Spinal cord injury (SCI) is a debilitating neurological condition with tremendous socioeconomic impact on affected individuals and the health care system. Today, the estimated lifetime cost of an SCI patient is $2.35 million per patient. According to the National Spinal Cord Injury Statistical Center, there are 12,500 new cases of SCI each year in North America. More than 90% of SCI cases are traumatic and caused by incidences such as traffic accidents, violence, sports, or falls. The Male-to-female ratio of 2:1 for SCI, which happens more frequently in adults compared to children. Demographically, men are mostly affected during their early and late adulthood (3rd and 8th decades of life) while women are at higher risk during their adolescence (15–19 years) and 7th decade of their lives i.e. age distribution is bimodal, with a first peak involving young adults and a second peak involving adults over the age of 60. Those over 60 years of age who suffer SCI have considerably worse outcomes than younger patients their injuries usually result from falls and age-related bony changes.

1. CASE PRESENTATION ON SPINAL
CORD INJURY PATIENT
Presented by: Himani Kaushik

3. ASSESSMENT
DEMOGRAPHIC DATA:
NAME: XYZ
AGE / SEX: 43 Yrs. / M
WEIGHT: 77 Kgs
HEIGHT: 173.73cms
BMI: 26.2Kg/m2
DOMINANCE: Right hand
OCCUPATION: Police Sub-inspector
ADDRESS: Mujafarpur, Bihar (Temporarily: Sahin
Bagh, Okhla, Delhi)
MOB. NO. xxxxxxx
SOCIOECONOMIC STATUS: Middle class family
DATE OF ASSESSSMENT: 18th October; 2019

4. Chief Complaints:
 Inability to move both the lower limbs.
 Loss of sensation in both the lower limbs and inability to control urine.
 Inability to sit properly, stand and walk.
 Feeling of lower back stiffness and left shoulder pain. .

5. History of present illness:
 Patient was apparently well 10 days back when he had an alleged history of RTA.
 On 10th June, 2019, 7:30 am patient had a RTA his 2 wheeler hit by the 4 wheeler.
 Initially patient was taken to the xxx Hospital in Bihar for the primary care of treatment
and from where he was referred to the yyyHospital, Delhi for the further management
and he was admitted in the ICU on 18th June, 2019.
 After that patient was coming into the department of Rehabilitation at zzz, Delhi on 16th
October, 2019 with the history of RTA.
 FUC of T11-T12 translational SCI with AIS-A, right femur fracture, right tibia fracture
and left tibia fracture.

6. Surgical history:
 He had a surgery for posterior stabilization of T11-L1 and T11-T12 transforaminal
(interbody) fusion was done under GA on 19th June, 2019.
 After that he had surgery for fracture of left proximal tibia ORIF was done and
extension tibia nail done for right leg and debridement of right knee was done under
GA on 26th June, 2019.
 After sometime patient was advice for removal of cement beads from right distal
femur and bone grafting and was done on 14th August, 2019 under GA.

7. Medical treatment history: Patient discharged with some medications:
 Inj. Clexane 60 mg once in a month
 Tab ultracet 100 mg 1 tab X2 daily for 7 days
 Cap Razo-D 40 mg 1 cap once daily for 7 days
 Tab Dulane 20 mg 1 tab X2 daily for 6 weeks
 Tab Emset 4 mg and Crocin 650 mg 1 tab X3 daily for 7 days
 Syrup Looz 45 ml at bed time
 Syrup Aristozyme and Mucaine gel 2 tsf X3 daily
 Dulcolax suppository 2 tsf once daily

8. Previously patient was taking physiotherapy management in yyy Hospital.
History of past illness and medications: No any relevant past medical history is
present.
Personal history: No any relevant personal history is present.
Family history: Father : Asthmatic but this history is not relevant to the case.
Social history: Patient family, relatives and colleagues are supported.

9. ON OBSERVATION:
Body built: Endomorphic.
Posture (sitting): Chin poked, shoulders protracted, elbows flexed, wrists
and arms rested on the armrests, thoracic spine kyphotic,
hips and knees flexed and foots rested on the foot rest in
the sitting posture.
Attitude of limbs: B/L UL: shoulders adducted, externally rotated,
elbows extended, forearms supinated, wrists neutral
and fingers extended.
B/L LL: hips adducted, externally rotated, knees
hyperextended and ankles plantarflexed.
Swelling: Present over the dorsum of the B/L ankles.

10. Skin color: No any skin discoloration is present.
Pressure sores: Not present.
Scar: Present over the thoracic spine, anteriorly above the
knee on the right side, on the medial malleolus of
the right leg and anteriorly below the knee on the
left side.
External aids: KAFO and walker is used B/L for the assisted standing.
Gait: Patient is coming into the department with the
wheelchair.

11. ON EXAMINATION:
Higher Mental Functions: Patient is alert, oriented to person, place and time and
follow all the commands properly.
Pain:
 Dull ache pain: VAS: On occasion: during left shoulder movements: 4.
At rest: 2.
 Diffuse pain on the lower-back: VAS: On occasion: prolonged sitting on the wheel-
chair: 2.
At rest: 2.
Tenderness : Not present.
Skin temperature: Normal.

12. MINI-MENTAL STATE EXAMINATION (MMSE)
Maximum Score Score
Orientation
5 (5) What is the (year) (season) (day) (date) (month)?
5 (5) Where are we: (state) (county) (town) (hospital)
(floor)?
Registration
3 (2) Name three unrelated objects. Allow one second to
say each. Then ask the patient to repeat all three
after you have said them. Give one point for each
correct answer. Repeat them until he or she learns all
three. Count trials and record. Trials: __2__ .
Attention and Calculation
5 (4) Ask patient to count backwards from 100 by sevens.
Give one point for each correct answer. Stop after
five answers. Alternatively, spell world backwards.
Recall
3 (3) Ask patient to recall the three objects previously
stated. Give one point for each correct answer.

13. Maximum Score Score
Language
9 (2) • Show patient a wrist watch; ask patient what it is.
Repeat for a pencil. (2 points)
(1) • Ask patient to repeat the following: "No ifs, ands,
or buts." (1 point)
(3) • Ask patient to follow a three-stage command:
"Take a paper in your right hand, fold it in half, and
put it on the floor." (3 points)
(1) • Ask patient to read and obey the following
sentence which you have written on a piece of
paper: "Close your eyes." (1 point)
(1) • Ask patient to write a sentence. (1 point)
Total Score: _28_ Assess level of consciousness along a continuum: Alert,
Drowsy, Stupor, Coma

14. Scoring:
24-30 Uncertain Cognitive Impairment
18-23 Mild to Moderate Cognitive Impairment
0-17 Severe Cognitive Impairment
The score ranges listed here are widely used, but it should be noted that an
MMSE score is only an initial indicator of cognitive status, and norms for the
MMSE vary greatly depending on a person's age, education level, and race.

15. Anterior shoulder
joint line pain
Body Chart
4
2
2
Back
stiffn
ess
VAS

16. INTERNATIONAL SPINAL CORD INJURY PAIN BASIC DATA SET
Date of data collection: 2019/10/22
Have you had any pain during the last seven days including today: Y N
If yes:
Please note that the time period during the last week applies to all pain
interference questions.
In general, how much has pain interfered with your day-to-day activities in the
last week?
No interference 0 - 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10 Extreme interference
In general, how much has pain interfered with your overall mood in the last week?
No interference 0 - 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10 Extreme interference
In general, how much has pain interfered with your ability to get a good night's
sleep?
No interference 0 - 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10 Extreme interference
How many different pain problems do you have? 1; 2; 3; 4; >5
Please describe your three worst pain problems:

17. 2019/10/05
Red color denotes the involved pain problems

18. 2019/10/12

19. NA

20. RT. UL LT.UL RT. LL LT.LL
Kinaesthesia 2 2 1 1
Proprioception 2 2 1 1
Vibration 2 2 0 0
Pressure 2 2 0 0
Sensory Examination:
• Superficial sensory examination: Done according to the ASIA scale used for the
SCI patients.
• Deep sensory examination:

21. RT. UL LT.UL RT. LL LT.LL
Steregnosis 2 2 0 0
Barognosis 2 2 0 0
Graphaesthesia 2 2 0 0
Texture
recognisation
2 2 0 0
• Combined cortical sensory examination:

24.  Manual muscle testing: Done according to the ASIA scale used for the SCI
patients.
 Range of motion: AROM of B/L LL is not documented because of patient is unable
to initiate the movement and flaccidity.

25. SENSORY SCORING:
0 = absent
1 = altered
2 = normal
NT = non-testable
MOTOR SCORING:
0 = No flicker or visible contraction
1 = Palpable or visible contraction
2 = Active movement in gravity eliminated plane
3 = Active movement in gravity against plane
4 = Active movement in gravity against plane with min. resistance
5 = Active movement in gravity against plane with max. resistance

26. JOINT RIGHT LEFT
AROM PROM AROM PROM
SHOULDER
Flexion
Extension
Abduction
Adduction
Internal Rotation
External Rotation
0-177 0-180
0-60 0-60
0-180 0-180
180-0 180-0
0-68 0-70
0-87 0-87
0-175 0-180
0-60 0-60
0-175 0-180
180-0 180-0
0-68 0-70
0-87 0-87
ELBOW
Flexion
Extension
0-140 0-140
140-0 140-0
0-140 0-140
140-0 140-0
WRIST
Flexion
Extension
Ulnar Dev.
Radial Dev.
FINGER
Flexion
Extension
0-90 0-90
0-70 0-70
0-30 0-30
0-15 0-15
0-90 0-90
0-30 0-30
0-90 0-90
0-70 0-70
0-30 0-30
0-15 0-15
0-90 0-90
0-30 0-30

27. JOINT RIGHT LEFT
AROM PROM AROM PROM
HIP
Flexion
Extension
Abduction
Adduction
Internal Rotation
External Rotation
0-120
0-30
0-45
45-0
0-40
0-45
0-120
0-30
0-45
45-0
0-40
0-45
KNEE
Flexion
Extension
7-110
110-7
7-135
135-7
ANKLE
P/F
D/F
Inversion
Eversion.
0-20
0-50
0-15
0-20
0-20
0-50
0-15
0-20

28. Reflexes:
 Superficial reflex:
 Abdominal reflex: Absent
 Plantar reflex: Absent
 Deep tendon reflex:
 Biceps reflex: 2+
 Triceps reflex: 2+
 Brachioradialis reflex: 2+
 Quadriceps reflex: 0
 Ankle reflex: 0
Motor Examination:
 Muscle tone:
 UL: 2+
 LL: 0

29. RIGHT LEFT
SHOULDER
Flexors
Extensors
Abductors
Adductors
Internal
Rotators
External
Rotators
2+
2+
2+
2+
2+
2+
2+
2+
2+
2+
2+
2+
ELBOW
Flexors
Extensors
2+
2+
2+
2+
WRIST
Flexors
Extensors
Ulnar Dev.
Radial Dev.
FINGER
Flexiors
Extensors
2+
2+
2+
2+
2+
2+
2+
2+
2+
2+
2+
2+
RIGHT LEFT
HIP
Flexors
Extensors
Abductors
Adductors
Internal
Rotators
External
Rotators
0
0
0
0
0
0
0
0
0
0
0
0
KNEE
Flexors
Extensors
0
0
0
0
ANKLE
Flexors
Extensors
Inversors
Evertors
0
0
0
0
0
0
0
0
MUSCLE TONE

30. RIGHT LEFT
SHOULDER
Flexors
Extensors
Abductors
Adductors
Internal
Rotators
External
Rotators
5
5
5
5
5
5
4+
2+
4+
2+
2+
2+
ELBOW
Flexors
Extensors
5
5
5
5
WRIST
Flexors
Extensors
Ulnar Dev.
Radial Dev.
FINGER
Flexiors
Extensors
5
5
5
5
5
5
5
5
5
5
5
5
RIGHT LEFT
HIP
Flexors
Extensors
Abductors
Adductors
Internal
Rotators
External
Rotators
0
0
0
0
0
0
0
0
0
0
0
0
KNEE
Flexors
Extensors
0
0
0
0
ANKLE
Flexors
Extensors
Inversors
Evertors
0
0
0
0
0
0
0
0
MMT

31. DTR SCORING:
0 = Absent, no response
1+= Slight reflex, low response
2+= Normal response, typical reflex
3+= Brisk reflex
4+= Very brisk reflex with clonus abnormally
MUSCLE TONE SCORING:
0= No response (Flaccid)
1+= Decreased response (Hypotonia)
2+= Normal response
3+= Exaggerated response (Mild to Moderate Hypertonia)
4+= Sustained response (Severe Hypertonia)

32.  End-feel: Right knee end-feel : Bony end-feel
 Limb girth:
 Limb length discrepancy : From ASIS to medial malleolus:
RT. 86.5cms ; LT. 87cms
Right UL: 4inches:
Above olecranon process: 29cms
Below olecranon process: 24cms
Left UL: 4inches:
Above olecranon process: 29.5cms
Below olecranon process: 24.5cms
Right LL: 6inches:
Above mid-patella: 44.5cms
Below mid-patella: 32.5cms
Left LL: 6inches:
Above mid-patella: 42.5cms
Below mid-patella: 32cms

33.  Deformity / contractures: B/L ankle P/F (deformity)
 Scar Examination:
 Thoracic scar: 10.5 cm
 Right femur: Anteriorly above the knee: 24 cm
 Right medial malleolus: Medially: 6 cm
 Left tibia: Anteriorly below the knee: 16.5 cm

34. Lumbar scar Right ankle scar
Right knee scar Left knee scar

35. Cardio-respiratory Assessment:
 Chest expansion:
 Axillary: 2.5cms
 Nipple: 3.5cms
 Lower ribcage:7cms
Bladder & Bowel Assessment: Bladder & bowel functions are impaired: sensory loss:
Complete injury.
Balance Assessment:
 Modified functional reach test: (22.9 cm)
3 trials: 18cm, 21.5cm, 20cm: Mean: 19.833 cm
 Trying to maintain long-sitting and bed-side sitting with assistance.
 Trunk control of the patient is fair.
 Unable to stand requires maximum assistance.

36. Balance Assessment:
Modified functional reach test
VIDEO

37. mFRT

38. Balance and Coordination tests:
Non-equilibrium test Equilibrium test
Finger to nose
Finger to finger
Alternate finger to nose
Pronation/supination
Heel-on-shin
Drawing circle foot
Foot tapping
Sitting independently
Standing
Tandem stance
Rombergs test
normal
Activity
impossible
fair
NT,
Poor
Functional Skills: SCIM Scale is used.
Bed mobility and Wheelchair skills:
Independently roll left and right.
Mild assistance to supine to prone and prone to supine.
Mild assistance for supine to long-sitting.
Moderate assistance for supine to bed-side sitting.
Maximal assistance requires for shifting the patient from wheelchair to bed and
bed to wheelchair

39. 2
2
1
2
1
1
9

40. 13
10
5
1
29

41. 2
1
4
1
1

42. 1
0
0
0
10
48

43. Gait Assessment: Patient is wheel-chair bound gait assessment is not possible.
Scales:
 MMSE: 28/30
 International Spinal Cord Injury Pain Basic Data Set
 ASIA: AIS-A
 SCIM: 48/100
Investigations:
 MRI
 X-RAYS
Diagnosis: FUC of post-surgical T11-T12 translational SCI with AIS-A, right femur
fracture, right tibia fracture and left tibia fracture

44. MRI: SPINE

47. PHYSIOYHERAPY MANAGEMENT:
Goals:
Precautions:
 Stress at fracture sites and overuse
 Skin integrity and risk of falls
SHORT TERM GOALS LONG TERM GOALS
To relief pain
To maintain the upper limb ROM &
activities within normal limits
To improve UL strength
Risk of secondary impairment is
reduced
Patient and caregivers counseling
Sensory and Motor re-education
Muscle performance is increased
Independence pressure relief
Improve balance
Independence in wheel-chair transfers
Independence self-directing care
Independence in ADL’S
Tolerates upright position
Patient and caregivers counseling

48. Plan of care:
For sensory and motor
reeducation and
psychological
motivation
For preservation of spared
activity and prevent
secondary impairments
For balance and coordination control and
make patient functionally independent as
much as possible
Patient and
caregiver
counseling
during each
phase of
rehabilitati
on about
the
prognosis of
the patient

49. TREATMENT
 Active range of motion exercises for the bilateral upper limb.
 TENS for left shoulder pain X 10 minutes.
 Hot-pack for left shoulder pain X 10 minutes.
 Strengthening exercises for the bilateral upper limb.
 Passive range of motion for the bilateral lower limb.
 Sensory re-education protocol:
 Tapping
 Brushing
 Pro-prioceptive neuromuscular facilitation for the bilateral lower limb.
 Static abdominal exercise.
 Long-sitting balance exercise.
 Wheel chair push-ups

50. AROM exs of
the B/L UL -
to preserve
and maintain
ROM.
TENS and
Hot-pack for
the pain
relief.
Strengthening
of B/L UL –
to maintain
and improve
the strength
of UL.
PROM exs of
the B/L LL to
prevent DVT,
Pressure
sores,
spasticity and
contractures.
Sensory re-
education :
tapping and
brushing
helps to
return sensory
function.
PNF for the
B/L LL to re-
educate and
facilitate the
movements.
Static
abdominal ex.
and long-
sitting
balance
exercise to
improve trunk
control.
Wheel-chair
push-ups to
prevent
Pressure sores
and improve
UL strength.

51.  Bridging exercises with assistance.
 Crunches exercise with assistance.
 Mat activities:
 Prone on elbows.
 Prone on hands.
 Assisted prone to quadruped position.
 Bed-side sitting balance exercise.
 Sitting reaching activities.
 Transfer activities:
 From bed to wheelchair.
 From wheelchair to bed.
 From mat to wheelchair.
 Hitching and hiking exercises.
 Standing exercises for 5 minutes (7 Nov; 2019)

52. Crunches and
bridging exs
for
strengthening
of
abdominals,
and weight-
bearing on
B/L LL.
MAT
ACTIVITIES
AND
TRANSFERS
ACTIVITIES
Bed-side
sitting and
sitting
reaching
activities – to
improve
sitting
balance.
Standing (to
improve
circulation)
for 5min/day
to hold &
regain the
correct
posture and to
improve
balance.

53. MAT ACTIVITIES
SUPINE LYING SUPINE ON ELBOWS
PRONE LYING LONG SITTING
PRONE ON ELBOWS
PRONE ON HANDS
QUARUPED POSITION
KNEELING
STANDING

54. Prone on elbows Prone on hands
Quadruped position

55.  Mat activities: Improves ROM, strength, restoration of functions and awareness
of COG.
 Prone on elbows : Improving bed mobility, helps in strengthening of scapular
muscles and improves stability by joint approximation.
 Prone on hands: Improves postural alignment includes development of
hyperextension of hip and low-back extension which required later on in standing
from wheelchair and ambulation. It facilitate tonic holding of proximal joints and
utilize as strengthening exercise for e.g. push-ups.
 Prone to quadruped position: It is useful for facilitating initial control of available
musculature of lower trunk and hips, helps to hold position, develop dynamic
balance, improve strength, coordination and timing e.g. creeping activity.

56. TRANSFERS ACTIVITIES
TRANSFERS
Initial
transfers
Advanced
transfers
• Transfer activities:
 From bed to wheelchair.
 From wheelchair to bed.
 From mat to wheelchair.

57. Standing

58. REFERENCES: