Presentation on theme: "Michael Keith MD Ann Bryden OTRL Cleveland Ohio USA."— Presentation transcript:
Michael Keith MD Ann Bryden OTRL Cleveland Ohio USA
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
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
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
NEW Version 2/2013
ASIA Update – Non Key Muscles MovementRoot Level Shoulder: Flexion, extension, abduction, internal and external rotation Elbow: Supination C5 Elbow: Pronation Wrist: Flexion C6 Finger: Flexion at proximal joint, extension Thumb: Flexion, extension and abduction in plane of thumb C7 Finger: Flexion at MP joint Thumb: Opposition, adduction and abduction perpendicular to palm C8 Finger: Abduction of the index fingerT1
Congruence with ICSHT? MovementRoot Level ICSHT Shoulder: Flexion, extension, abduction, internal and external rotation Elbow: Supination C5No Shoulder Elbow: Pronation Wrist: Flexion C64545 Finger: Flexion at proximal joint, extension Thumb: Flexion, extension and abduction in plane of thumb C Finger: Flexion at MP joint Thumb: Opposition, adduction and abduction perpendicular to palm C88 Finger: Abduction of the index finger T1
Current Classifications A 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.
Current Classifications A 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.
Clinical Decision Support Evidence Based Clinical Practice Guidelines Appropriate Use Criteria Cumulative experience without evidence Informed Opinion
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:
Appropriate Use Criteria RAND Methodology Writing Group Classification Risk Adjustment Important Clinical Criteria Alternative Treatments
Appropriate Use Criteria Review Group Refine credibility of application by experts Voting Group Shareholders Rate for Appropriate, Maybe Appropriate, Rarely Appropriate
Examples of AUC- AAOS App.
Examples of AUC- AAOS App.
AAOS AUC App, Distal Radius Fx
Potential AUC writing table Scenarios for AUC on Tetraplegia Management Appropriate *, Maybe &, Not % Muscle Scores- Voluntary ICKey Muscle ASIA/AIS/ISN CSCI/ISCOSKey MuscleContracture release Osteotomy, HO resection Hyper-reflexia Botox, Chemo neuromodulation Tendon, Nerve Transfer, O:0A-C4 O:1DeltoidA-C5Elbow FlexorBi to Tri*Baclofen Pump& Radial Osteotomy- pronation 40* Ocu2ECBLECRBA-C6Wrist Extensor Ocu3BicepsBRA-C7Elbow Extensor Ocu4FDPFDSA-C8Finger FlexorFractional Lengthening* APBADQA-T15th Abductor etc These combinations include both.AND. And.OR.
Measuring Spasticity Challenges in measuring spasticity Ashworth Tardieu Other Distinguishing between measures of spasticity and spasms Penn spasm scale, others>
Lets write a AUC about Surgical Decision Making in Tetraplegia. Review the literature for outcomes summary. CPG unlikely. Writing group Review Group Voting Group