A PROJECT
Entitled
“REHABILITATION IN PARAPLEGIA”
Submitted To
The Department Of Physiotherapy
I.T.S PARAMEDICAL COLLEGE
Affiliated To
CHAUDHARY CHARAN SINGH UNIVERSITY, MERRUT
In The Partial Fulfillment of Degree Of
BACHELOR OF PHYSIOTHERAPY
Guide
Dr Shubhra Narang
Submitted By
Vishakha puri
March 2010
CERTIFICATE
This is to certify that the project work entitled “REHABILITATION IN PARAPLEGIA”
by VISHAKHA PURI BPT 2006-2010 Batch , Enroll No._____________has been
completed in the partial fulfillment for the degree of Bachelor of Physiotherapy from
C.C.S. University, Meerut, U.P., India. I recommend him/her for the award of BPT Degree.
DR.C.S.RAM
DIRECTOR
DEPT. OF PHYSIOTHERAPY
I.T.S PARAMEDICAL COLLEGE
CERTIFICATE
This is to certify that the project work entitled “REHABILITATION IN PARAPLEGIA”
is conducted by VISHAKHA PURI in the partial fulfillment for the degree of Bachelor of
Physiotherapy under my guidance and supervision .
GUIDE
Dr SHUBHRA NARANG
MPT NEUROLOGY
(i)
CERTIFICATE OF ORIGINALITY
I hereby declare that the project work entitled “REHABILITATION IN PARAPLEGIA ”
embodies the original work by me . This work in part or full has not been submitted to any
other university for award of degree. I shall not publish the contents of this project in part
or full without the written consent of my guide and college.
VISHAKHA PURI
B.P.T 2006-2010 Batch
Enroll. No. ________
(ii)
ACKNOWLEDGEMENT
I would like to express my sincerest gratitude to the following individuals without whom
this study would have been unattainable.
I offer my sincerest gratitude to Dr. Shubhra Narang (M.P.T) whose guidance constructive
concel , unmatchable suggestions and unstinted encouragement enlightened me throughout
the project.
I express my heartiest gratitude to Dr. C.S. Ram , H.O.D , Department Of Physiotherapy ,
I.T.S Paramedical college for kindly permitting us to pursue research work.
I am thankful to Dr. M Thangaraj , Dr. Stuti Sehgal , Dr. Tanu Shrivastava , Dr. Kanika
Govil , Dr. Ekta for their constant inspiration and support in pursuing the study .
I would like to thank my colleagues Ashish gautam , Pooja sinha , Priyenka tyagi and
Yukti sharma for their co-operation in my project .
Remarkable co-operation and dedication by the subjects laid milestone for the success of
project completion.
And finally thanks to all those who have contributed directly and indirectly towards this
study.
VISHAKHA PURI
(iii)
DEDICATED
TO
MY PARENTS
AND
ALL MY FACULTY
(iv)
TABLE OF CONTENTS
Certificate ( Guide)
i
Certificate Of Originality
ii
Acknowledgement
iii
Dedication
iv
List of figures
v-vi
List of Tables
vii
1) INTRODUCTION

Anatomy – The basis of injury classification

Epidemiology

Mechanism of injury

Designation of lesion level
2) TYPES OF LESIONS IN SPINAL CORD

Complete injury

Incomplete injury
a) Central cord syndrome
b) Anterior cord syndrome
c) Brown sequard syndrome
d) Posterior cord syndrome
e) Cauda equine syndrome
f ) Sacral sparing

Stages after spinal cord injury
a) Stage of spinal shock
b) Stage of reflex activity
c) Stage of reflex failure
3) CLINICAL MANIFESTATIONS

Direct Impairments
a) Autonomic dysreflexia
b) Impaired temperature regulation
c) Orthostatic hypotension
d) Bladder dysfunction
e) Bowel dysfunction

Indirect impairments
a) Pressure sores
b) Deep venous thrombosis
c) Contractures
d) Heterotopic ossification
e) Pain
4)
HOSPITAL MANAGEMENT

Prehospital management

Immediate management of patient with spinal cord injury
a) transfer from the site of emergency
b) assessment of ABCDE
c) neurological status examination
d) skin inspection
e) temperature examination
f) bladder function

Investigations

Fracture stabilization

Pharmacological management
5) REHABILITATIVE MANAGEMENT

Acute phase rehabiltation

Active phase rehabilitation

Transition phase of rehabilitation
( 6 ) BIBLIOGRAPHY
(7 ) APPENDICES

Appendix A

Appendix B

Appendix C

Appendix D
LIST OF FIGURES
Figure 1)
Figure 2)
:
:
Etiology of spinal cord injury
Types of thoracolumbar fractures
Figure 3)
:
Central cord syndrome
Figure 4)
:
Anterior cord syndrome
Figure 5)
:
Brown sequard syndrome
Figure 6)
:
Cauda equine syndrome
Figure 7)
:
Stage of spinal shock
Figure 8)
:
Autonomic dysreflexia
Figure 9)
:
Pressure sore
Figure10)
:
Deep venous thrombosis
Figure11)
:
Heterotopic ossification
(a) Hip
(b) Knee
Figure12)
:
Harrington rod
Figure13)
:
Jewett brace
Figure14)
:
Phenol peripheral nerve block
Figure15)
:
Negative pressure vacuum technique
Figure 16)
:
Elastic support stockings
Figure 17)
:
Tilt table
Figure 18)
:
Rolling
Figure 19)
:
Supine to long sitting position
Figure 20)
:
Prone on elbow position
Figure21)
:
Prone on hand position
Figure22)
:
Quadruped position
Figure23)
:
Kneeling position
(v)
Figure24)
:
Push up weight shift
Figure25)
:
Bed to wheelchair transfer
Figure26)
:
Wheelchair to bed transfer
Figure27)
:
Wheelchair to car transfer
Figure28)
:
Car to wheelchair transfer
Figure29)
:
Wheelchair to toilet transfer
Figure30)
:
Toilet to wheelchair transfer
Figure 31)
:
Wheelchair to bath seat transfer
Figure 32)
:
Bathseat to wheelchair transfer
Figure 33 )
:
Oswestry standing frame
Figure34)
:
Orthosis prescribed in case of paraplegics
a) Knee ankle foot orthosis
b) Scott craig orthosis
Figure35)
:
Standing from wheelchair with crutches
a) Forward technique
b) Sideway technique
c) Backward technique
Figure 36)
:
Crutch balancing
Figure 37)
:
Ambulation activities with crutches
a)
Swing to gait
b) Swing through gait
c) Four point gait
Figure38)
:
Partial body weight support treadmill
Figure39)
:
Functional electrical stimulation
(vi)
LIST OF TABLES
Table 1
:
Etiology
Table 2
:
Mechanism of injury
Table 3
:
Pharmacological management of spasticity
Table 4
:
Pharmacological management of pain
Table 5
:
Correlation of complete injury levels and orthosis prescription
ABBREVIATIONS USED
LMN - Lower motor neuron
UMN - Upper motor neuron
SCI
- Spinal cord injury
DVT - Deep vein thrombosis
PaO2 - Partial pressure of oxygen
BP
- Blood pressure
CT Scan-Computed tomographic scan
MRI - Magnetic resonance imaging
IM
- Intramuscularly
IV
- Intravenously
TENS - Transcutaneous electrical nerve stimulation
KAFO - Knee ankle foot orthosis
RGO - Reciprocal gait orthosis
AFO - Ankle foot orthosis
FES
- Functional electrical stimulation
Ft
- Feet
#
- Fracture
N
- Normal
I
- Intact
PT
- Performance time
Rep
- Repetitions
Sec
- Seconds
H
- Hold
Res
- Resistance
(vii)
CHAPTER 1
INTRODUCTION
( SIMILARLY FOR OTHER CHAPTERS)
Spinal cord injury is a central neurological disorder1
.
It occurs due to damage to neurological
components in spinal cord occurring as a result of primary or secondary effects of disease or trauma 2.
Spinal cord injury is a low incidence , high cost disability requiring tremendous changes in an individuals
life style3 . Normal events of life driving a car, diving into lake or walking down stairs can suddenly
results in life changing injury with physical and lifestyle constraints that totally refigure the realities of
daily life .
SPINAL CORD INJURY ANATOMY – THE BASIS OF INJURY CLASSIFICATION
The term spinal column refers to the vertebral column bones and disc that collectively
encases and protects the soft tissue of the spinal cord .The spinal cord is made up of nerve tracts
carrying signal back and forth between the brain and rest of the body4 .
Etiology of SCI
60
Percentage of SCI
50
40
On /before
1980
30
Since 2000
20
10
0
Rta
Falls
Violence
Cause
Sports
Others
Figure 1: Incidence of spinal cord injury
(2)
ETIOLOGY10
Trauma
Road traffic accident , Gun shot wounds.
Non traumatic factors
Meningioma , astrocytoma , metastatic
Tumours
Ischaemia
Developmental disorders
Neurodegenerative disease
Transverse myelities
tumour in spinal cord
Arteriosclerosis , dissecting aortic aneurysms
Spina bifida , meningomyelocele
Friedreich's ataxia , spinocerebellar ataxia,
Resulting from stroke or inflammation.
Vascular Malformation
Arteriovenous
arteriovenous
malformation
fistula
,
,
dural
spinal
hemangioma , cavernous angioma and aneurysm.
Tabl
e1:
Etiol
Demyelinating disease
Multiple sclerosis
ogy
of
spinal cord injury
(3)
(5)
Figure 2 : Thoracolumbar fractures
END OF CHAPTERS
BIBLIOGRAPHY
Books Referred
1. Susan B O’ Sullivan , Thomas J Schmitz : Physical Rehabilitation and
Assessment and
Treatment (Fifthedition) : chapter 23 : Traumatic spinal cord injury : page 932-9
2. Cameron Monroe : Physical rehabilitation : chapter 20 : Non progressive spinal cord disorders : page
539-573
3. Ida Bromley : Tetraplegia and Paraplegia (fourth edition) : chapter 10-12 : Mat work , wheelchair
and wheelchair management , transfers : page 95 – 115.
4. Tidy`s Physiotherapy, Twelfth edition , Ann Thompson , Alison Skinner , JoanPrierly : chapter 7 : 229243
5. Darcy. A. Umphred : Neurological Rehabilitation : Fourth Edition :Chapter 16 : Page 477530.
6. Louis Solemom , Davi J. Warwick Silva Durai Nayagam : Apley`s System of orthopaedics and fractures
: The spine : page 1130-1135
7. Lorriane William Pedretti : Occupation Therapy Practice skills for physical Dysfunction 4 th edition :
Chapter 6 : 224-245
8. Kloth, Le and Feeder : Rehabilitaton in Occupational Physical Therapy : Page 334-356
9. Ebnezer : Essentials of Orthopaedics and applied Physiotherapy: Chapter 23 : page 143-147
10. Carolyn Kisner , LynnAllencolby : Theraputic exercises Foundation and techniques : section 2 : page
140 -174
11. McKinnis, LN: Fundamentals of orthopedic radiology : Chapter 12 : Spinal cord Fractures : Page
(1231-1268).
12. Daniel`s L ,Worthingham C , Muscle Testing : Techniques of Manual Examination, 5th edition :
Chapter 3 : Page 35-60
13. Norkin`s CC, White DJ: Measurement of Joint Motion : A Guide to Goniometry : Chapter 4 : page
164-176
14. Morison, M.J. (Ed) . The Prevention and Treatment of Pressure Ulcers. St. Louis : Mosby, 2001
Chapter 31:The Prevention and Management of Pressure Ulcer : Page : page 636-647.
15. Arthur C. Guyton, John E. Hall : Textbook of Medical Physiology: Chapter 54 : Motor Functions Of
The Spinal Cord :The Cord Reflexes: Page 622-632.
16. Kenneth W. Lindsay, Ian Bone : Neurology and Neurosurgery Illustrated : 3rd edition : Chapter 22 :
Spinal cord and Root compression. Page : 377-390.
17. Kissner Carolyn, Lynn Allen Colby : Theraputic Exercises Foundation and Techniques : Chapter 14,
Chapter 15 :The Spine : Subacute , Chronic and Postural Problems : Page 531-576.
Journals Referred:
1. Houte SV, Vanlandewijck Y (2006) Respiratory muscle training in persons in persons with
spinal cord injury : A systematic review: Respiratory medicine : 100 , (1886-1895).
2. Waters RL , Adkins Rh (1991) Definition of Weurmser LA (2007) Spinal cord injury medicine :
Epidemiology and classifications : Arch Phys Medical Rehabilitation : 88, (S49-S54).
3. Nobunga AI, Go BK : Recent Demographics and injury trend sin people served by model spinal cord
injury care system : Arch Physical Medicine Rehabilitation : 80,1372-1382.
4. Andrew Swain, David Grundy : ABC of spinal cord injury : Chapter 1 : At the site of accident : Page
(112-143).
5. Waters RL, Adkins RH : Definition of complete spinal cord injury: Paraplegia 29 , 573-581.
6. Comarr , AE : Autonomic Dysreflexia (Hyper reflexia) , Journal Spinal cord , 1997 : page
345-354
7. Erickson, RP : Autonomic Hyperreflexia : Pathophysiology and medical management.
Journal : Archives of physical medicime and rehabilitation, 1980 : 61:431
8. Lamount LS: A Comparison of two arm exercises in patients with paraplegia: Journal :
paraplegia : 1996, 61: Page 441-567
9. Hussey RW and Stauffer ES : Spinal Cord injury: Requirements for ambulation: Journal :
Archieves of Physical medicine and rehabilitation 1973 : 54:544.
10. Mikel berg R, Reid S : Spinal cord lesion and lower extremity bracing: An overview and
Follow up study : Paraplegia , 1999 : 379, 19.
11. Bernardi M, Et al : The Efficiency of walking of paraplegic patients using reciprocal gait
orthosis : Paraplegia : 2000 : 78 : 552-559
12. Sipski ML, Delisa JA : Functional electrical stimulation spinal cord injury rehabilitation A
review of literature. Journal : Physical therapy : 56 : 778-789.
Web site referred
1)
2)
3)
4)
5)
6)
http://www.google.com
http : // www.yahoo.com
http:// www.searchi.com
http:// www.meditech.com
http://www.emedicine.com
http://www.medscape.com
7) http:// www.pubmed .com
8) http:// bartleyby.com
APPENDICES
APPENDIX- (a)
APPENDIX-(b)
FORMAT FOR CASE REPORT-1
(please note it is of a different project)
Name: Mrs. Kamlesh
Age: 51 years
Gender: Female
Occupation: House wife
Any other recreational activity: No
Address: Railway Road, New Defence Colony, Muradnagar, Ghaziabad
Chief Complaint: Patient complaints of Low back pain since 3-4 months with the pain on the left side of
buttocks.
History of Past Illness
A) History of Previous similar Problem: Same type of illness occurs 2 year back, but the intensity of
episode was less problematic then present.
Any Previous traumatic History: History of fall from the stairs 2 years back.
History of Present Illness:
A) Episode of illness: The illness started 8-9 years back. The episode is of recurrent low back pain
with aggravation of symptom since 3-4 months. This is second episode of illness.
B) Onset
: (i) PathologicalYes
a) Sudden - N
b) Gradual -Y
No
(ii) Traumatic-
Mechanism of injuryC) Site of pain: Pain is in lower lumbar region and the left side of buttocks
D) Is there is any radiation of pain:
Yes/No-
Y
If yes: where it goes- It radiated form the lower back to the left side of buttocks
thigh.
E) Is any paraesthesia / numbness / tingling sensation:
No
F) Most preferred position of the patient: Lying in the supine position.
G) Sleeping position of the patient: Patient preferred to lie in the right side lying position.
H) Mattress used: Hard Surface
I) Any other history: No
Medical History
Diabetes
√
Y/N
Hypertension
√
Y/N
till mid of
Cardiac disease
√
Y/N
Cancer
√
Y/N
Tuberculosis
√
Y/N
Infection
√
Y/N
Repetitive Coughing
√
Y/N
√
Y/N
Any other medical problem
Drug History
Past drugs History:
No
Present drug History: On Phase Medications -
Analgesic
Allergic to any Drug:
No
Surgical History
Any surgery:
Hysterectomy has been done 5 years back.
Date of Surgery:
Not known
Any complication after Surgery:
No.
Bed stay after Surgery:
15 -20 days.
Occupational History: - Home maker.
Personal History:
Smoking:
No
Alcohol:
No
Dietary Habits: Regular
History of Constipation: No
Other Details:
Fever:
N
Malaise:
N
Any other joint problem:
N
Any bladder/ bowel symptoms like incontinence or retention
N
Any respiratory problem
N
Symptoms suggestive of major neurological disturbances
Frequency of episodes of pain:
N
1 attack before 8 years
2 attack before 2 years
3 attack before 3 months
Intensity (VAS) (On first visit) - 9 out of max. of 10
Type of Pain:
Superficial-
X
Deep-
√
Nature of Pain:
Sharp-
X
√
Dull-
Aggravating Factors:
Pain is aggravated by prolonged sitting, standing, and bending forward.
Relieving Factors:
Patient got relief after lying in right side lying position.
Does pain aggravates with coughing, sneezing:
N
(But previously it was present)
On Observation:
Body type:
X
Ectomorphic
o
√
Mesomorphic
Endomorphic
X
Gait: Patient walks with the lordotic posture and takes precautionary measures during walking
to avoid the jerk.
Assistive device:
No
Attitude of patient:
Normal
Lethargic
√
X
Tense
Over anxious
X
X
X
Bored
X
Spinal posture:
Standing: Patient was having protruded neck with excessive lumbar
Lordosis.
Lying:
Patient lies in supine lying position and avoids bending forward
while getting up from bed.
Spinal curvature:
Lumbar spine:
Normal lordosis
X
Excessive lordosis
√
X
√
X
√
X
Flat back
Scoliosis
Sway back
X
Thoracic spine: Normal Kyphosis
√
Excessive kyphosis
X
Scoliosis
Any Step off sign:
No.
Any presence of tuft of hairs:
No
Others:
On Palpation
No
Muscle tone (Lumbar muscle): Tone Increased
Tenderness:
Present
Site:
Left PSIS and L3-L4 spinous process.
Odema:
Absent
Swelling:
Absent
On Examination:
MOVEMENTS:
JOINT
MOVEMENTS
ACTIVE
PASSIVE
LUMBAR
FLEXION
P, TR
P,TR
EXTENSION
NP
NP
SIDE FLEXION
ROTATION
P- PAINFUL
NP- NON PAINFUL
IR-INITIAL RANGE
MR- MID RANGE
TR- TERMINAL RANGE
LEFT
RIGHT
LEFT
RIGHT
NP
P
NP
P
LEFT
RIGHT
LEFT
RIGHT
NP
NP
NP
NP
RANGE OF MOTION:
JOINT
MOVEMENTS
ACTIVE
PASSIVE
LUMBAR SPINE
Flexion
0-74*
0-75*
Extension
0-18*
0-20*
Side Flexion
RIGHT
LEFT
RIGHT
LEFT
62-47
62-49
62-48
62-50
*- signifies taken from the inclinometer
END FEELS:Lumbar Flexion:
Tissue Stretch
Lumbar Extension:
Tissue Stretch
Lumbar Side Flexion:
Lumbar Rotation:
JOINT
HIP JOINT
Right
Tissue Stretch
Left
Tissue Stretch
Right
Tissue Stretch
Left
Tissue Stretch
MOVEMENTS
Flexion
ACTIVE
PASSIVE
Right
Left
Right
Left
0-100
0-100
0-110
0-110
Extension
0-15
0-15
0-15
0-15
Abduction
0-35
0-35
0-40
0-40
Adduction
0-20
0-20
0-25
0-25
Internal Rotation
0-35
0-35
0-35
0-35
External Rotation
0-45
0-45
0-45
0-45
END FEELS:Hip Flexion:
Right-
Tissue Stretch
Left-
Tissue Stretch
Hip Extension: Right-
Tissue Stretch
Left-
Hip Abduction: Right-
Tissue Stretch
Tissue Stretch
LeftHip Adduction: Right-
Tissue Stretch
Tissue Stretch
Left-
Tissue Stretch
MANUAL MUSCLE TESTING OF LUMBAR SPINE
1) Abdominals :
4
2) Lumbar Extensors :
4
MANUAL MUSCLE TESTINGOF HIP
1) Hip Flexors:
2) Hip extensors:
3) Hip Adductors:
4) Hip abductors:
5) Hip Internal rotators:
6) Hip External Rotators:
Left-
4+
Right-
4+
Left-
4+
Right-
4+
Left-
4+
Right-
4+
Left-
4+
Right-
4+
Left –
4+
Right-
4+
Left-
4+
Right-
4+
MUSCLE LENGTH TEST:
Hamstring test:
Normal
Rectus femoris test/ Ely’s test: Normal
MYOTOMES:
Affected myotomes are:
L3, L5
DERMATOMAL EXAMINATION:
Affected Dermatomes are: L3, L4, L5
SPECIAL TEST:
SLR:
Negative for neural tissue
Slump test-
Positive
Prone Knee Bending – Negative
Bowstring test –
Positive
Valsalva maneuver-
Negative
ANY OTHER FINDINGS:
PROVISIONAL DIAGNOSIS:
Lumbar PIVD (L3, L4, L5) WITH RADICULOPATHY
INVESTIGATIONS:
MRI FINDING:
MRI reveals: Disc Degeneration at L4-L5 levels
Diffuse Posterior disc herniations with extrusion at L5-S1
Diffuse Posterior herniations with annular tear at L4-L5 level
Disc bulge at L3-L4
DIAGNOSIS:
LUMBAR PIVD (L3- L4-L5) without radiculopathy to left buttocks.
PHYSIOTHERAPY TREATMENT:
Treatment A: (10 DAYS)
1) Hot pack for 15 minutes
2) Interferential Therapy- 10 minutes, Four pole vector 45 degree scan, square waveform
3) Traction: 20 Kg, intermittent traction with hold time 5seconds and relax time 20 second for the
duration of 10 minutes is given in straight leg position.
Treatment B: (Next 10 DAYS)
1) Hot pack for 15 minutes
2) Transcutaneous Electrical Nerve Stimulation- HI TENS, 2 channels, 1st at the nerve roots of L3,
L4, and L5. 2nd channel at the nerve course at left buttocks for 15 minutes
Treatment C: (Next 5 days)
1) Ultrasound at the L4-L5 level- pulsed 1.2W/cm2 for 5minute and at the left sacroiliac joint pulsed
0.8 W/cm2 for 5 minutes
2) Transcutaneous Electrical Nerve Stimulation- HI TENS, two channels, one at the nerve roots of
L3, L4, and L5. two channel at the nerve course at left buttocks for 15 minutes
HOME PROGRAM AND ERGONOMICS:
1)
Patient is advised to use the lumbosacral orthosis to support the back during travelling.
2)
Patient is advised for hot fomentation at home.
3)
Patient is advised to lying in prone lying position for at least 15 minutes duration twice in
a day.
4)
Patient is explained about the proper sitting, standing, lying, and lying to standing, doing
the household activities in a proper way.
5)
Patient is advised to take rest and to avoid the forward bending as much as the patient can
avoid.
Exercises:
Protocol A:
Pelvic tilting
Hamstring Stretching
Spinal Rotation
Calf Stretching
Neck Raising
Knee Rolling
These exercises are advised to be done twice daily for the 10 seconds hold time and 10
repetitions.
Protocol B:
Lying in extension
Extension exercises
Back and Gluteal exercise
PROGRESS NOTE:
Pain Reduction Progress: Visual Analog Scale (VAS):
Dated:
0
5
No pain
Mild Pain
10
Severe Pain
4/3/10- 5 out of max 10
9/3/10- 3 out of max 10
17/3/10-
1out of max 10
The patient had the treatment A for 10 days continuous then the patient pain subsided to the lower lumbar
back and slightly to the left buttocks area. All the lumbar muscle spasm has been also reduced.
After 10 days the Treatment plan B started and continued for the 7 days. Now the pain was reduced to a
limit and patient was able to do her ADL’s. Along with the treatment plan B, the patient was advised to
start the exercise protocol A. But the patient had the slight tenderness at the lower lumbar spinous
process.
After that the treatment plan C was started for 5 days.
Pictures Of assessment:
Posture assessment:
Tenderness checking: Fig 1 & 2
Fig 1
Fig 2
Two tender points: Fig 3
Fig 3
Lumbar movement assessment:
Lumbar flexion and extension Fig 4 & 5
Fig 4
Fig 5
Measurement of lumbar range by inches tape (schobber’s test)
Measuring Lumbar Flexion: Fig 6
Fig 6
fig 7
Measuring Lumbar Movement by Inclinometer:
Fig 8
Fig 9
Special test:
PKB
Fig 10
SLR Test
Slump Test
Fig 12
APPENDIX
ASSESSMENT SCALES
Scale For Assessment Of Spinal Cord injury


ASIA Scale
Impairment Scale
Fig 11
Scale For Assessment Of Spasticity


Spasm Frequency Scale
Modified Ashworth Scale
Scale for Assessment Of Pressure Sore Risk

Bradens scale
Scales For Assessment Of Activities of Daily Living


Barthel Index Scale
Functional Independence Measure Scale
Scale For Assessment Of Ambulation

Walking Index Scale For Spinal Cord Injury
ASIA Scale ( Standard neurological classification of spinal cord injury )
Impairment Scale
A - Complete : No motor or sensory function is preserved in the sacral segment
S4 -S5 level
B - Incomplete : Sensory but not motor function is preserved below the neurological
level and includes the sacral segments S4- S5
C - Incomplete : Motor function is preserved below the neurological level and more
than half of the key muscles below the neurological level have a
muscle grade less than 3 .
D- Incomplete : Motor function is preserved below the neurological level and at least
half of the key muscles below the neurological level have a grade of 3
or more
E- Normal
: Motor and sensory function is normal
SCALES FOR ASSESSING SPASTICITY
Spasticity Rating Scale
Spasm Frequency Scale
0 - No spasms
1 - One spasm or fewer per day
2 - Between one and five spasms per day
3 - Between five and nine spasms per day
Ten or more spasms per day
4 -
Modified Ashworth Scale
0 - No increase in muscle tone
1 - Slight increase in muscle tone, manifested by a catch and release or by minimal
resistance at the end range of motion when the part is moved in flexion /extension
abduction or adduction
1+ - Slight increase in muscle tone, manifested by a catch, followed by minimal
resistance throughout the remainder (less than half) of the ROM
2 - More marked increase in muscle tone through most of the ROM, but the affected
part is easily moved
3 - Considerable increase in muscle tone, passive movement is difficult
SCALE FOR ASSESSING PRESSURE SORE RISK
Braden Scale
Patients Name _____________________________________
Evaluators Name
Name________________________________ Date of Assessment
Sensory perception
Ability to respond meaningfully to pressure-related discomfort
Completely Limited

Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished .level of
consciousness or sedation / limited ability to feel pain over most of body
Very Limited

Responds only to painful stimuli
. Cannot communicate discomfort except by
moaning or restlessness / has a sensory impairment which limits the ability to feel pain or
discomfort over 2 of body.
Slightly Limited

Responds to verbal commands, but cannot always communicate discomfort or the need to be
turned / has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2
extremities.
No Impairment

Responds to verbal commands
pain or discomfort .
. Has no sensory deficit which would limit ability to feel or voice
Moisture

Degree to which skin is exposed to moisture
Constantly Moist

Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time
patient is moved or turned.
Very Moist

Skin is often, but not always moist .Linen must be changed at least once a shift.
Occasionally Moist

Skin is occasionally moist, requiring an extra linen change approximately
once a day.
Rarely Moist

Skin is usually dry, linen only requires changing at routine intervals.
Activity
Degree of physical activity
Bed fast

Confined to bed.
Chair fast

Ability to walk severely limited or non-existent . Cannot bear own weight and/or must be assisted
into chair or wheelchair.
Walks Occasionally

Walks occasionally during day, but for very short distances, with or without assistance . Spends
majority of each shift in bed or chair
Walks Frequently

Walks outside room at least twice a day and inside room at least once every two hours during
waking hours .
Mobility

Ability to change and control body position
Completely Immobile

Does not make even slight changes in body or extremity position without assistance
Very Limited

Makes occasional slight changes in body or extremity position but unable to make frequent or
significant changes independently.
Slightly Limited

Makes frequent though slight changes in body or extremity position independently .
No Limitation

Makes major and frequent changes in position without assistance.
Nutrition

Usual food intake pattern
Very Poor

Never eats a complete meal . Rarely eats more than a of any food offered . Eats 2 servings or less of
protein (meat or dairy products) per day . Takes fluids poorly . Does not take a liquid dietary
supplement /or maintained on clear liquids or IV for more than 5 days.
Probably Inadequate

Rarely eats a complete meal and generally eats only about 2 of any food offered. Protein intake
includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary
supplement / receives less than optimum amount of liquid diet or tube feeding
Adequate

Eats over half of most meals . Eats a total of 4 servings of protein (meat, dairy products per day .
Occasionally will refuse a meal, but will usually take a supplement when offered / is on a tube
feeding or TPN regimen which probably meets most of nutritional needs
Excellent

Eats most of every meal . Never refuses a meal . Usually eats a total of 4 or more servings of meat
and dairy products . Occasionally eats between meals . Does not require supplementation.
Friction and shear
Problem

Requires moderate to maximum assistance in moving. Complete lifting without sliding against
sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with
maximum assistance . Spasticity , contractures or agitation leads to almost constant friction.
Potential Problem

Moves feebly or requires minimum assistance. During a move skin probably slides to some extent
against sheets, chair, restraints or other devices. Maintains relatively good position in chair or bed
most of the time but occasionally slides down.
No Apparent Problem

Moves in bed and in chair independently and has sufficient muscle strength to lift up completely
during move . Maintains good position in bed or chair.
SCALES FOR ASSESSING ACTIVITIES OF DAILY LIVING
Functional Independence Measure ( FIM SCALE )
The Functional Independence Measure (FIM) scale assesses physical and cognitive disability.
Fim scale
Self-care
1. Eating
2. Grooming
3. Bathing/showering
4. Dressing upper body
5. Dressing lower body
6. Toileting
7. Swallowing
Sphincters
1. Bladder management
2. Bowel management
Mobility
1. Transfers
: bed/chair/wheelchair
2. Transfers
: toilet
3. Transfers
: bathtub/shower
4. Transfers
: car
5. Locomotion : walking/wheelchair
6. Locomotion : stairs
7. Community mobility
Barthel index
Activity Score
Feeding
0
-
unable
5
-
needs help cutting, spreading butter, etc., or requires modified diet
10
-
independent ______
Bathing
0
-
dependent
5
-
independent (or in shower) ______
Grooming
0
-
needs to help with personal care
5
-
independent face/hair/teeth/shaving (implements provided)
Dressing
0
-
dependent
5
-
needs help but can do about half unaided
10
-
independent (including buttons, zips, laces, etc.) ______
Bowels
0
-
incontinent (or needs to be given enemas)
5
-
occasional accident
10
-
continent
Bladder
0
-
incontinent, or catheterized and unable to manage alone
5
-
occasional accident
10
-
continent ______
Toilet use
0
-
dependent
5
-
needs some help, but can do something alone
10 -
independent (on and off, dressing, wiping) ______
Transfers ( bed to chair and back )
0
-
unable, no sitting balance
5
-
major help (one or two people, physical), can sit
10
-
minor help (verbal or physical)
15
-
independent ______
Mobility (on level surfaces)
0
-
immobile or < 50 yards
5
-
wheelchair independent, including corners, > 50 yards
10 -
walks with help of one person (verbal or physical) > 50 yards
15 -
independent (but may use any aid; for example, stick) > 50 yards ______
Stairs
0 - unable
5 - needs help (verbal, physical, carrying aid)
10 - independent ______
TOTAL (0–100): ______
SCALE FOR ASSESSING AMBULATION
Walking index scale for spinal cord injury (WISCI II)
Physical limitation for walking secondary to impairment is defined at the person level and indicates the
ability of a person to walk after spinal cord injury. The development of this assessment index required a
rank ordering along a dimension of impairment, from the level of most severe impairment (0) to least
severe impairment (20) based on the use of devices, braces and physical assistance of one or more
persons.
Level Description
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 .
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.