[Music] we're going to learn today there's a spinal cord injury levels I've had many requests just within the last 24 hours I had two requests for this content area Jessica I have you being one of them so I'm really excited to talk about it today I'm not going to go over all the levels just seen one through CA but really the intent behind me doing this video is to demonstrate how I went about approaching this content area how I tackled it so that you guys can do the rest on your own now I'm going to give you guys a very black-and-white textbook knowledge for your learning but to understand that in the clinical situation the functional outcomes as well as the prognosis may vary depending on many different factors so although it's black and white today just know that in the back of your mind that when you're working in the real world it may not always look like this in its perfect quadrants okay because we're all different and we have to provide individualized client centered care okay enough with the intro I am gonna get started and this is gonna be a quite lengthy video I presume because there's a lot to go over but I try my best to make it fun for you guys and the white board came back so sit back relax grab a cup of tea or whiskey if you prefer and enjoy let's get started okay now before I go over each level here I want to briefly talk to you guys about the function of the spinal cord now if I were to describe a human characteristic or role to a spinal cord I probably gave her the title executive director of communication and that's because the spinal cord is essentially a charge of relaying messages so it's kind of like a conduit between the brain and the rest of our body relating messages so when there's an injury to the spinal cord then the functions below that level of injury will suffer impairment and these impairments include motor and sensory impairments it could also be bowel and bladder dysfunction and even respiratory difficulties and the letters and numbers you see here they refer to where in the body the spinal cord injury occurred and the higher the point of injury the greater the impairment okay all right so let's get started beginning with the highest point of injury c1 through c3 the caption here is ventilator please and don't forget your generator and you can see here that I have an image of Superman who as many of you know was played by the actor Christopher Reeve and if you recall he had a terrible horse riding accident that resulted in a complete spinal cord injury above c3 now with this kind of high cervical level injury a ventilator is a must it's required to breathe won by the best side and another one that's portable so when thinking about safety what comes to mind a generator right or a backup battery this is really important guys because if your ventilator dependent you'll need to have a backup generator and that's why the caption here Rhys ventilator please and don't forget your generator now let's move down here and look at the movements possible with an injury I see one through c3 you only have head and neck movement specifically neck flexion extension and rotation with paralysis below that region so what does that tell you about their ability to perform ADL's essentially non-patients that these levels will require total assistance around-the-clock for all aspects of care including respiratory bladder and bowel management and ADL's so in terms of bed mobility and safety we are looking at a full electric hospital bed which ran down their feature and side rails in terms of getting them to transfer to and from bed and wheelchair remember that they will require total assistance so in this case a power or mechanical liquid come in handy right I mean if your movement is limited to just head and neck think of how that would impact your mobility so when considering a wheelchair or c1 through c3 we're thinking power wheelchair with a tilt and recline function that can be controlled by the chin or head or breath control and be sure to really understand the importance of the tilt and recline function because pressure relief is critical with sensory loss and with a spinal cord injury the patient just may not feel that pressure or shearing from extended sitting or lying and this can lead to skin breakdown or pressure sores particularly in those vulnerable areas like the bony prominence so remember that pressure relief should be performed at 30 minute intervals to protect our patients from moisture or heat or shearing and speaking of pressure relief another important thing we can consider here would be pressure relief mattress and this is an important consideration not just for c1 that through c3 but for every level of spinal cord injury now I know I just talked a lot about pressure relief but it probably will be the last time in this video because determining a way to relieve pressure to prevent skin breakdown is maybe one of the highest and most important priorities for our patients with spinal cord injury particularly during an active phase of rehabilitation finally let's talk about communications in addition to having a generator and backup battery at c1 through c3 another key important consideration is to ensure access to environmental control unit and high-tech computer access even though there is no function in the upper extremities sophisticated electronic communication devices exist which is really important if your communication is limited to inability to talk right so assistive technology is like computer for speech or typing with mouse tick or voice activation will be important to communicate with caregivers and family and friends so don't underestimate the utility of Mouse States electric page-turner what else head pointer or even voice activation because these technologies will allow our patients to play I don't know computer games access the internet and even use email so meaningful occupational engagement is possible at every level and it really is our job to create these opportunities for meaningful participation alright so let's move on to C for now the caption here reads catch a breath that C for cuz you've got the diaphragm now so yes at this level the patient will have inspiration thanks to the innervation to the diaphragm and that's a big deal you guys because that means you're no longer a ventilator dependent however in terms of movement possible patients that c4 still don't have much movement the only functional movement we've added here from level c1 through c3 is shoulder elevation so when thinking about the type hospital they required as well as the level of assistance required for ADL's and transfers hmm it's pretty much the same as level c1 through C 3 which means 24 hours around the clock care okay moving on up to c5 the caption carries universal cuffs please because I've got no wrist or hand movements now I don't have that iconic image of Winnie the Pooh eating honey out of the jar but this picture is pretty close to what I wanted demonstrate for level c5 so we'll use this image and call him Vinny the Pooh instead no take the food look at Vinny the Pooh here because we're gonna use him for a little bit of storytelling he is a level c5 now notice how this arm is bent in flexion ok cieariy this image into your brain because this is the key functional outcome for c5 the ability to bend or flex the elbows thanks to innervation to the biceps now you might think that this is a big deal but because of the ability to bend the elbow Vinnie the Pooh se5 can begin to participate and some of his ADL's using adaptive devices so for example at this level patients can eat independently with adaptive devices once the meal is set up and they can also participate in grooming and upper-body dressing with some assistance and adaptive devices even so c5 still requires a lot of assistance particularly with transfers and bathing anyway let's try back our attention to Vinny the Pooh again who despite his c5 spinal cord injury decided to venture out in search of some honey but notice here he's dipping his entire hand into the jar and is eating off of his hand and this is not because he has poor table manners it's because I c5 he still doesn't any finger or wrist movement to use the utensils so this is what we're gonna do for any the poo we're gonna get him Arisa ports to stabilize his wrists hmm something like a wrist caucus splint and we're also gonna get him some Universal come back and hold his eating you son utensils to compensate for his limited grass and oh let's be sure to also get him some long opponent splint for him to hold his pen or paintbrush or typing stick or whatever he needs in case he wants to ride paint or use the keyboard after his indulgence with honey what else do you think Vinny the Pooh might need a c5 if you said mobile arm support you are correct these mobile arm supports will come in handy at c5 for Finny the Pooh who will need to support the weight of his arms and improve its position for activities and thanks to all these creative opportunities made possible for the wonderful perfection of occupational therapy many the Pooh was able to have a full day of fun doing things that are important and meaningful to him and now it's time to get him home so what kind of wheelchair do you think he'll need a c5 injury to get home a power wheelchair with arm drive control did you guys catch that I just said arm drive control that's a big difference you guys from c1 through c4 because if you recall from c1 through C for patients who are using a power wheelchair that is controlled with the head general breath remember but with the biceps and the ability to bend the elbows at c5 we are now using a power wheelchair with arm drive control another option for Benny the Pooh a c5 might be to drive his own vehicle you heard that right this is how advanced our technology is a c5 driving just may be possible with higher specialized equipment and technology modification but I don't know that many of the pou will choose that option because he'll need to go through extensive evaluation and training in order to drive and it just might not be worth his time and effort all right what about mobility indoors once he gets home because beneath Appu is on the level c5 with biceps he can actually switch to a manual Lightwave rigid or a folding frame with hammer modifications once he's in the house as long as it's on level surface and it's non carpeted and when using a wheelchair always remember to provide pressure relief cushion which will allow for independent pressure relief at this level okay so now Vinny the Pooh is back home after a long day and is going to need a bath at this level he'll still require total assistance for bathing using a padded tough transfer bench or a shower or commode chair now know what I just said Pat it ok that's because being wet on a hard surface can put you at risk of developing a pressure sore so when considering a tub transfer bench be sure to use one that's padded all right now once we get many of the pou all cleaned up we'll need to get the bed ready and for c5 it'll still be the same as level c1 3 C 4 and that is a full electric hospital they would Trendelenburg feature in side rails still requiring total assistance for transfers to get to and from the bed and wheelchair so a power mechanical lip would still be useful here all right and that wraps up c5 and now we're at c6 where the caption reads hold and take a bite with a tenodesis grasp this is a big one because here you have wrist extension so not only do you have the ability to bend the elbows now you can also extend your wrist so take a look here a snow-white look-alike good for a visual will pretend it's no white sister and named her snow grass that is grass with a G R a SP and you'll see why soon do you see how her wrist is extended back while holding this Apple she has functional grasp here with wrist extension now listen carefully because this is important at c6 a major intervention goal is to enhance the development of a tenodesis grass so that you can promote a strong tripod pinch with those wrist extension in other words you're trying to promote a functional grass and in case you don't know what tenodesis is here's a quick review tenodesis is basically just the natural tendency of the fingers to curl or flex when the wrist is extended and that happens because our finger flexor muscles are actually in our forearm and bending the wrist back shortens these tendons making these finger fingers curl so try this with me right now um I want you to extend your wrist back and observe what happens to your fingers naturally people curl right extend it back you'll see those fingers curl and now bring your wrist back to flexion and naturally your fingers will extend that my friends is tenodesis now remember how I said earlier that a major intervention goal for c6 is to enhance the development of a tenodesis grasp here's how you do it you can have a caregiver passively provide range of motion by arranging the finger flexors with the wrist fully extended and the finger extensors when the wrist is flexed basically we want to really strengthen the wrist extensors to maximize natural tenodesis this will help develop a tenodesis grass and this grass along with the radial wrist extension that's possible sc6 will allow the patient to stabilize their hands for compensatory grasp activities like picking up the bottle or sliding an object or in the case of snow white pickup that Apple for that one last fatal bite okay oh and here's one thing to note here about the tenodesis grass although the patient may be able to perform a slight rip through extending the wrist they would not be able to sustain this grip for functional activity due to limited hand and finger strain so we would need a tenodesis splint which is also known as the wrist driven flexor hinge tenodesis but as c6 okay now let's talk about bed mobility and transfers in terms of the type of bed required patients at level c6 can use either a full electric hospital bed or they may be able to use a full t'king standard bed okay and as long as the surface is even for transfers they'll be able to transfer independently using a transfer board and this is a key difference from level c5 to c6 if you recall every level from c1 through c5 required a full electric hospital bed which had elenberg feature and side rails remember that and they also require total assistance for transfers but a c6 you just may be able to use a standard bed and even transfer independently on even surface with a transfer board and to remember this I like to think of Snow White story and draw parallels so in the same way that Snow White makes a transition for her fancy Palace and bed to a standard bed in a cottage I like to think the patient's ic6 making a transition from a fancy high-tech electronic Bay with all the bells and whistles of a Trendelenburg turn and side rails to a modest standard bet at home and by the time you're using a standard bed transfer to and from the bed and wheelchair become that much more manageable with a transfer board oh and here's another parallel you can make with a Snow White story se6 patience can groom somewhat independently using adaptive devices and you need to look no further than Snow White's impeccable hair and glamorous makeup to help you remember that patience at this level are capable of grooming and dressing themselves using adaptive devices so let's talk about what some of these devices are and how patience with the help of occupational therapy might achieve Snow White's glamour even at level c6 spinal cord injury a first for that royal princess gown we can provide a front opening drives and attach loops to zipper pulls to make it easy to pull up the zipper up the dress and how about for a blouse for days that you don't want to wear a dress and you have to button well buttonhook would be great to compensate for poor finger dexterity but that might not be not because you still have pretty weak grasp at c6 and you may not be able to hold on to that button hug for a sustained period of time to actually button everything so we might actually provide a Palmer cuff button hug for a sustained activity and the what about Oh undergarments we'll need a bra so we can get some front opening bras and adapted by adding velcro closure for easy opening and as for underwear in the case of patients with a spinal cord injury it's actually more cumbersome than not because underwear it can potentially lead to skin breakdown and make it that much more difficult to use the restroom so we can probably ditch the underwear and finally shoes we can adapt it by adding velcro or large buckles or even elastic shoelaces I mean it's really not the cutest option but it's functional and practical and it'll help to enhance independence so this is the kind of knowledge application clinical application that we need to be doing at each level instead of practically trying to memorize every single thing here which admittedly I've been guilty of it's really important I think to understand the functional outcome that is possible with every level and how that might facilitate or help with participation and occupations so think about the muscles innervated and the possible movements that come with those innovative muscles and apply this knowledge to what you might need to provide the patient to make them as independent as possible let me give you another example bathing same concept what would be some adaptive tools you can give to patients who c6 might have limited hand function and wheatgrass built-up candles yes or you can just eliminate the need to grasp all together by using bath mitts or bathtubs and for hard-to-reach areas you can give long handled bath brushes with soap insert see how that works I see six there is a greater level of independence with adaptive devices because you have wrist extension and with that comes tenodesis grasp but because patients still don't have great hand and finger strength and dexterity here at this point Beast adaptive devices play a critical role in promoting independence for ADL's know right oh and I almost forgot one more important thing I see six at this level patients can do their own skin inspection using a long handle mirror and they can also turn it back to perform pressure reliefs independently se6 which will help in preventing skin breakdown so a lot of good things happening here z6 finally let's talk about wheelchair mobility so at level c6 patrons can use a power wheelchair with a standard arm drive control or a manual lightweight rigid or folding frame with modified rims so if you remember that's essentially the same as level c5 right so at this point you might be thinking to yourself with all these wheelchair options available for both c5 and c6 how am I gonna choose the right one and what factors do I have to consider well we certainly have to consider the functional outcome possible and what the patients are able to do but this is just the beginning you guys we have to go beyond that and think about the patient's needs and the context of what they actually want to do as well as the environment that the wheelchair will be used in so if we take it back to level c5 very briefly as a reminder and think about when you the COO who loves honey loves being outdoors and expresses his desire to venture out daily in search of honey what do you think would be the best wheelchair for him out in the community we'd give him a power wheelchair with a standard arm drive right and bringing it back to snow why here I level c6 well although she may be able to use a manual rigid wheelchair on the smooth surface of her palace floors and doors it would be way too cumbersome and taxing for her to have to use a manual wheelchair outdoors she would not be able to get very far at all so in both cases for Winnie the Pooh or Snow White a better option for community mobility outdoors would be a power wheelchair with arm traffic control and I promise this is the last thing I'll mention before moving on to c7 but this is so important and I didn't want to forget what is one thing that you might do first to know why before she returns back to her palace living in the forest all these years a home evaluation or in this case you might call it a palace evaluation mm-hmm you guys get the point this is important you guys to make sure that's know why can return home and actually do the stuff she'd need to do as much as possible and as safely as she can so we are thinking safety and accessibility okay so once the discharge location is determined the home evaluation is an important step okay that was a lot finally moving on to see 700 this is my favorite one not because seven is my lucky number but because I get to talk about Ariel here she's my favorite Disney character and I think I have the entire movie memorized a verbatim mm-hmm anyway let's take a look here at Ariel the caption is pushup and lit because you got the triceps now that's right at c7 the main functional outcome is elbow extension and full strength of all shoulder and thanks to innervation of the triceps so to visualize this think back to the scene in the movie when Ariel is sitting on a rock singing part of your world do you guys remember that epic moment on the rock when she powerfully extend her arms to push up against the rock with waves crashing all around Matt I think it's one of my favorite scenes well here have my own version of that song and hopefully it'll help you remember c7 you entertain me when's it my turn when I love love to extend these arms and push out out of my seat wish I could be c7 now oh boy no alright moving on at this level se7 the patient is independent but eating grooming dressing bathing and transfers with adaptive devices and equipment and although you rely on adaptive equipment to compensate for a limited grass you're not using these devices nearly as much as you did at c5 or even c6 because you now have full strength of all shoulder and elbow extension here so to remember this let's think back again to Ariel and her quest to be independent out of the sea she hadn't learned to adapt with human tools remember even brushing her hair with a fork but she pretty much went on to be independent and using these tools and adaptive devices to help her along the way so sc7 remember you have elbow extension with full strength of the arms relying minimally on adaptive equipment for eating we mean dressing or bathing oh and one more very important thing to know my c7 is the ability to do depression transfer don't forget this one guys it's an important functional outcome at c7 we made it guys who are on see a prior to uh almost there so the caption for this one is eighth grade graduation so c8 eighth grade because when I graduated from middle school in eighth grade and started high school I felt like I was on top of the world capable of doing anything I wanted well from level seeing patients are pretty much independent in all aspects of self care because they have enough fine motor control with finger and thumb flexion extension and abduction and they can also participate in most leisure activities because they have good functional use of both upper extremities they have the triceps and shoulders oppressors to complete transfers independently from bed to wheelchair without any assisted equipment with just damn biases so very independent SCA but the most important functional outcome to remember here is that you've got greater hand function which allows for greater independence and that concludes our review of functional outcome c1 through C a but wait don't go anywhere because we're not quite done yet I want to talk to you guys about two things to watch out for with spinal cord injuries now take a look at the photo of this woman here her face is flushed and you can see the beads of sweat on her face what she may be experiencing here is autonomic dysreflexia also known as autonomic hyperreflexia this is a medical emergency and life-threatening condition caused by a reflex action in the autonomic nervous system this is an acute uncontrolled hypertension meaning dangerously high blood pressure which presents with a pounding headache nausea sweating flushed face and Radia cardia which means that the heartbeat slows down and if this occurs we need to immediately place a client in an upright position remove anything restrictive and check the catheter for an obstruction and that's because this is often triggered by a strong painful or not just input and a common causes include bladder and bowel distension as well as irritation to the skin or anything that's really just strong or painful and once the inciting nauseous stimulus is removed this hypertension will usually resolve itself so finding out the source that this trigger is important okay now remember this can occur for anyone with injuries above t-6 so be sure to watch out for this with any patient with a spinal cord injury c1 through t6 okay secondly watch out for orthostatic hypotension this is the opposite of autonomic dysreflexia this is where there is a drop in blood pressure it is common with cervical levels and high thoracic spinal cord injuries it is also most common right after the injury and in the few weeks of rehabilitation and one of the more common signs you'll see is a lightheadedness or dizziness when you see this in a patient we would want to immediately recline that patient and raise the lights that elevate the blood pressure so let's review these two conditions in terms of what happens to your blood pressure with autonomic dysreflexia you get increased blood pressure and you sit the patient upright with orthostatic hypotension your blood pressure decreases and you reclaim the patient so an easy way to remember would be to know that when the blood pressure goes up paster goes up because you sit them upright and when the blood pressure goes down posture goes down because you put them in recline and raise the legs so let's see how long it's been oh my goodness 33 minutes I cannot believe it I think this is the longest video I've done yet I don't know anything else are still here you probably turned it off and got snacks or something halfway through but I hope this was helpful for you guys I enjoyed of creating this for you but I would also encourage you to come up with your own stories your own examples and learn them with your own life stories and experiences because I don't really help you to learn and retain the information okay all right you guys have a wonderful rest of the day and be sure to incorporate study breaks and remember what we need up loosen tag you are smarter and you think okay bye