Articles from prior issues of The Advocate

September/October, 2000

Rehabilitation of Head/Spinal Cord Injuries by Shari Bratt and Linda Cordes, Nebraska DDS LANA MINNIGERODE, M.D., PHYSIATRIST AND Chief Medical Consultant in the Missouri DDS, assisted by Patrick Caffrey, Ph.D., Neuropsychologist, addressed head and spinal cord injuries and rehabilitation. Dr. Minnigerode began by stating that a patient with a coma which lasts greater than 30 days will most likely be severely impaired at the end of one year. Persistent vegetative state (PVS) should be considered to be nearly as severe as a coma, but will usually not be mentioned until later in the person’s medical course. These cases usually involve mid-brain lesions. The person may look around, but they cannot follow a command. This state is like a coma, but the person’s eyes are open. Adjudicators will usually have to wait the full three months, for coma patients who are waking up but still have significant motor deficits, to meet 11.18 or equal 11.04. With head injuries, involvement just has to include two extremities. This is not necessarily hemiparesis, and could include both upper extremities or both lower extremities. Spastic paraparesis secondary to a head injury is not uncommon. These cases involve anterior lesions and there is impairment of two extremities. If severity and duration are met, this would meet the listing. A Glasgow Coma Scale (GCS) is used to evaluate motor skills, verbal commands and if the eyes are open. A score of 3, means the patient is totally comatose and has no response to pain. There is a poor prognosis with a GCS of 8 to 10 at three weeks.

Next, Dr. Caffrey discussed understanding the traumatically brain injured worker. Rehabilitation may include physical, occupational, speech, art, music and other forms. Rehabilitation concerns include acute, post acute, and placement in the least restrictive setting. Rancho Los Amigos Cognitive Function Scale is used. Levels in function range from no response to pain, touch, sound or sight, to purposeful-appropriate function in a series of eight levels. Predictors for return to work involve patient factors such as age, preserved abilities, physical capacities, day to day carryover, initiation and severity of the injury, and whether or not the person has intact inhibitory and arousal/attentional mechanisms. Job factors in return to work predictors include routine, structure, the amount of exposure to hazards and availability of a modified job.

The five most common characterological alterations due to a brain injury are impaired social perceptiveness, impaired inhibitory control and self regulation, stimulus-born behavior, emotional alterations and inability to profit from experience.

Common emotional disturbances correlate neuroanatomically with the injury. Emotional disturbances may include an inability to perceive and interpret feelings in self and others, denial of illness, disorientation to time and place, poor self-awareness, thought disorders, poor visual discrimination, depression or amotivational states.

In a brain injured person, there may be problems with capacity for new learning, planning and organizing, initiative, distractibility, maintaining sustained effort, impulsivity, extreme variability in performance and poor problem solving ability.

Complete transection of the spinal or cauda equina shown by CT scan, MRI or surgical observation could reasonably equal listing 11.08 prior to the 3 month waiting period. The treating physician should be contacted and an RC obtained. If a spinal cord patient is close to 3 months post injury and has muscle grades in the 2 to 3 range below the level of the lesion, the listings will likely be met. If the patient is rapidly developing spasticity, even if there is neurological return, the spasticity is functionally quite hampering and needs to be considered. This information will often be found in P.T. notes. In cases such as this, the patient is unable to inhibit reflexes. Although surgery is performed on a completely severed spinal cord, this is done for stabilization purposes. There is no hope for neurological recovery.

The American Spinal Injury Association (ASIA) Motor Classification is as follows:

A - complete, poor prognosis B - motor complete but with sacral sen- sory sparing C - fewer than half the “key” muscles have a 3/5 motor grade D - half or more of the “key” muscles have a 3/5 motor grade E - normal motor function

Key muscles in the upper extremities are biceps, wrist extensors, triceps, flexor profundus and hand intrinsics. Key muscles in the lower extremities are iliopsoas, quadriceps, anterior tib, EHL, and gastroenemius. The ASIA Numerical Classification is a motor scale which adds the grading for motor function of the 5 key muscles in the upper extremities and 5 in the lower extremities together for a total score. Complete quadriplegia scores a 0 and a normal score is 100.

Dr. Minnigerode closed by stating that the real adjudicative problems come more with the head injuries.