VOLUNTARY ANAL CONTRACTION (VAC)
• A FINGER IS INSERTED 1-2 CM INTO THE ANUS, PATIENT ASKED TO ”SQUEEZE MY FINGER”
• GRADE AS PRESENT (YES) OR ABSENT (NO)

2. SENSORY EXAMINATION

• EYES CLOSED, ORIENTATE THE PATIENT TO WHAT IS BEING TESTED

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• COMPARISON IS MADE TO THE SENSATION ON THE FOREHEAD (“NORMAL”)

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• 28 BILATERAL DERMATOMES
• EACH WITH A KEY SENSORY POINT
• LIGHT TOUCH 🡪 COTTON WOOL (ONE STROKE, NOT MORE THAN 1-2CM)
• PIN PRINK 🡪 SAFETY PIN (OPENED, SHARP AND DULL ENDS USED)

2. SENSORY EXAMINATION

POINTS TO NOTE:

• C6 – DORSUM THUMB
• C8 – DORSUM PINKY
• T2 – AXILLA
• T4 – NIPPLE LINE
• T10 – UMBILICUS
• L3 – MEDIAL KNEE
• L4 – MEDIAL MALLEOLUS
• S1 – LATERAL HEEL
• S3 – GLUTEAL FOLD
• S4/S5 – MUCOCUTANEOUS JUNCTION

SENSORY GUIDELINES ARE AVAILABLE ONLINE ☺

3. MOTOR EXAMINATION

• EXAMINATION OF 10 KEY MUSCLE GROUPS TESTED IN SUPINE

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NB – THIS IS NOT OXFORD GRADING ☺

MOTOR GUIDELINES ARE AVAILABLE ONLINE

NEUROLOGICAL LEVEL OF INJURY

THE MOST CAUDAL SEGMENT (LOWEST LEVEL) OF THE SPINAL CORD WITH BOTH INTACT SENSATION AND MOTOR FUNCTION

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ONLINE CALCULATOR: HTTPS://WWW.ISNCSCIALGORITHM.COM/

This will give you your ISNCSCI classification / diagnosis

I.E: “T10, COMPLETE AIS A PARAPLEGIA”

ASIA IMPAIRMENT SCALE (AIS)

SPINAL CORD INDEPENDENCE MEASURE�(SCIM IV)

What is the SCIM?

• Assesses persons with spinal cord injuries’ performance in daily activities¹
• Most common tool used for research when monitoring treatment responses in persons with SCI¹
• Many other outcome measures are not able to detect NB functional changes due to reduced specificity or sensitivity¹

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^{NOT only for occupational therapists!}

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What is the SCIM?

• Total – out of 100
• Higher the score = less assistance required/ fewer AD’s needed (i.e. greater independence)¹

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Respiration & sphincter management

(40 points)

Self –care

(20 points)

Mobility

(40 points)

19 tasks

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SCIM IV

• Published in 2022 d/t previous version:
• internal inconsistency problem in some subtests e.g. clarification that it is observed not assumed
• low interrater reliability for some subtests
• floor effect for ground/wheelchair subtest
• change in phrasing based on feedback³

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Validity & Reliability

SCIM I-III

• Good reliability, responsiveness & validity³

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SCIM IV

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• Sample size larger than SCIM III with broader cultural representation³
• valid, responsive, and reliable³
• very good psychometric properties³

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Why is SCIM NB/ useful?

• Monitors progress regarding ADL
• Guides & prioritizes therapy required
• Assists with setting goals with the individual and his/her caregiver
• Helps to determine the equipment and physical assistance needed prior to discharge (time to prepare & make arrangements)⁴

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Why is SCIM NB/ useful?

• Monitors if Rx is effective
• ? Need to change therapy approach
• Encourages continuity of care – all healthcare professionals can be on the same page regarding function
• Motivation to continue rehab
• Data collection for research⁴

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Administration of SCIM IV

• Scored through observations
• Can use the same form for 6 assessments/ re-assessments
• Record the date
• Score each subtest below each date⁴

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3:441/442

Self-care subscale

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• Feeding
• Bathing or showering
• Dressing
• Grooming

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3:441

Respiration and Sphincter management

• Respiration
• Sphincter management – Bladder
• Sphincter management – Bowel
• Use of toilet

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Mobility subscale

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• Mobility in bed and action to prevent pressure sores
• Transfers
• Mobility indoors
• Mobility for moderate disatances
• Mobility outdoors
• Stair mobility

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3:441

Reasonable accommodations

Access

Things to remember

• Re-evaluation of equipment and environment
• Terrain around work
• Parking
• Opportunity for remote work?
• Evaluate assistance required and available
• Consider both physical and psychological aspects
• Navigating stigma and response to disability by colleagues (education session?), often requires significant and prolonged advocacy

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Travelling: Toileting

Driving

• Driving assessment
• Consider how adapted seating and vehicle adaptions can facilitate return to work

Manual labour

• The use of cuffs to stabilise tools
• Adding extended handles or built-up grips can compensate for hand function
• Tool cabinet on wheels that allows for easier mobility

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Computer work

• “Finger gun” pattern that would facilitate typing using the index finger
• Implement the use of a gutter splint when forming this pattern
• When needing to press two keys at once (e.g. Alt + Ctrl) you can bend a fork or design something out of splinting material
• For higher level quads, consider a mouth stylus and dictation software

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Predictors of RTW⁵

• Among individuals with SCI working at the time of injury 21 - 67% returned to work after injury.
• RTW was higher in persons injured at a younger age, had less severe injuries and higher functional independence.
• Employment rate improved with time after SCI.
• Individuals who sustained SCI during childhood or adolescence had higher adult employment rates.

Predictors of RTW⁵

Most common reported barriers to employment were:

• problems with transportation,
• health and physical limitations,
• lack of work experience, education or training,
• physical or architectural barriers,
• discrimination by employers.

References

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1. Itzkovich M, Shefler H, Front L, Gur-Pollack R, Elkayam K, Bluvshtein V, et al. SCIM III (Spinal cord independence measure version III): Reliability of assessment by interview and comparison with assessment by observation. Spinal Cord. 2018;56(1):46–51.

2. World Health Organization. International Classification of Functioning, Disability and Health Short Version. Geneva: WHO Library Catalouging-in-Publication Data; 2001. 3–228 p.

3. Catz A, Itzkovich M, Elkayam K, Michaeli D, Gelernter I, Benjamini Y, et al. Reliability Validity and Responsiveness of the Spinal Cord Independence Measure 4th Version in a Multicultural Setup. Archives of Physical Medicine and Rehabilitation [Internet]. 2022 Mar 1;103(3):430-440.e1. Available from: https://doi.org/10.1016/j.apmr.2021.07.811

4. Walden K, Plashkes T, Sproule S, Morin C. Toolkit For SCIM III [Internet]. Vancouver; 2016. Available from: chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://scireproject.com/wp-content/uploads/2022/04/SCIM_Toolkit_Printable-1-1-1.pdf
5. Lidal, I. B., Huynh, T. K., & Biering-Sørensen, F. (2007). Return to work following spinal cord injury: a review. Disability and rehabilitation, 29(17), 1341-1375.