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Appendix: Solutions to Problem-Solving Exercises

CHAPTER 1

Problem-Solving Exercise 1-1

  • IMPAIRMENTS: lower extremity paralysis, limited range of motion

  • ACTIVITY LIMITATIONS: unable to walk, transfer independently, negotiate obstacles (uneven terrain, ramps, curbs) in a wheelchair

  • PARTICIPATION RESTRICTIONS: unable to return to work, take care of son, live at home with spouse and son

  • ENVIRONMENTAL BARRIERS: steps at home's entrance, narrow bathroom doorway (Uneven terrain, ramps, and curbs are also environmental barriers. The inability to negotiate these obstacles, however, would be classified as activity limitation.)

CHAPTER 2

Problem-Solving Exercise 2-1

  • CLASSIFICATION: Applying the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), this patient's neurological level of injury (NLI) is right T11, left T12. (If identifying only one level, it is T11.) They have complete (ASIA Impairment Scale [AIS] A) paraplegia.

  • MOTOR RETURN: Based on the initial presentation (AIS A, with no sparing of pinprick sensation or voluntary motor function in the lower extremities), this patient is not likely to regain significant motor functioning in the lower extremities. HOWEVER, although motor return is not likely, it is possible. Thus, it would not be accurate to tell them that they definitely will not regain the use of their legs.

Problem-Solving Exercise 2-2

All of the patients have incomplete injuries. The following table presents the AIS, zone of partial preservation (ZPP), clinical syndrome, and neuroanatomical basis for the clinical presentation of each patient.

TABLE A-1Problem-Solving Exercise 2-2
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TABLE A-1 Problem-Solving Exercise 2-2
Patient # AIS ZPP Clinical Syndrome Neuroanatomical Basis for Clinical Presentation
#1 B

R & L sensory: N/A

R & L motor: C6

 Anterior cord Damage to the anterior and anterolateral aspects of the cord results in bilateral loss of voluntary motor function because all of the descending tracts are located in these areas. Pain and temperature sensations are lost due to interruption of the anterolateral system. The dorsal columns remain intact, resulting in preserved proprioception. The patient's ability to detect pressure during the rectal examination may reflect preservation of deep touch, another sensory modality that travels in the dorsal columns.
#2 D R & L sensory and motor: N/A Central cord The clinical picture typical of central cord syndrome is due to the spatial orientation of the fiber tracts in the cord: fibers innervating the cervical segments are located more centrally within the cord. Thus, damage in the central region of the cord affects the tracts that innervate the upper extremities. Fibers innervating the thoracic, lumbar, and sacral segments are located progressively more peripherally in the cord and are spared if the peripheral area of the cord is undamaged.
#3 D R & L sensory and motor: N/A Brown–Séquard The clinical presentation of Brown–Séquard syndrome makes sense when one recalls the course of the motor and sensory ...

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