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Redefining Tetraplegia

Michael Keith MD Ann Bryden OTRL Cleveland Ohio USA. Redefining Tetraplegia. SCI Classification. An important component in determining potential interventions is the classification of the level of injury

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Redefining Tetraplegia

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  1. Michael Keith MD Ann Bryden OTRL Cleveland Ohio USA Redefining Tetraplegia

  2. SCI Classification • An important component in determining potential interventions is the classification of the level of injury • Classification schemes provide a common platform for understanding the degree of function associated with the level of SCI

  3. SCI Classification • International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) • American Spinal Injury Association (ASIA) • International Spinal Cord Society (ISCoS) • Most commonly used • International Classification for Surgery of the Hand in Tetraplegia (ICSHT) • For cervical level SCI only • Both classifications include a motor and sensory portion • The ICSHT is focused on the upper extremity

  4. Who are the Stakeholders, and Why? • An increasing number of stakeholders • International Tetraplegia Group – Therapists and Surgeons • International Campaign for Cures of Spinal Cord Injury Paralysis (ICCP) • American Spinal Injury Association (ASIA) / International Spinal Cord Society (ISCoS) – UE Basic Data Set • Why? • Detect changes from natural recovery • Better define incomplete lesions • Measure the impact of interventions • Aimed at cure • Activity based therapy • Surgical reconstruction

  5. NEW Version 2/2013

  6. ASIA Update – Non Key Muscles

  7. Congruence with ICSHT?

  8. Current ClassificationsA classification should tell you what to do. • ASIA, ISCOS, AIS, ISNCSCI • Work well with complete lesions, complicated - perhaps without predictive use for surgical treatment. Does not classify results or permit patient reported outcomes.

  9. Current ClassificationsA classification should tell you what to do. • International Surgical Classification • Work well with complete motor paralysis, voluntary (C5,C6), Group 0,1,2,3, 1/3 of cases. • Many Patient choices, surgical variations in C7,C8 • Does not report anatomic change or PRO. Can be used for equivalency of function.

  10. Functional Enhancement for Cervical SCI - 1990 . Electrical Stimulation Tendon Transfers Shoulder abduction C4 Elbow flexion O:0 Wrist extension C5 O:1 FES Br->ECRB OCu:2 PD->Triceps OCu:3 Elbow extension C6 Finger, thumb extension OCu:4 OCu:5 Br->FPL ECRL->FDP Finger, thumb flexion OCu:6 C7 PT->FPL Br->EDC Thumb abduction OCu:7 OCu:8 C8 OCu:9

  11. ICSHT (arms) Where do the Classifications Fail? Specific Examples • Group 0 – 4 • Group 1 – 3 • Group 2 – 5 • Group 5 – 3 • NC - 3 Subject Characteristics(n=9, 18 Arms*) ASIA (arms) C4 – 2 C5 – 5 C6 – 6 C7 – 3 NC - 2

  12. Where do the Classifications Fail? • Incomplete Injuries • Spasticity • Characterizing Paralysis • Examples • 77VC R: C5, -C6, C7, C8 / 5, -6, -7, 8 • 99VC R: C6 / 0, -1, 2, -3, 4, 5, 6, -7 • 99 VC L: C6, -C7, C8 / 2, -3, -4, 5, 6, -7, 8

  13. “IC Exceptions” • Partial Tetraplegia • Asymmetrical lesions • Recovered- • Regenerated, Repaired • Hyper-reflexive • Contracted • Bi-manual activities

  14. Clinical Decision Support • Evidence Based Clinical Practice Guidelines • Appropriate Use Criteria • Cumulative experience without evidence • Informed Opinion

  15. Clinical Practice Guidelines • Evidence based if outcome based. • Solve problems of clinical decision making. • Make Recommendations based on strong evidence. • Find directions for outcomes research. • Form the basis for national Performance Measures and Appropriate Use Criteria. • Search: www.guidelines.gov

  16. Appropriate Use CriteriaRAND Methodology • Writing Group • Classification • Risk Adjustment • Important Clinical Criteria • Alternative Treatments

  17. Appropriate Use Criteria • Review Group • Refine credibility of application by experts • Voting Group • Shareholders Rate for Appropriate, Maybe Appropriate, Rarely Appropriate

  18. Examples of AUC- AAOS App. • www.aaos.org/auc

  19. Examples of AUC- AAOS App. • http://aaos.webauthor.com/go/auc

  20. AAOS AUC App, Distal Radius Fx

  21. Potential AUC writing table

  22. Measuring Spasticity • Challenges in measuring spasticity • Ashworth • Tardieu • Other • Distinguishing between measures of spasticity and spasms • Penn spasm scale, others>

  23. Lets write a AUC about Surgical Decision Making in Tetraplegia. • Review the literature for outcomes summary. CPG unlikely. • Writing group • Review Group • Voting Group

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