SCI/MM L3 AD Recommendation

[Katherine Zuppann]

Hello!
I am seeking clarification re: spinal cord levels and recommended assistive devices (SCI and MM). In your Case study practice test I was confused on questions 13 & 14 as well as 64 & 65. In general, clinically speaking I would think of a KAFO for those with L3 level injuries due to weaker quads, and AFOs for injuries L4 and below, assuming functioning quads.
In questions 13 & 14, we are looking at a pt with a SCI, with knee ext 3+/5, no active DF/PF. Injury level is L3. The next question is related to ADs, and the “correct” answer is “MWC for community and AFO and cane for household.” I answered “MWC for community and KAFO/forearm crutches for household.” Is this answer correct? I’m having a hard time understanding why L3 with 3+ quads would be an effective ambulator with just AFOs, as gait requires greater strength than simply moving in full arc against gravity; I would assume functionally you’d need more strength that 3+ to ambulate effectively.
Additionally, in questions 64 & 65, we are talking about a pt with MM, L3-4 with hip flexion, knee ext/flex 3/5 and 2/5 ankle DF, inv, toe ext. Question 65 the answer is AFO, but I’m having a hard time understanding why such limited quad/DF strength would allow for ambulation with only AFOs.
I thought I had this fairly clear in my mind (generally speaking, children can ambulate w KAFOs at L3 and AFOs at L4, based off MM graphs in Campbell 5th ed. on p 568-70 which states that those with L4-S1 may ambulate w AFOs and those w L3-4 may ambulate w KAFOs, those w L1-3 amb w RGOs), but this seems to contradict graphs in the PCSA course for SCI on p 9 of the study guide (stating L3-S1 may ambulate independently w AFOs, may need AD). I understand we’re looking at both SCI and MM but I would think that clinically, we’d see more similarities as we’re discussing spinal cord levels and related functionality. Can you clarify so I have a clearer picture in my head?! Thank you SO much!

[Jessica Lewis]

For question 13/14: When reading the questions focus more on the information about the motor level and not necessarily the lesion level. We realize that clinically an L3 could look very different across different individuals and that we should make decisions solely on lesion level (for both SCI and MM). Our reasoning that someone with 3+ quads could potentially do household distances with AFOs and not the more bulky KAFOs (although for distances outside of the house, KAFOs would be needed if they are not using the manual wheelchair).

Working on question 64/65…

[Helen Carey]

In regards to the issue with L3 levels between MM and SCI. The study guide has L3-S1 as a general group, so it seems possible for a L3 lesion due to SCI to require a bit more support, however, it will really depend on the individual’s motor function and muscle strength. Our information comes from published sources and doesn’t always capture all possible clinical variability (including an incomplete SCI). I think a good strategy is to focus on information regarding motor function and muscle strength since clinically we use that information to determine orthoses and assistive devices, not lesion levels.

Helen

[Katherine Zuppann]

Thank you. So for question 13/14 do you think a better more consistent answer might actually be the MWC with KAFOs, to stay consistent with the graphs in Campbell and lesion level? Or is the key “household” ambulation? My concern was that there was a different AD prescription approach for MM vs SCI, which doesn’t make sense to me right now. Basically, I’m trying to come up with consistency on lesion level and expectations re AD prescription. There is, of course, clinical wiggle room in each specific case, but lesion levels and SD recommendations here seem to be quite different in Campbell vs the study guide and I’m curious which approach/resource is best for the actual exam. Again, thank you so much for clarifying!

[Helen Carey]

Yes, household ambulation is an important consideration as we know short distances are much less demanding in terms of motor control and muscle strength. Individuals with MM and SCI often use different means of mobility for community vs household ambulation.

AD prescription should be based on motor function level, not lesion level, since lesion levels are not an exact science. It is possible for 2 children with MM with the same lesion level to have some differences in functional motor levels and, therefore, different orthotic and AD needs. We developed our study guides using multiple sources, not just Campbell. We tried to include evidence presented from these different sources.

Hope that helps!
Helen

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