What Is Spinal Cord Injury (SCI)?

Spinal cord injury (SCI) is an injury of the spinal cord. SCI can be traumatic such as resulting from a motor vehicle accident, fall, sports injury, acts of violence, and surgical complications. It can also be non-traumatic such as resulting from a tumor or diseases .

The spinal cord is located in the spinal canal of the spine. The spine reaches from the nape of the neck to the sacral bone and forms the framework of our body. It consists of 33 single overlapping bones, the vertebrae. These are held together by disks, tendons and ligaments. The spine can be divided into five sections:

  • cervical spine (cervical, abbr. C)
  • thoracic spine (thoracic, abbr. T)
  • lumbar spine (lumbar, abbr. L)
  • sacral spine (sacral, abbr. S)
  • coccyx (tailbone)

The spinal cord, in principle, is a cord of nerves, and can be compared with a telephone cable that transports signals back and forth between the brain and the body. The spinal cord can be divided into four sections, which can be further subdivided into individual segments (neurotoms). In between the vertebrae, the nerves of the spinal cord branch off on each side to the respective body regions. There are

  • 8 cervical segments (C1 to C8)
  • 12 thoracic segments (T1 to T12)
  • 5 lumbar segments (L1 to L5)
  • 5 sacral segments (S1 to S5)

In case of a SCI, the spinal cord is damaged or even severed at a specific spot due to an accident or a health condition, resulting in a disruption of communication between the body parts below the damage and the brain. The damage of the spinal cord is called lesion. Important functions such as mobility (motor functions) or sensation (sensory functions) fail below the lesion.

Literature

  • Chin LS, Mesfin FB, Dawodu ST. Spinal cord injuries: Practice essentials, background, anatomy,  pathophysiology, etiology, epidemiology, prognosis, patient education. [Internet] 10 August 2017. Available from: http://www.emedicine.com/pmr/topic182.htm. Accessed March 2018.
  • Swiss Paraplegic Research. Community. [Wiki/Body & complications]. Spinal cord injury - What does this mean?  Basic knowledge about the injured body. [Internet] March 2018. Available from: https://community.paraplegie.ch/. Accessed March 2018.
  • Shepherd Center. Understanding spinal cord injury: What you should know about spinal cord injury and recovery. 2018. [Internet]  Available from: http://www.spinalinjury101.org/details/levels-of-injury. Accessed March 2018.

What Is the Difference Between Paraplegia and Tetraplegia?

Paraplegia is a paralysis starting in the thoracic (T1-T12), lumbar (L1-L5) or sacral (S1-S5) area, while tetraplegia is caused by damage in the cervical area (C1-C8). Persons with paraplegia possess good functioning of the arms and hands. The lesion occurs primarily in the trunk and legs. In comparison persons with tetraplegia additionally experience paralysis of the hands and partially of the arms.

In an initial clinical examination, the physician can locate the injury using x-rays or computer tomography (CT). While this technology makes the damage to the vertebrae visible, magnetic resonance imaging (MRI) can show the damage to the spinal marrow. The lesion height is defined by the last fully functioning segment of the spinal marrow. Tetraplegia "sub C6", for example, means that the marrow segments C1 to C6 are fully functioning whereas the segment C7 and below are affected.

Literature

  • Chin LS, Mesfin FB, Dawodu ST. Spinal cord injuries: Practice essentials, background, anatomy,  pathophysiology, etiology, epidemiology, prognosis, patient education. [Internet] 10 August 2017. Available from: http://www.emedicine.com/pmr/topic182.htm. Accessed March 2018.
  • Swiss Paraplegic Research. Community. [Wiki/Body & complications]. Spinal cord injury - What does this mean?  Basic knowledge about the injured body. [Internet] March 2018. Available from: https://community.paraplegie.ch/. Accessed March 2018.
  • Shepherd Center. Understanding spinal cord injury: What you should know about spinal cord injury and recovery. 2018. [Internet]  Available from: http://www.spinalinjury101.org/details/levels-of-injury. Accessed March 2018.

What Does “Complete” and “Incomplete” Mean?

Depending on the damage to the spinal cord nerves, the result is considered a complete or an incomplete lesion. Paraplegia is considered complete if no motor or sensory functions can be clinically determined below the lesion caused by the damage. As long as sensory and/or motor functions are detectable, the lesion is considered incomplete.

Neurological examinations enable the physician to locate the damage and determine its extent. The physician uses two international scales for this purpose  – the American Spinal Injury Association Impairment Scale (AIS), often referred to as ASIA scale, and the "Scale for the Autonomic Nervous System". The use of these scales are dependent on an exact assessment of the injury, the person's sustained sensory and motor functions, the injury level and the degree of lesion  – all of which help to forecast the possible impact on the person's daily living.

Literature

  • Chin LS, Mesfin FB, Dawodu ST. Spinal cord injuries: Practice essentials, background, anatomy,  pathophysiology, etiology, epidemiology, prognosis, patient education. [Internet] 10 August 2017. Available from: http://www.emedicine.com/pmr/topic182.htm. Accessed March 2018.
  • Swiss Paraplegic Research. Community. [Wiki/Body & complications]. Spinal cord injury - What does this mean?  Basic knowledge about the injured body. [Internet] March 2018. Available from: https://community.paraplegie.ch/. Accessed March 2018.
  • Shepherd Center. Understanding spinal cord injury: What you should know about spinal cord injury and recovery. 2018. [Internet]  Available from: http://www.spinalinjury101.org/details/levels-of-injury. Accessed March 2018.

What Are the Most Prevalent Consequences of Spinal Cord Injury?

When it comes to paralysis, people generally think about the inability to move the legs and/or hands. However, the consequences of damage to the spinal cord can go beyond the impact on mobility. This can be seen as impacting on three levels:

  • the motor level  – mobility is decreased
  • the sensory level  –  for example, sensitivity of the skin is decreased
  • and the autonomic level  – the activity and functions of the inner organs (bladder, bowel, cardiovascular activities, respiration, etc.) or sexual functions are controlled involuntarily, meaning that the person does not consciously control these functions.

If autonomic functioning of the bladder and bowel is impaired, the person affected would have to learn to manage these functions consciously. Optimal bladder and bowel management is important to avoid complications such as recurring bladder or kidney infection, or in the worse case, permanent damage.

Until 60 years ago, the life expectancy of persons with SCI was low due to such complications and for which no long-lasting treatment options were available. Thanks to the development of effective bladder and bowel management strategies including trained professional care, technological and medical aids, the life expectancy of persons with SCI has increased to almost the same level as persons without SCI. Bladder and bowel management is also an issue addressed early on in the treatment of SCI.

Another major issue confronting persons with SCI is recurring pressure sores. Specific attention should be paid to the sensitivity of the skin, since this is decreased in persons with SCI. Furthermore, persons with SCI frequently experience respiratory difficulties, and body temperature regulation in tetraplegics and paraplegics with high lesion levels is affected.

Despite the range of complications and difficulties that a person with SCI can experience, these can be addressed in a concerted effort by the person with SCI, his/her family or caregiver and, if engaged in a rehabilitation program, the rehabilitation team.

Literature

  • Chin LS, Mesfin FB, Dawodu ST. Spinal cord injuries: Practice essentials, background, anatomy,  pathophysiology, etiology, epidemiology, prognosis, patient education. [Internet] 10 August 2017. Available from: http://www.emedicine.com/pmr/topic182.htm. Accessed March 2018.
  • Swiss Paraplegic Research. Community. [Wiki/Body & complications]. Spinal cord injury - What does this mean?  Basic knowledge about the injured body. [Internet] March 2018. Available from: https://community.paraplegie.ch/. Accessed March 2018.
  • Shepherd Center. Understanding spinal cord injury: What you should know about spinal cord injury and recovery. 2018. [Internet]  Available from: http://www.spinalinjury101.org/details/levels-of-injury. Accessed March 2018.

American Spinal Injury Association (ASIA) Impairment Scale

American Spinal Injury Association (ASIA) impairment scale

The American Spinal Injury Association (ASIA) impairment scale or AIS describes a person's functional impairment as a result of a SCI. This scale indicates how much sensation a person feels after light touch and a pin prick at multiple points on the body and tests key motions on both sides of the body.

LT = light touch; PP = pin prick; DAP = deep anal pressure; AIS = ASIA Impairment Scale; NLI = neurologcal level of injury

  • Grade A = Complete. No sensory or motor function is preserved in the sacral segments S4-5.
  • Grade B = Sensory Incomplete. Sensory but no motor function is preserved below the neurological level and includes the sacral segments S4-5 (LT or PP at S4-5 or DAP), and no motor function is preserved more than three levels below the motor level on either side of the body.
  • Grade C = Motor Incomplete. Motor function is preserved at the most caudal sacral segments for voluntary anal contraction OR the patient meets the criteria for sensory incomplete status (sensory function preserved at the most caudal sacral segments (S4-S5) by LT, PP or DAP), and has some sparing of motor function more than three levels below the ipsilateral motor level on either side of the body. (This includes key or non-key muscle functions to determine motor incomplete status.) For AIS C  – less than half of key muscle functions below the single NLI have a muscle grade ≥ 3.
  • Grade D = Motor Incomplete. Motor incomplete status as defined above, with at least half (half or more) of key muscle functions below the single NLI having a muscle grade ≥ 3.
  • Grade E = Normal. If sensation and motor function as tested with the ISNCSCI are graded as normal in all segments, and the patient had prior deficits, then the AIS grade is E. Someone without an initial SCI does not receive an AIS grade.
Muscle Function Grading
0 Total paralysis
1 Palpable or visible contraction
2 Active movement, full range of motion (ROM) with gravity eliminated
3 Active movement, full ROM against gravity
4 Active movement, full ROM against gravity and moderate resistance in a muscle specific position
5 (normal) Active movement, full ROM against gravity and full resistance in a functional muscle position expected from an otherwise unimpaired person
5* (normal) Active movement, full ROM against gravity and sufficient resistance to be considered normal if identified inhibiting factors (i.e. pain, disuse) were not present
NT Not testable (i.e. due to immobilization, severe pain such that the person cannot be graded, amputation of limb, or contracture of > 50% of the normal range of motion)
Sensory Grading
0 Absent
1 Altered, either decreased/impaired sensation or hypersensitivity
2 Normal
NT Not testable

Literature

Functioning at the Core

Functioning is a central dimension in persons experiencing or likely to experience disability. Accordingly, concepts, classifications and measurements of functioning and health are key to clinical practice, research and teaching. Within this context, the approval of the International Classification of Functioning, Disability and Health (ICF) by the World Health Assembly in May 2001 is considered a landmark event. The ICF establishes a new era of patient-oriented clinical practice, research, and teaching.

The ICF is a classification of the World Health Organization (WHO) based on the integrative bio-psycho-social model of functioning, disability and health. Functioning is the human experience related to body functions, body structures, and activities and participation. It is viewed in terms of its dynamic interaction with a health condition, personal and environmental factors. Disability, on the other hand, is the human experience of impaired body functions and structures, activity limitations and participation restrictions in interaction with a health condition, personal and environmental factors. Although distinguishing between functioning and disability is often helpful when reading medical literature, in the bio-psycho-social perspective of the ICF, functioning is implicitly addressed when disability is mentioned and vice versa.

Functioning and disability according to the integrative bio-psycho-social model of the ICF corresponds to the perspective of rehabilitation medicine i.e. functioning is seen as closely interacting with the environment and the person’s characteristics. Moreover, functioning represents not only an outcome, but also the starting point of the clinical assessment, intervention management, the post-intervention evaluation and quality management.

Literature

  • Bickenbach J. What is functioning and why is it important. In: ICF Core Sets: Manual for Clinical Practice. Bickenbach J, Cieza A, Rauch A, Stucki G. ed. Göttingen: Hogrefe; 2012.
  • Gutenbrunner C, Meyer T, Melvin J, Stucki G.  Towards a conceptual description of Physical and Rehabilitation Medicine. J Rehabil Med 2011;43(9):760-764.
  • Steiner WA, Ryser L, Huber E, Uebelhart D, Aeschlimann, A, Stucki G. Use of the ICF model as a clinical problem-solving tool in physical therapy and rehabilitation medicine. Phys Ther. 2002; 82(11): 1098-1107.
  • Stucki G. International Classification of Functioning, Disability, and Health (ICF): a promising framework and classification for rehabilitation medicine Am J Phys Med Rehabil. 2005; 84(10): 733-740.
  • Stucki G, Ewert T, Cieza A. Value and application of the ICF in rehabilitation medicine. Disabil Rehabil. 2002; 24(17): 932-938.
  • Stucki G, Cieza A Melvin J. The International Classification of Functioning, Disability and Health (ICF): a unifying model for the conceptual description of the rehabilitation strategy J Rehabil Med. 2007; 39(4): 279-285.
  • Stucki G Melvin J. The International Classification of Functioning, Disability and Health: a unifying model for the conceptual description of physical and rehabilitation medicine J Rehabil Med. 2007; 39(4): 286-292.
  • World Health Organization. International Classification of Functioning, Disability and Health, Geneva, World Health Organization; 2001.

The Integrative Bio-psycho-social Model of Functioning, Disability and Health

CS Introduction 2015 03 04 03 DB Seite 07

Figure 1: The Integrative Bio-psycho-social Model of the International Classification of Functioning, Disability and Health (ICF)

A health condition is an umbrella term for disease, disorder, injury or trauma and may also include other circumstances, such as aging, stress, congenital anomaly, or genetic predisposition. It may also include information about pathogeneses and/or etiology.

Body functions are defined as the physiological functions of body systems, including psychological functions. Body structures are the anatomical parts of the body, such as organs, limbs and their components. Problems in body functions (e.g. reduced range of motion, muscle weakness, pain and fatigue) or significant deviation or loss of body structures (e.g. deformity of joints) are referred to as impairments of a body function and structure respectively.

Activity is the execution of a task or action by a person. Participation refers to the involvement of a person in everyday situations and in society. Difficulties at the activity level are referred to as activity limitations (e.g. limitations in dressing) and problems a person may experience in being or getting involved in everyday situations and in society are denoted as participation restrictions (e.g. restrictions in recreation and leisure).

Contextual factors represent the entire background of a person's life and living situation. Among the contextual factors, the environmental factors make up the physical, social and attitudinal environment in which people live. These factors are external to the person and can have a positive or negative influence, i.e., they can serve as a facilitator or a barrier for a person's functioning. Personal factors are the particular background of a person's life and living situation, and comprise features that are not part of the primary health condition. These may include but not limited to gender, age, race, fitness, lifestyle, habits, and social background. They can be considered factors which define the person as a unique individual. Like environmental factors, personal factors can have a positive or negative impact on a person's body functions and structures, and activities and participation.

Literature

  • World Health Organization. International Classification of Functioning, Disability and Health, Geneva, World Health Organization; 2001.

The Content of the Classification

Structure of the ICF

This bio-psycho-social perspective guided the development of the International Classification of Functioning Disability and Health (ICF). As such, the components of the classification correspond to the components of the model. Within each component, there is an exhaustive list of ICF categories that serve as the units of the classification. ICF categories are denoted by unique alphanumeric codes and are hierarchically organized in chapter, second, third and fourth levels. When going from the chapter level to the fourth level, the category's definition becomes more detailed.

ICF categories are arranged in a stem-branch-leaf structure within each component, in which the more detailed level categories share the same attributes as the more broader level categories. Every component consists of chapters, with chapters representing the broadest level. Each chapter then consists of second-level categories, which in turn, are composed of categories at the third level. Some third level categories also include fourth-level categories. This structure can be compared to that of school books, in which the information is usually organized in chapters and subheadings to help locate the information sought.

An example from the component body functions is presented below:

CodeLevel
b2 Sensory functions and pain (chapter level)
b280 Sensation of pain (second level)
b2801 Pain in body part (third level)
b28013 Pain in back (fourth level)

Although the ICF reflects the bio-psycho-social model, there are some differences between the model and the classification. For example, the bio-psycho-social model depicts activities and participation as distinct entities. However, clearly distinguishing between them based on ICF categories is not yet possible given international variation, differing approaches of professionals and theoretical frameworks. For this reason, the ICF keeps activities and participation as one component of functioning. Moreover, although personal factors are included as a component of the bio-psycho-social model, they are not yet classified in the ICF.

ICF Qualifiers

The classification also comprises so-called ICF qualifiers, which quantify the extent of a problem experienced by a person in a specific ICF category. The World Health Organization proposes that the categories in the components of body functions and structures, and activities and participation be quantified using the same generic scale:

ValueDescription
0 NO problem (none, absent, negligible,...) 0-4%
1 MILD problem (slight, low,...) 5-24%
2 MODERATE problem (medium, fair,...) 25-49%
3 SEVERE problem (high, extreme,...) 50-95%
4 COMPLETE problem (total,...) 96-100%
8 not specified (used when there is insufficient information to quantify the extent of the problem)
9 not applicable (used to indicate when a category does not apply to a particular person)

The ICF qualifier is added to the category following a 'dot' e.g. b280.1 (mild sensation of pain) or b28013.3 (severe pain in the back).

Environmental factors are quantified with a negative and positive scale that denotes the extent to which an environmental factor acts as a barrier or a facilitator:

Qualifier - BarrierQualifer - Facilitator
0 - NO barrier +0 - NO facilitator
1 - MILD barrier +1 - MILD facilitator
2 - MODERATE barrier +2 - MODERATE facilitator
3 - SEVERE barrier +3 - SUBSTANTIAL facilitator
4 - COMPLETE barrier +4 - COMPLETE facilitator
8 - barrier, not specified (the environmental factor is a barrier; however there is insufficient information to quantify the extent of the problem) +8 - facilitator, not specified (the environmental factor is a facilitator; however there is insufficient information to quantify the extent of the facilitative inpact)
9 - not applicable (used to indicate when a category does not apply to a particular person)  

To indicate that an environmental factor serves as a barrier, the ICF qualifier is added to the category following a 'dot' e.g. e150.2 (moderate barrier posed by the design, construction, products and technology of buildings for public use). To indicate that an environmental factor serves as a facilitator, the ICF qualifier is added to the category following a plus sign e.g. e1151+4 (Assistive products and technology for personal use in daily living serves as a complete facilitator).

An ICF qualifier of '8', not specified, is used when it is known that the environmental factor is a barrier, however there is insufficient information to quantify the extent of the problem. Likewise an ICF qualifier of '+8', also not specified, is used when it is known that the environmental factor is a facilitator, however there is insufficient information to quantify the extent of the problem. The ICF qualifier of '9', not applicable, is used in the same way as with the generic scale.

It is important to note that in addition to this generic scale, the ICF contains additional qualifiers specific to the different components. For example, the second and third qualifiers of the component body structures are used to indicate the nature of a body structure change and its location respectively.

The ICF contains more than 1400 categories, making it a highly comprehensive classification. This comprehensiveness is a major advantage and strength of the ICF. It is, however, also the biggest challenge to its practicability. To enhance the applicability of the classification, ICF-based tools must to be tailored to the needs of the users - without weakening the strengths of the ICF. One approach is the development of ICF Core Sets.

Literature

  • World Health Organization. International Classification of Functioning, Disability and Health, Geneva, World Health Organization; 2001.

Introduction to ICF Core Sets

ICF Core Sets

ICF Core Sets, a selection of ICF categories from the entire classification for specific health conditions, condition groups and settings, have been developed to facilitate a systematic and comprehensive description of functioning for use for various purposes and in various settings including clinical practice and research. In these settings an ICF Core Set can serve as a minimal standard for the assessment and documentation of functioning and health in clinical studies and comprehensive single or multi-professional clinical encounters.

Read more: Introduction to ICF Core Sets

ICF Core Set Manual

ICF Core Set Manual

A manual on one approach of using ICF Core Sets in clinical practice has been available since 2012: Bickenbach J, Cieza A, Rauch A, Stucki G. ed. ICF Core Sets: Manual for Clinical Practice: Göttingen: Hogrefe; 2012.

Read more: ICF Core Set Manual

Introduction to ICF-based Documentation Tools and Rehab-Cycle

The Rehab-Cycle®

To facilitate the use of the ICF in clinical practice, it is essential to have ICF-based tools that could be integrated into the existing processes. In the rehabilitation setting, ICF-based tools can be employed in rehabilitation management - the multidisciplinary team can use them to comprehensively describe the functioning of persons experiencing or likely to experience disability, to guide the planning of functioning-oriented rehabilitation services and evaluate changes in the functioning status over a certain time period.

Rehabilitation management can be characterized with a problem-solving approach. One such approach based on the ICF is the rehabilitation cycle, called Rehab-Cycle®. The Rehab-Cycle® can facilitate the structuring, organization and documentation of the rehabilitation process, as well as help the professionals involved in a patient's rehabilitation with coordinating their actions. This iterative process includes four key elements: 1) assessment, 2) assignment, 3) intervention and 4) evaluation.

Read more: Introduction to ICF-based Documentation Tools and Rehab-Cycle

The ICF Assessment Sheet

The ICF Assessment Sheet provides a comprehensive overview of the person’s functioning state by presenting the assessment results in all the components of functioning, environmental and personal factors with input from both the health professional and the person (patient). The ICF Assessment Sheet can help the rehabilitation team to understand the person's functioning and to identify the needs to be addressed in rehabilitation.

Read more: The ICF Assessment Sheet

The ICF Categorical Profile

The ICF Categorical Profile is a visual depiction of a person's functioning status at the time of assessment showing the qualifier values for selected ICF categories considered relevant to a individual patient's case. It can facilitate the identification of intervention targets that are related to shared goals, serving as the central source of information for the rehabilitation team for intervention planning.

Completing the ICF Categorical Profile requires the rehabilitation team, with input from the patient, to state long and short-term goals, link these goals with the ICF categories that should be targeted for intervention, and identify for each category the qualifier value that should be achieved after intervention. The ICF Categorical Profile is generally set-up using a suitable ICF Core Set. If no ICF Core Set exists for the respective health condition, the ICF Categorical Profile should include the ICF categories that are essential for comprehensively describing the health status of the person at the time of assessment.

Read more: The ICF Categorical Profile

The ICF Intervention Table

Information from the ICF Categorical Profile can be used to complete the ICF Intervention Table.

The ICF Intervention Table can facilitate the coordination of interventions, roles and resources within a multidisciplinary team. It provides a comprehensive overview of all the intervention targets (as represented by ICF categories), the interventions themselves and the corresponding rehabilitation professional(s) who is (are) assigned to address each intervention target. It also shows the initial ICF qualifier rating of the intervention targets, the goal value i.e. the ICF qualifier expected to be achieved after intervention, and the end or final value i.e. the ICF qualifier rating at a second assessment or evaluation. Logically, the end value is entered in the table after completion of intervention.

Read more: The ICF Intervention Table

The ICF Evaluation Display

The ICF Evaluation Display is based on the ICF Categorical Profile. In comparison to the ICF Categorical Profile, the ICF Evaluation Display includes only the ICF categories that were defined as intervention targets i.e. those categories that were related to a specific goal (global goal, service-program goal and/or cycle goal). The ICF Evaluation Display is also enlarged to include a visual depiction of the person's functioning status at the time of the second assessment or 'evaluation' and a column indicating goal achievement. It provides a picture of the change between functioning status before and after intervention. It is important to note however that this “before-after” picture of change does not necessarily signify that the change is due to the intervention itself, but only that there was a change.

Read more: The ICF Evaluation Display

ICF Research Branch CoordinatorICF Research Branch in cooperation with the WHO Collaborating Centre for the Family of International Classifications in Germany (at DIMDI)

Swiss Paraplegic Research
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6207 Nottwil (Switzerland)


Tel. +41 41 939 66 31
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