Total flaccid paralysis and loss of all reflexes below the level of injury. 6. C5 Spinal Cord Injury. Expected level of functional independence after complete spinal cord injury. . Spinal cord injury (SCI) is the injury of the spinal cord from the foramen magnum to the cauda equina which occurs as a result of compulsion, incision or contusion. High-Cervical Nerves (C1 – C4) Most severe of the spinal cord injury levels. When ordering Brian a w/c, our goal was to find him a w/c that would provide him with optimal postural support and safety, but at the same time allow for independent mobility at home and in the community. Clients with an incomplete spinal cord injury may present with asymmetrical head control or upper limb function that will alter the selection of power wheelchair options. C1-C4 complete injuries; Complete Cervical SCI with poor scapular stability. This chart is a guide, with general information only; impairments and rehabilitation potential can vary depending on the type and severity of SCI. C5-6 ... • Finger flexors C8 (C7-T1) • Knee L3 (L2-L4) ... • C4 Shrugs shoulders – Blow wheelchair • C5 Biceps, bends elbow – Propel wheelchair; self feed with a splint • … Target Population: People using manual wheelchairs for community locomotion (spinal cord injury, stroke, elderly) Most of the sites are in need of volunteers to participate in the Up-LIFT Study, a single-arm study designed to evaluate the safety and effectiveness of non-invasive electrical spinal cord stimulation. Spinal Cord Injury C4-C8 with a Ventilator A Guide for Families 1 of 11 To Learn More • Rehabilitation Services - 206-987-1500 • Occupational/Physical Therapy 206-987-2133 • Ask your child’s healthcare provider • seattlechildrens.org Free Interpreter Services • In the hospital, ask your nurse. To help you understand what to expect after C8 spinal cord injury, this article will discuss potential complications … Focus on abilities and functional goals ... C8 This is great – now my thumb can manipulate . A spinal cord injury can cause one or more symptoms including: Numbness, tingling, or a loss of or changes in sensation in the hands and feet. Paraplegia Wheelchair management. There are significant impairments classically associated to the location of the injury in the spinal cord, with the higher in the spinal cord the injury is, the worse will be the impairment. On the other hand, Acute spinal cord injury (SCI) is due to a traumatic injury that can either result in a bruise (also called a contusion), a partial tear, or a complete tear (called a transection) in the spinal cord. Exercise. This chart is a guide, with general information only; impairments and rehabilitation potential can vary depending on the type and severity of SCI. Within these 291,000 people, approximately 78% of new cases are male and the average age of SCI is 43 years old. Purpose To investigate the relationship between the classification systems used in wheelchair sports and cardiovascular function in Paralympic athletes with spinal cord injury (SCI).Methods 26 wheelchair rugby (C3–C8) and 14 wheelchair basketball (T3‐L1) were assessed for their International Wheelchair Rugby and Basketball Federation sports classification. The latest statistics that have been released from the National Spinal Cord Injury Statistical Center(NSCISC) states that approximately 291,000 people are currently living with spinal cord injury in the United States. Communication: Talking is sometimes difficult, very limited or impossible. injury or spinal cord injury provide a synthesis of the recent research evidence and guidance to help work out which is the most appropriate wheelchair. History of diving and hitting with neck, loss of sensation and movement below the chest. If you’re a practitioner working with one of the many patients with a spinal cord injury (SCI), you know the diagnosis presents unique challenges. Paralysis that may happen immediately or develop over time as swelling and bleeding affects the spinal cord. Independent in all. It is a debilitating problem for patients with a spinal cord injury. • Hematoma causes pressure to the cord Spinal Cord Injury • Named for the level of injury – eg. Driving may be possible after being evaluated by a qualified professional to determine special equipment needs. There are an estimated 282,000 people in the U.S. who currently have a spinal cord injury (National Spinal Cord Injury Statistical Center: Facts and Figures at a Glance, 2016). Power Wheelchair. ... (BMI), race, marital status, place of residence, highest level of formal education, SCI level (tetraplegia [C8 and higher] vs paraplegia [below C8]), length of time using a wheelchair, and age of wheelchair used most often. Spinal cord injury levels are used to explain the different severities of paralysis, following an injury. Man with a spinal cord injury using a Jouse 2 sip n puff switch. An Incomplete Spinal Cord Injury. Every spinal cord injury is different, and there are four distinct regions of the spinal column that, if damaged, can greatly determine the extent of a person’s mobility and sensation. Recent Articles More than half of wheelchair users with spinal cord injury needed repairs in past 6 months July 1, 2021 Self-feeding, prolonged electric wheelchair use and bladder/bowl manageability are all possible at this point. Most of the sites are in need of volunteers to participate in the Up-LIFT Study, a single-arm study designed to evaluate the safety and effectiveness of non-invasive electrical spinal cord stimulation. Independent at C4. Expected level of functional independence after complete spinal cord injury. Support of heart and lung function, nutritional needs, and skin care. Wheelchair Skills Capacity and Performance of Manual Wheelchair Users With Spinal Cord Injury. Physical care. Wheelchair Transfer | Spinal Cord Injury In this video I show you how I do a Placemat Wheelchair Transfer. Also, using the right techniques and positions can make it much easier for you to dress. The types of spinal cord injury corresponding to these regions of the spine have the potential to impact everything below the top of … Deltoid Press 2. Some assist at C5. Power wheelchair propulsion – Total assist from C1 to C3. May be able to use powered wheelchairs with special controls to move around on their own. While individuals with C8 spinal cord injuries generally can control movement in their arms, they may experience weakness and loss of sensation in the hands, trunk, and lower body. Pain or … Therapists should understand the effects of co-morbidities and other medical conditions on functional abilities e.g. All cervical spinal cord injuries will cause issues for bladder and bowel control, but those with lower-level injuries will be … YouTube. A Guide for People with Spinal Cord Injury 3 A spinal cord injury (SCI) is damage to the spinal cord resulting in a loss of movement or feeling. Paralysis that may happen immediately or develop over time as swelling and bleeding affects the spinal cord. Spinal cord injury and stroke were the two top causes of paralysis in 2013, according to research published in the American Journal of Public Health. A spinal cord injury (SCI) is damage to the spinal cord that causes temporary or permanent changes in its function. ... Power wheelchair, joystick hand control, high back, seat belt, cushion, removable desk arms, modified van lift, hand controls: C7: Independent with the use of adaptive equipment: ... C8 and below, including: thoracic, lumbar, and sacral: Independent: Pain or … A person with this level of injury may be able to breathe on their own and speak normally. Page 1 of 7. [Back to top] Wheelchairs. A spinal cord injury (SCI) is damage to the spinal cord that results in a loss of function, such movement and/or feeling. Loss of fine motor skills, paralysis of the arms, and partial impairment—usually less pronounced—in the legs are common. Therefore, the purpose of this study was to identify the factors contributing to shoulder pain and injury in manual wheelchair using persons with tetraplegia. The spinal cord does not have to be severed for a loss of function to occur. Postural Benefits. Spinal Cord Injury Levels. Co1 spinal nerve supplies the genital and rectal areas. ABLEDATA is a non-commercial information center for assistive technology, including wheelchairs. The functional outcomes in spinal cord injury rehabilitation per each level of complete injury. SPINAL CORD INJURY (SCI) defined as a traumatic insult to the spinal cord can result in alterations in normal motor, sensory and autonomic function a devastating event. Paralysis happens when an injury or illness causes damage to the brain, the spinal cord, or the nerves at the end of the spinal cord. Self care after a spinal cord injury. SCI causes serious disability among patients. An individual with a C8-T1 complete spinal cord injury has the potential to primarily/solely be a manual wheelchair user. For people with spinal cord injuries, the selection of a wheelchair and seating system involves many factors. 1994 Mar;32(2):70-80. Requires 24-hour-a-day personal care . Each injury is different, and injuries can affect the body in many different ways. physiologic response that occurs between 30 and 60 minutes after trauma to the spinal cord and can last up to several weeks. The spinal cord does not have to be severed for a loss of function to occur. Go to www.abledata.com (select Products, then Wheeled Mobility) or call 800-227-0216. Spinal cord injury occurs when there is any damage to the spinal cord that ... power wheelchair, can move from one place to another independently n C6 injury o Nerves affect wrist extension. Paraplegia. The guidelines also affirm that the person is, and should be, central to the prescription of their wheelchair, and involved in all stages. The four types of spinal cord injuries are cervical, thoracic, lumbar, and sacral. ... Archive for the Wheelchair Category. After a spinal cord injury, daily activities like dressing can be challenging. It is the largest nerve in the body. The financial implications associated with living with spinal cord injury (SCI) can depend on the severity of the injury and also the age at which the injury occurs. (persons with a neurological level of injury between C5 and C8). Middle Deltoid Pectoralis major, Anterior Deltoid, Supraspinatus, Upper and lower trapezius. Cross-sectional. A spinal cord transection is an injury in which the spinal cord is cut. The most common complication of spinal cord injury is contractures. Depending upon the completeness, a C8 injury will lead to paralysis of the legs, trunk, and hands, with patients maintaining shoulder and arm movement. Treatment for these types of spinal cord injury are aimed at retaining as much function as possible while regaining lost function. The following are general guidelines and considerations when prescribing wheeled mobility for different clinical Spinal Cord Injury patients. Rehabilitation Potential with Spinal Cord Injuries The following chart is a comparison of the specific level of SCI and the resulting rehabilitation potential. Zone of preservation. 2008;46:785–90. Inclusion criteria were SCI injury level C5–C8 and for the reference group T7–T12; ... Energy expenditure in ball games for wheelchair users. Runge M. Follow-up study of self-care activities in traumatic spinal cord injury quadriplegics and quadriparetics. Types of Spinal Cord Injuries. • Describe the rationale behind post-acute rehab in spinal cord injury • Understand the basis for adaptive-based therapies by level of spinal cord injury • Identify a variety of adaptive-based therapies and their functional benefits (e.g., activities of daily living and functional mobility) • Discuss spinal cord … Any damage to the spinal cord is a very complex injury. Purpose To investigate the relationship between the classification systems used in wheelchair sports and cardiovascular function in Paralympic athletes with spinal cord injury (SCI). The international stan- dards booklet for neurological and functional classification of spinal cord injury. ... • Wheelchair/cushion (pressure management) • Home assessment for wheelchair access and ... C8 and below. Will not be able to drive a car on their own. Learn more about spinal cord injury levels, treatments, rehabilitation, symptoms, causes, diagnosis, and how the injury will affect the rest of the body. Participants must be 22-75 years old with injury level between C2-C8 and at least one year out from their injury. A spinal cord injury (SCI) is damage to the spinal cord that results in a loss of function, such movement and/or feeling. Also, a person with a level T2-T6 level spinal cord injury can perform all of their daily task activities without help. Increases in wheelchair breakdowns, repairs, and adverse consequences for people with traumatic spinal cord injury. The spinal cord is a bundle of nerves that runs through the bones making up the spinal column. L1 through L5 spinal nerves supply the lower abdomen and the lower extremities. Paralysis in arms, hands, trunk and legs. The latest statistics that have been released from the National Spinal Cord Injury Statistical Center(NSCISC) states that approximately 291,000 people are currently living with spinal cord injury in the United States. Mobility: Dependent for bed mobility and transfers, independent in electric wheelchair and with pressure relief by reclining wheelchair. Typically has head and neck control, can shrug shoulder and has shoulder control. Can bend his/her elbows and turn palms face up. Certain tricks can help you do more by yourself. Read below to learn more about each type of SCI. A C8 spinal cord injury refers to damage at the nerve roots between the C7 and T1 vertebrae. Symptoms may include loss of muscle function, sensation, or autonomic function in the parts of the body served by the spinal cord below the level of the injury. Consortium for Spinal Cord Medicine, Preservation of Upper Limb Function Following Spinal Cord Injury: What You Should Know (Paralyzed Veterans of America, 2005). The spinal cord is a bundle of nerves that runs through the bones making up the spinal column. IADLs – Total assist from C1 to C5. Learn vocabulary, terms, and more with flashcards, games, and other study tools. The Spinal Cord Injury Association website is a not-for-profit.We believe no person should be excluded from opportunity on the basis of their disability.The mission of The Spinal Cord Injury Association is to archive important Spinal Cord Injury Information for education and awareness This clinical perspective describes a model that includes consideration of the person, the wheelchair, the immediate environment between the person and the wheelchair, the intermediate environment of the home and work, and the community environment. • From outside the hospital, call the Following is a brief summary of changes that can take place after a spinal cord injury. Track ball: A computer mouse that incur-porates a ball held in by a socket. Within these 291,000 people, approximately 78% of new cases are male and the average age of SCI is 43 years old. ... C8-T1: Has added strength and precision of fingers that result in limited or natural hand function. C8 Spinal Cord Injury: These nerves are in control of some of your hand’s movements. There are two main classifications of spinal cord injuries, complete and incomplete. The spinal vertebral and cord segmental levels become increasingly discrepant further down the spinal column. Spinal cord injury can cause a range of symptoms, including weakness, loss of muscle function, and loss of sensation. A range of functional goals are determined based on the location of your spinal cord injury. With a spinal cord injury at level T2-T6, the person still has a normal motor function in their head, neck, shoulders, arms, hands and fingers. • From outside the hospital, call the Self care activities, Loading and unloading wheelchair, Lifting objects. Generally, the higher the level of injury to the spinal cord, the greater the degree of paralysis will result. A T11 vertebral injury, in fact, will result in a L5 lumbar spinal cord level. Spinal Cord. C7- C8 Spinal Cord Injury The lowest part of this section of the spine, injuries on this level allow for more significant movement and independence depending on flexibility and strength of the individual. Traumatic spinal cord injury is a devastating irreversible life-changing condition often caused by incidents such as motorcycle accidents, trucking accidents, diving accidents, pedestrian accidents, bicycle accidents as well as assault, car accidents and falls.. C8 Vertebrae: The individual should be able to grasp and hold objects as the nerves involved in hand movement are not damaged. An SCI may result from trauma, tumor, ischemia, a developmental birth defect (such as spina bifida), transverse myelitis or vascular malformations. Cervical Vertebrae Levels: C1 – C8. Zone of preservation. Purpose To investigate the relationship between the classification systems used in wheelchair sports and cardiovascular function in Paralympic athletes with spinal cord injury (SCI). C6 Spinal Cord Injury. With a C6 injury, there is enough movement in the hands that an electric wheelchair with hand controls for uneven surfaces may be used as well as a manual wheelchair for a short period of time on a flat surface. To describe the manual wheelchair (MWC) skill profiles of experienced MWC users with spinal cord injury and their wheeled mobility (distance and … W/C Mobility and Skills. Start studying Spinal Cord Injury: Functional Outcomes. ... Power wheelchair, joystick hand control, high back, seat belt, cushion, removable desk arms, modified van lift, hand controls: C7: Independent with the use of adaptive equipment: ... C8 and below, including: thoracic, lumbar, and sacral: Independent: Introduction [edit | edit source]. A power wheelchair with hand controls is typically used for daily activities. Most victims are able to drive with hand controls, can maintain floor to chair transfers, and can propel a wheelchair in the community. For example, a T8 vertebral injury will result in a T12 spinal cord or neurological level. Loss of movement and feeling depend on what part of the spine is damaged. THE NORMAL SPINAL CORD The spinal cord is a part of your nervous system. The C6 and C7 cervical vertebrae (and the C8 spinal nerve) form the lowest levels of the cervical spine and directly impact the arm and hand muscles. Limited movement of head and neck. I … poor or trace motor or sensory function for up to 3 levels below the neurologic level of injury. Spinal cord is like a communication between the receptor and muscle, and the brain on the other side. On the other hand, ... Mobility: Can operate an electric wheelchair by using a head control, mouth stick, or chin control, and can tilt wheelchair for independent pressure relief. o Paralysis in hands, trunk and legs, typically ... n C8 injury o Nerves control some hand movement. The spinal cord does not have to be totally cut or torn for a loss of functioning to occur. The following chart is a comparison of the specific level of SCI and the resulting rehabilitation potential. Communication: Talking is sometimes difficult, very limited or impossible. Manual Wheelchair Propulsion: Typically, the lowest level of cervical cord injury in which the patient will be independent for this task is C6 SCI. Spinal Cord Injury Levels A Summary of Spinal Cord Injury Levels: C1-C8. 1966 Sep-Oct;20(5):241-9. Low-Cervical Nerves (C5 – C8) Corresponding nerves control arms and hands. Individuals at any of these levels should be independent in all ADLs and in computer and EADL operation using a … Spinal Cord Injury C4-C8 with a Ventilator A Guide for Families 1 of 11 To Learn More • Rehabilitation Services - 206-987-1500 • Occupational/Physical Therapy 206-987-2133 • Ask your child’s healthcare provider • seattlechildrens.org Free Interpreter Services • In the hospital, ask your nurse. The Spinal Cord Injury Zone website is a not-for-profit Spinal Cord Injury educational Knowledge Base. The spinal cord running through the cervical region of the spine is identified by the level of the vertebra in which it is contained. Spinal Cord Injury (SCI) Case Presentation Nature of . Wheelchair Propulsion - Spinal Cord Injury Research Evidence. This injury is an injury to the center of the cord, and damages nerves that carry signals from the brain to the spinal cord. The spinal cord is a bundle of nerves that carries messages between the brain and the rest of the body. When all four limbs are affected, this is called tetraplegia or quadriplegia. this video is about incorporating adaptive devices and sex toys into your sex life. Participants had to have a chronic tetraplegia secondary to a spinal cord injury Or disease Independent also with level outdoor surfaces at C7. Ability to speak is sometimes impaired or reduced. The spinal cord is a bundle of nerves that carries messages between the brain and the rest of the body. Limited movement of head and neck. A person with a C8 injury should be able to release and grasp objects and complete most daily activities on their own, but may need assistance completing more challenging tasks. American Spinal Injury Association. Acute spinal cord injury (SCI) is due to a traumatic injury that can either result in a bruise (also called a contusion), a partial tear, or a complete tear (called a transection) in the spinal cord. ... (C7-C8) Wheelchair management. Authorship “Understanding Spinal Cord Injury: Part 2—Recovery and Rehabilitation” was developed by Phil Klebine, MA; Olivia Smitherman, MOTR/L. poor or trace motor or sensory function for up to 3 levels below the neurologic level of injury. physiologic response that occurs between 30 and 60 minutes after trauma to the spinal cord and can last up to several weeks. Wheelchair Order Posted in Wheelchair on April 27, 2008 by Brian. ... A manual wheelchair may be used for everyday living, with an ability to go on uneven surfaces. C8, T1 – T12 SCI—The finger muscles are added at C8, upper trunk muscles are added at T1 – T6 and lower trunk muscles are added at T6 – T12. Regardless of how an injury occurs, the victim is typically left with substantial medical bills, in addition to the cost for wheelchairs and other assistive devices, home modifications, adapted vehicles, and home health aides. Manual wheelchair skills 2 total scores for version 4.1: safety and performance; safety component added to help clinicians identify completion of a skill based on patient judgment Psychometrics of WST 4.2 are being reviewed. The locations of C6 and C7 vertebrae are both in the lowest levels of the cervical spine, near the base of the neck. . Spinal Cord Injury. Methods 26 wheelchair rugby (C3-C8) and 14 wheelchair basketball (T3-L1) were assessed for their International Wheelc … MSKTS offers an outstanding three part series aimed at familiarizing people with a spinal cord injury with need to know wheelchair information. ... anti tip levers, and wheelchair maintenance; able to verbally direct. The functional outcomes in spinal cord injury rehabilitation per each level of complete injury. Independent indoors at C6. Light meal prep at C6. Patient may not be able to breathe on his or her own, cough, or control bowel or bladder movements. Spinal Cord (2012) 50, 595–598. Videos on exercise system for people with C4-C5, C6 & C7 spinal cord injury. Total flaccid paralysis and loss of all reflexes below the level of injury. Some clothes are easy to put on while others are more difficult. Spinal cord injury may cause changes in the sympathetic nervous system, keeping blood pressure low during very hard exercise. • Sensory – according to dermatomes – NOT peripheral nerve distribution: Look in the thoracic region and 5. Cervical injuries above the C4 level may require a ventilator for the person to breathe. Muscles Strengthened. Using adapted devices or adapting your current clothing can help. REHABMEDICINE| SPINAL CORD INJURY | DR. CEMBRANO202 0. Areas covered in spinal cord injury rehabilitation programs may include: Patient need: Example: Self-care skills, including activities of daily living (ADLs) Feeding, grooming, bathing, dressing, toileting, and sexual functioning. The spinal cord does not have to be totally cut or torn for a loss of functioning to occur. Breathing: Depends on a ventilator for breathing. Am J Occup Ther. Spinal cord injury C5-C8, paraplegic D1-D11, and D11 paraplegic below only for phases 1 and 2 phase 1 and 2; Spinal cord injury D1 and above only for phase 3; Having given free and informed consent; Negative pregnancy test for women of childbearing age; Exclusion Criteria: No affiliation to a social security scheme There is an additional cervical-level injury known as a C8 injury which relates to damage to the spinal cord root that exits the spinal column between vertebrae C7 and T1. high-level spinal cord injuriesmay not be able to fully control their arms. What You Need to Know About Stroke and Paralysis. S1 through S5 spinal nerves also supply the lower extremities as well as the pelvic region. Injuries to the cervical spine – which includes eight vertebrae labeled C1 through C8 from top to bottom – are the most severe spinal cord injury levels. Breathing: Depends on a ventilator for breathing. These terms mean exactly the same thing; one has Greek origins and the other Latin. Independent at T1. Participants must be 22-75 years old with injury level between C2-C8 and at least one year out from their injury. He can able to move hand mildly. Functional Benefits. W/C ( Floor: has the potential to be independent, may require minimal assistance initially with technique and lift. Self care after a spinal cord injury. Manual wheelchair propulsion – Total assist from C1 to C4. Twitter. The common causes are injury and accidents, or from such diseases as polio, spina bifida, Friedreich’s ataxia, and so on. Spinal Cord Injury (SCI) is damage to the spinal cord that results in loss of function such as mobility or sensation. ; Laney Gernenz, PT; and Jill Baldessari, OTR/L, ATP in collaboration with the Model Systems Knowledge Translation Center. The person also has increased use of rib and chest muscles. A complete spinal cord injury (SCI) is one in which the spinal cord is totally severed and no signals pass from the brain to the distal nerves; this is as opposed to a partial SCI, in which a significant portion of the cord … A survey of 723 participants with SCI who use a wheelchair for more than 40 hrs/wk treated at a … Tetraplegia (or Quadriplegia) Tetraplegia (or Quadriplegia) is injury or damage to the spinal cord in the cervical region (neck) and will result in partial or complete paralysis of the upper and lower portion of the body. Welcome to SCIRE Professional. A spinal cord injury can cause one or more symptoms including: Numbness, tingling, or a loss of or changes in sensation in the hands and feet. C8 Tetraplegia. Injury to the spinal cord is an extremeley serious injury and can result in paralysis. Rehabilitation Potential with Spinal Cord Injury. Paraplegia. T1 through T12 spinal nerves supply the chest, abdomen, and mid-back. Cervical spine injury is an injury to an individual’s upper (cervical) spine, causing paralysis or weakness in both the arms, hands, trunk and legs. A Guide for People with Spinal Cord Injury 3 A spinal cord injury (SCI) is damage to the spinal cord resulting in a loss of movement or feeling. The common causes are injury and accidents, or from such diseases as polio, spina bifida, Friedreich’s ataxia, and so on. These symptoms are important to keep in mind for those doing very strenuous activities due to increased risk of lightheadedness or other problems related to … As a result of the injury, the functions performed by the spinal cord are interrupted at the distal level of the injury. C6 Spinal Cord Injury. Ventilator assistance is not necessary for this level of injury but clearing secretions and coughing still require help. Most patients also have the ability to dress the upper half of their body by themselves as well as perform simple grooming tasks such as shaving and brushing hair and teeth with the use of palm straps. , independent in electric wheelchair use and bladder/bowl manageability are all possible at this point one! And lift over time as swelling and bleeding affects the spinal cord is debilitating... A ball held in by a socket C8 vertebrae: the individual be... Nerves involved in hand movement Hematoma causes pressure to the spinal cord injuries below..., C6 & C7 spinal cord is like a communication between the receptor and muscle, and Recovery ''!, with an ability to go on uneven surfaces elbows and turn palms up... Modified rims B causes temporary or permanent changes in its function S5 spinal nerves also supply the chest abdomen! & C7 spinal cord is a bundle of nerves that runs through the bones making up the cord... 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Daily activities with a level T2-T6 level spinal cord injury runge M. Follow-up study of self-care activities traumatic. Her own, cough, or control bowel or bladder movements complete and incomplete bleeding the! Wheelchair Users with spinal cord is cut this is called tetraplegia or quadriplegia such as mobility or sensation the severities! By a qualified professional to determine special equipment needs causes pressure to the spinal cord the cord! ( C1 – C4 ) Most severe of the specific level of functional after.
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